Golden Years Center for Rehab and Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out Activities of Daily Living (ADLs-fundamental self-care tasks like bathing or eating) received the necessary services to maintain good personal hygiene by failing to ensure bathing was completed and documented according to the residents individual preference and facility policy for four sampled residents (Resident #2, #3, #4, and #5) out of six sampled resident's. The facility census was 62 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' medical records were complete and accurate for four sampled residents (Resident #2, #3, #4, and #5) out of six sampled residents, when on 5/1/26 the Director of Nursing (DON) advised Certified Nurse Assistant (CNA) B and CNA C to retroactively complete and sign Skin Monitoring: Comprehensive CNA shower sheets for prior dates. The facility census was 62 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the inside laundry wall on the parking lot side in good repair to prevent water from entering the laundry area and failed to prevent the growth of moldlike substance on the laundry wall. This practice affected one non-resident use area. The facility census was 62 residents.1. Observation with the Administrator and the Maintenance Person on 5/1/25 at 10:57 A.M., showed:-An area of the wall that was 8 feet (ft.) 7 inches (in.) high by 15 ft. wide that was covered in a moldlike substance.-One area behind a large stainless-steel sink with the presence of a moldlike substance on the wall that was 14 in. high by 4 ft. wide. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility van used to transport residents to appointments was currently licensed. The facility census was 62 residents. Review of the facility's policy dated [DATE], Transporting a Resident - Facility Van showed:-It is the policy of this facility to provide residents safe, non-emergency transportation to physician's appointments, activity outings, and any other trips the faculty deems necessary.-The van would be well maintained. -Facility liability and insurance would have covered staff transportation of residents. 1. Review of emails between the Administrative Team at the facility and the parent company showed:-On [DATE] needing to register the van. The license plates expires on Friday. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the walk-in freezer floors clean; failed to ensure food preparation equipment were kept in a sanitary condition; failed to maintain plastic cutting boards and plate covers in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 67 residents with a licensed capacity for 119 residents at the time of the survey. 1. Observation on 1/21/26 between 12:29 P.M. and 12:43 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure smoking assessments were completed in a timely manner to ensure resident safety for three sampled residents (Resident #20, #65, and #4) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Resident Smoking dated 6/10/25 showed:-All residents would be asked about tobacco use during the admission process, and during each quarterly or comprehensive Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) assessment process.-Residents who smoked would be further assessed to determine whether supervision was required for smoking, or if a resident was safe to smoke at all.-If a resident who smoked experienced any decline in condition or cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the facility census and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift and to update the posting as necessary for view by residents, family members and visitors. The facility census was 67 residents. Review of the facility Nurse Staffing Posting Information policy dated 5/13/2025 showed:-The Nurse Staffing Sheet would be posted on as daily basis and would contain the facility census, the total number and the actual hours worked for licensed and unlicensed nursing staff responsible for resident care per shift.-The facility would post the Nurse Staffing Sheet at the beginning of each shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a drug regimen review (DRR) was completed monthly for four sampled residents (Resident #7, #10, #6, and #69) out of 17 sampled residents. The facility census was 67 residents. Review of facility policy entitle Quality Reporting: Drug Regimen Review revised 6/30/25 showed:-It was the policy of this facility document whether a drug regimen review was conducted upon a residents Skilled Nursing Facility (SNF) Prospective Payment System (PPS) admission and throughout the resident's stay, and to document whether any clinically significant medication issues identified were addressed in a timely manner. -Documentation of a drug regimen review may be located in various locations throughout the medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (5%) when staff failed to prime the insulin pen needles prior to administering Insulin for three sampled residents (Residents #27, #61 and #56) out of three sampled residents observed for Insulin administration resulting in a medication error rate of 11.54%. The facility census was 67 residents. Review of the facility Insulin Pen policy dated 5/16/2025 showed:-The facility would use Insulin pens to improve accuracy of insulin dosing.-A new needle would be used for each injection.-Insulin pens would be primed prior to each use to avoid collection of air in the Insulin reservoir.-Attach the needle to the Insulin pen.-Remove the outer cover from the pen needle.-Dial two (2) units of Insulin by turning the dose selector to clockwise to 2 units. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #44) rights remained intact when he/she had to move to a different room out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Resident Rights dated 6/10/25 showed Information about resident rights and responsibilities would be given to the resident both orally and in writing.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure documentation of non-pharmacological behavioral interventions were attempted prior to administering pro re nata (PRN as needed ) antianxiety medication (medication to address the symptoms of anxiety); to document events/triggers preceding behaviors; to ensure the PRN antianxiety medication had a stop date; and failed to include comprehensive symptoms and/or target behaviors and individualized interventions for one sampled resident (Resident #12) who was taking multiple psychotropic medications (drugs which affect psychic function, behavior, or experience) out of 17 sampled residents. The facility census was 67 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #44 and #75) physician's orders were followed out of 17 sampled residents. The facility census was 67 residents. A policy related to following physician orders was requested and not received prior to exit on 1/20/26.1. Review of Resident #44's admission Record showed he/she was admitted to the facility with the following diagnoses:-Retention of Urine (the inability to completely empty your bladder), Unspecified.