Gainesville Nursing

Inspectors wroteBased on observation, interview and record review, the facility failed to protect all residents from misappropriation of resident property when staff could not account for 19 missing narcotics tablets for 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). The facility census was 43. Review of the facility policy titled Abuse, Prevention and Prohibition Policy, revised 10/22, showed the following information:-Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy;-The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect all resident from misappropriation of property when one facility staff member (Environmental Services Employee A) used one resident's (Resident #1) debit card without consent. The facility census was 46. On 12/26/25, the Social Services Worker became aware of the misappropriation. The facility immediately began their investigation, including multiple interviews of other residents and staff. The facility began education on abuse, neglect, and misappropriation of resident's property. The facility removed Environmental Services Employee A from the facility. The facility reviewed all other resident's accounts with a debit card, as well as educated the residents on the process for debit card transactions. [...]

Inspectors wrote1. Please refer to Event ID B3N912, exit date 11/14/24. Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. -Resident abuse must be reported immediately to the Administrator. [...]

Inspectors wrote1. Please refer to Event ID B3N912, exit date 11/14/24. Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food prepared by the facility was palatable when residents complained the food was served cold at times, the food lacked flavor/seasoning, and the meat was tough at times. 1. Observations and interview on 09/11/24, at 1:07 P.M., showed the following: -The Dietary Manager (DM) confirmed testing the food on the last (test) tray on the cart. Prior to leaving the kitchen the temperature of the cheesy rice casserole was 120 degrees Fahrenheit (F); pork chop was 125 degrees F; and the broccoli was 115 degrees F. -When the tray was presented after the last tray was delivered, the casserole was 110 degrees F, the pork chop was 95 degrees F, and the broccoli was 90 degrees F. -The DM said the food was cool and should have been warmer to be palatable for the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. -Resident abuse must be reported immediately to the Administrator. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop complete a person centered care plan for each resident when staff failed to care plan related to side rails use for one resident (Resident #13) and wandering/elopement risks for one resident (Resident #36) of 21 sampled residents. Review of the facility's Care Planning - Interdisciplinary Team policy, dated January 2017 showed the following: -Upon completion of comprehensive assessments care areas of concern will be triggered to be addressed in the plan of care for that resident. -Each triggered care area will be reviewed by designated staff to determine if a triggered condition affects the resident's function and quality of life. -Staff will document whether or not a care plan is needed to address the triggered area. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible for all residents when staff failed to evaluate effective of interventions, care plan new interventions, and failed to complete root cause analysis after multiple elopement attempts and combativeness for one of two residents (Resident #22) reviewed for wandering. Review of the facility's policy titled Elopement Policy, undated, showed it was the intent of the facility to maintain and enhance a resident's dignity by promoting free access in and around the facility, while safeguarding the well-being of the resident, and to monitor behavior or residents to identify potential elopers, such as excessive wandering, especially to doors. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all food was prepared in a form designed to meet the needs of each resident when the facility failed to cut up meat as ordered for one resident (Resident #17). Review of the facility policy titled Menus and Food Preparation-Nutrition Services, revised January 2018, showed the purpose of the policy was to ensure resident nutritional needs are met in conjunction with resident preferences. 1. Review of Resident #17'sadmission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 10/18/21; -readmission date of 08/09/22; -Diagnoses included gastroesophageal reflux disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for five residents (Residents #8, #12, #27, #31, and #199); failed to obtain informed consent prior to the use side rails for one resident (Resident #31); failed to address the use bed rails in residents' care plans for four residents (Residents #8, #12, #31, and #199); and failed to obtain physician's orders for bed rail use for two residents (Resident #12 ad #199); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 48. Record review of a facility policy entitled Proper Use of Side Rails, reviewed 2/2021, showed the following: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for one resident (Resident #37) and failed to notify the ombudsman of transfers to the hospital for two residents (Residents #6 and #37). The facility census was 48. Record review showed the facility did not provide a a written policy pertaining to transferring a resident to the hospital. Record review of a facility form entitled Notice of Resident Transfer or Discharge, revised 11/2016, showed the following spaces to fill: -Date of notice; -Name, address, city, state, and zip (did not specify for whom); -Salutation to addressee; -Name of resident; -Name and location of institution where resident to be transferred/discharged ; -Date of transfer; -Rationale for transfer; [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #6 and #37) who were transferred out to the hospital. The facility census was 48. Record review of the facility's policy entitled Bed Hold Policy & Agreement Form, revised February 2014, showed the following: -Purpose to establish policy and procedure for facility to notify the resident/responsible party of the Bed Hold Policy and Agreement To Pay Charges For Bed Hold. The facility is to execute an acknowledgement stating whether or not such resident desires to exercise his or her right to a bed hold. The policy should meet applicable regulatory, federal and state program guidelines; -The Bed Hold Agreement is to be obtained for each occurrence - hospital or therapeutic home leave; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #6) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 48. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure proper care for all residents with catheters (a sterile tube inserted into the bladder to drain urine) when staff failed to obtain updated physician orders for an indwelling catheter for one resident (Resident #12). The facility census was 48. 