-Neuromuscular Dysfunction of Bladder (occurs when nerve damage disrupts the brain-bladder communication, causing problems with storage or emptying), Unspecified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #13) gastrostomy tube (also known as G-tube, percutaneous endoscopic gastrostomy/PEG tube/feeding tube - a flexible tube inserted through the wall of the abdomen directly into the stomach that is used to give medications, fluids and liquid food) placement was confirmed prior to administration of medication in accordance with facility policy and current professional standards of practice. The facility census was 67 residents. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed:-The placement of an enteral tube is immediately verified after insertion by an X-ray; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident #13) tracheostomy (a surgical procedure that creates an opening (stoma) through the neck into the trachea (windpipe), to provide a direct airway) suctioning supplies were stored appropriately and that staff were trained and competent in the correct method of suctioning out of 17 sampled residents. The facility census was 67 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure orders were clarified for one sampled resident (Resident #7), who was receiving hemodialysis (a process of cleansing the blood of wastes, toxins and excess fluid by passing it through a special machine - necessary when the kidneys were not able to filter the blood), out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Hemodialysis policy, dated 5/2/25, showed:-The facility will assure each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.-The facility will ensure the physician's orders for dialysis include the location and type of access for dialysis (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with one sampled resident (Resident #6) who experienced past trauma, to identify triggers which may re-traumatize the resident and develop care plan interventions to decrease the resident's exposure to triggers and to minimize the effect of the trigger on the resident out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Trauma Informed Care (TIC) policy, dated 6/10/25, showed:-The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as their cultural preferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and behavioral health services for three sampled residents (Resident #4, Resident #7, and Resident #3) who had known behavioral health history and mental health diagnoses. The facility staff failed to implement a PASRR for Resident #4 and failed to create a plan of care for Resident #3 and Resident #4 to provide interventions for behaviors. The facility failed to transcribe, order, and administer Resident #4's psychotropic medications from [DATE] - [DATE] followed by an escalation of aggressive behaviors. The facility staff also failed to implement Resident #7's PASRR to create a plan of care for his/her known self-harming behavior suicidal ideation which resulted in the resident experiencing increased agitation and reporting thoughts of suicidal ideation and an elopement from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet the medical needs of two of three sampled residents (Resident #12 and Resident #4). On 10/15/2025, Resident #12 admitted to the facility with diagnoses including end stage renal disease and post operative right renal kidney transplant. The facility failed to give the resident their ordered anti-rejection medication, failed to provide wound care for their surgical wound for two and a half days, and failed to notify the resident's physician and transplant physician of the missed medications and wound care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident #12) was free from a significant medication error. The facility failed to order and administer Resident #12's antirejection medication after the resident admitted to the facility post kidney transplant. Resident #12 did not receive ordered medications for immunosuppression (a state in which the body immune system is weekend and less effective in fighting infection) on 10/15/25 and 10/16/25. The resident admitted back to the hospital with an undetectable amount of the anti-rejection medication in his/her bloodwork and with potential rejection of the transplant organ and sepsis (a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction). The facility census was 90 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #5 and Resident #6) were free from physical abuse when Resident #4 verbally abused and attempted to physically abuse Resident #5 which caused the resident to fall and resulted in feelings of embarrassment and humiliation for Resident #5. In addition, Resident #4 physically abused Resident #6 which caused Resident #6 pain and the need to be sent to the hospital for evaluation. Thirteen residents were sampled. The facility census was 90. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had appropriate competencies and skills to manage resident behaviors. The facility failed to provide education to employees related to behaviors and de-escalation including handling verbal and physical outbursts/aggression, suicidal ideation, refusal of antipsychotic medications, and destruction of the environment. Staff reported no knowledge of how to properly and safely care for Resident #4, Resident #7, or Resident #3. Staff stated they were fearful and did not feel competent to care for the residents' safely, and felt they could not keep themselves or other residents safe. The facility census was 90. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's dignity was respected when a Licensed Practical Nurse (LPN) called one sampled resident (Resident #13) dumb out of 13 sampled residents. The facility census was 90 residents. Review of facility policy entitled Resident Rights, revised 6/10/25, showed: -All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. -The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Training topics will be appropriate to the individual's role. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. In addition, the facility failed to provide a Director of Nursing (DON) for 40 hours per week. The facility census was 73 residents. Review of the facility policy titled Director of Nursing Services, with no date, showed:-The nursing services department was under the direct supervision of a Registered Nurse (RN).-The nursing services department was managed by the Director of Nursing services. The Director was a Registered nurse, licensed by the state, and had experience in nursing service administration, rehabilitative and geriatric nursing.-The Director was employed full time, 40 hours per week. [...]