1. Record review of Resident #12's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/26/22, showed the following information: -admitted to the facility on [DATE]; -Diagnoses included history of neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve condition); -Cognitively intact; -Total dependence on staff assistance for transfers, dressing, toileting, and bathing; -Limited assistance required with bed mobility and personal hygiene; -Always continent of bowel and bladder; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one nursing assistant (NA B) completed a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. This deficient practice had the potential to affect all residents who received care from the NA. The facility's census was 48. Record review showed the facility did not provide a written policy pertaining to Certified Nurse Aide (CNA) training and certification testing. 1. Record review of NA B's personnel file showed the following: -Date of hire: 6/28/2022; -Staff did not have documentation NA B had completed the nurse aide training program and passed the required certification testing. Record review of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to follow proper hand hygiene when handling food items and food contact surfaces; when staff failed to properly wear facial hair nets and hair nets; when staff failed to ensure that the warewasher was working properly; and when staff failed to keep open drinks out of the kitchen. The facility had a census of 49 residents. 1. Record review of the 2013 Food and Drug Administration (FDA) Food Code showed the following information: -Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan that included interventions to address facility identified resident care needs for three residents (Resident #2, #25, and #146) in a sample of 18 residents in a facility with a census of 49. 1. Record review of Resident #25's nurses' notes, dated 8/13/19, showed the resident admitted to the facility. The resident reported blindness in the right eye and vision clear in the left eye. The resident did not wear glasses. Record review of the resident's physician progress notes, dated 8/14/19, showed the resident had head trauma injury several years prior and became combative and verbally abusive. Since that time, his/her organic brain trauma has been complicated by dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form to meet each resident's nutritional needs when staff did not follow portion sizes for mechanical soft diets or prepare and serve pureed foods according to the approved recipe and the correct consistency for three residents (Resident #9, #11, and #16). The facility census was 49. Record review of facility records showed the facility did not provide a policy for therapeutic diets. 1. Record review of the facility's weekly menu, dated October 20, 2019 through October 26, 2019, showed the following information: -Wednesday, October 23, 2019: Salisbury steak, au gratin potatoes, and mixed vegetables; -Thursday, October 24, 2019: Roast turkey with gravy, sweet potatoes, and whole green beans. Record review of the facility's menu cycle, entitled Week 1 Wednesday, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve residents, including six sampled residents (Resident #4, #15, #17, #26, #33, and #196) palatable and attractive food to resident. The facility census was 49. 1. Record review of the facility's resident council minutes dated 6/18/19, at 10:30 A.M., showed the meat was too tough to cut. Record review of the facility's resident council Quality of Life questionnaire, dated 6/18/19, showed the following information: -Is the flavor and appearance of your food satisfactory? Sometimes; -Are the meats tender enough? No. Record review of the facility's grievance log dated 6/18/19, showed Resident #33 filed a grievance and said the meat was still tough. Record review of the facility's resident council minutes dated 7/16/19, at 10:15 A.M., showed the the food did not taste good. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity when staff failed to interact with one resident (Resident #196) in a respectful manner while assisting the resident to eat. The facility census was 49. 1. Record review of Resident #196's 5 day Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 9/30/19, showed the following information: -Original admission date of 5/1/19; -Diagnoses included Alzheimer's disease, dementia, diabetes, anxiety disorder, seizure disorder, and psychosis; -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfers, toilet use, personal hygiene, and eating. Observation on 10/22/19, beginning at 12:55 P.M., showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' end of life wishes reflected throughout the medical record remained consistent for two residents (Resident #4 and #246) out of a sample of 18 residents. The facility census was 49. Record review of the American Heart Association website, showed the following information regarding Advance Directives: -Advance directives, also referred to as living wills, can address a number of issues, such as whether a patient wants to receive artificial respiration, dialysis, tube feeding or artificial hydration, or donate an organ in the event of death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to check one resident's (Resident #1) blood glucose level (blood test to determine glucose level) before meals as ordered by the physician and according to the standard of practice. Facility staff failed to administer two residents' (Resident #1 and #146) insulin injections timely and as ordered by the physician. Staff failed to ensure the resident's physician orders included the sliding scale for insulin administration ordered by the physician. A sample of 18 residents was reviewed in a facility with a census of 49. Record review of a facility policy and procedure entitled, Insulin Administration (Revised April 2007), showed the following information: -The three key characteristics of insulin are onset of action (how quickly the insulin reaches the bloodstream and begins to lower blood glucose); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to care plan and implement effective interventions to prevent one residents (Resident #25) from exiting the facility and/or wandering into another resident's room. The facility census was 49. 1. Record review of Resident #25's face sheet (brief resident information sheet), showed the following information: -admitted to the facility on [DATE]; -Diagnoses included unspecified dementia with behavioral disturbance. Record review of the resident's physician order sheet (POS) showed order, dated 8/13/19, for Perphenazine, 4 milligram (antipsychotic medication) three times a day. Record review of the resident's nurses' notes, dated 8/13/19, showed the resident as alert and oriented to self, forgetful. The resident had poor short term memory. Staff to monitor safety awareness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed attempt effective interventions, including non-pharmacological interventions and failed to develop an individualized, person-centered care plan to meet the needs of one resident (Resident #32) with dementia and exhibiting continued behaviors. The facility census was 49. Record review of the facility's (undated) behavior policy showed the following information: -Goal was to encourage individual resident independence and autonomy by structuring a least restrictive environment which allows each resident to be restraint free for optimal periods of time and enhances the goal of quality therapeutic, preventative, restorative, and rehabilitative care; [...]