Inspectors wroteBased on interview and interview, the facility failed to ensure the facility adhered to all the applicable components of the process for discharging a resident which included reassessment and the identification of how the facility could not meet the needs for one sampled resident (Resident #2). The facility census was 73 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure procedures were in place and followed in order to ensure physician notification was completed and documented regarding missed medications for two sampled residents (Residents #1, #2) out of four sampled residents, and failed to ensure blood pressure monitoring was completed for one resident with a physician's order to administer medication based on the resident's blood pressure (Resident #1). The facility census was 76 residents. Review of the facility Medication Administration Policy dated December 2012 showed: -Medications must be administered in accordance with physician orders. -For residents not in their room or otherwise unavailable to receive medication, the MAR may be flagged (identified for further attention) and the nurse will return to administration of the medication at a later time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure and document measurement of the resident's gastrostomy tube (G-tube/PEG tube, a flexible tube inserted into the stomach through a small incision in the abdominal wall that provides a direct route for administering food, fluids, and medications ) to ensure correct placement in the resident's stomach prior to giving fluids, medications and feedings for two sampled residents (Residents #1 and #4) out of four sampled residents. The facility census was 76 residents. A policy for administration of medication via G-tube was requested and not received. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floors under and behind the ice-machine free of debris; failed to ensure that items which were labeled refrigerate after opening, were refrigerated; failed to wrap a bowl of pureed pineapple in the kitchen reach-in refrigerator; failed to ensure the fan vent cover in the walk-in refrigerator, was free of dust; failed to label items (syrup and vinegar) with what they were in the containers those items were in; failed to ensure three cutting boards were free from stains and numerous grooves which caused those cutting boards to not be easily cleanable; failed to ensure the spatulas were maintained in an easily cleanable condition; failed to maintain the wall behind the dishwasher free of black colored debris; failed to maintain the floor under the six-burner stove free of debris; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required nurse aide in-services that included dementia (progressive loss of intellectual functioning, with impairment of memory, abstract thinking, and personality change, resulting from disease of the brain) and Abuse/Neglect/Exploitation training for three sampled Certified Nursing Assistants (CNA) (CNA B, H and J) from April 2023 through April 2024. The facility census was 67 residents. Review of the facility's In-Service Training Program, Nurse Aide Policy, dated December 2016, showed: -All nurse aide personnel participated in regularly scheduled in-services training classes. -All personnel were required to attend regularly scheduled in-service training classes. -In-service training was based on the outcome of the annual performance reviews, which addressed weaknesses identified in the reviews. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who allowed the facility to manage their resident funds, received interest payments and failed to ensure signed authorization forms were present for three residents (Residents #11, #32 and #1) selected for the resident trust review. The facility census was 67 residents. 1. Review of the reconciled bank statements, dated April 2023 through March 2024, showed the absence of any interest payments on the any of the bank statements. During an interview on 4/18/24 at 10:55 A.M. the Corporate Director of Fiscal Services said: -He/she did not see any interest on the bank statements. -He/she was not aware of any changes made to the account. 2. Review of Resident #11's authorization records showed there was no authorization form to manage funds found for the resident. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the water at the handwashing faucet in resident rooms 517, 520 and 523 at a temperature at or above 105 ºF (degrees Fahrenheit); failed to maintain sprinkler heads over the the therapy area, the Main Dining Room (MDR) and the side Dining room without dust; and failed to maintain two stand up lifts without cracks in the base of those lifts. This practice potentially affected at least 30 residents who resided in those areas, used those area or required assistance of the stand-up lifts. The facility census was 67 residents. 1. Observation on 4/16/24 with the Maintenance Director, showed: -At 9:06 A.M., the water temperature at the handwashing sink in resident room [ROOM NUMBER], was 97.2 ºF after the water was allowed to run for two minutes in that room. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the resident discharges/transfers for two sampled residents (Residents #48 and #23) and one supplemental resident (Resident #268) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's undated policy titled Transfer and Discharge) showed the policy did not include notification of the ombudsman when residents were transferred or discharged . 1. Review of Resident #48's health status note dated 3/16/24 at 6:56 A.M. showed the resident was sent to the hospital due to seizures. Review of the resident's admission summary showed the resident returned to the facility on 3/23/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #2) care plan (written out plan for the care of the resident) reflected the resident's need to receive Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST); out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Goals and Objectives, Care Plans policy dated April 2009 showed: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Care plan goals and objectives are defined as the desired outcome for a specific resident problem. -When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. [...]

Inspectors wroteBased on interview and record review, the facility failed to update residents' care plans with a change of condition and/or needs for five sampled residents (Residents #65, #41, #13, #19, and #52) and to invite a resident to his/her care plan meeting for one sample resident (Resident #37) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Goals and Objectives, Care Plans policy dated April 2009, showed: -Care plans incorporated goals and objectives that led to the resident's highest obtainable level of independence. -Goals and objectives were entered on the resident's care plan so all disciplines had access to needed information and were able to report if the desired outcomes were being achieved. -Goals and objectives were reviewed and revised when: --The resident had a significant change. --When the outcome was not achieved. --At least quarterly. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an activity program directed by a qualified Activity Director. The facility census was 67 residents. Review of the facility's undated Activity Director job description showed the following requirements: -High school diploma or General Educational Development (GED). -Two years experience in a social or recreational program within the last five years, one of which was full-time in a patient activities program in a health care setting; or a qualified occupational therapist or occupational therapy assistant; or must have completed a training course approved by the state. 1. During an interview on 4/22/24 8:59 A.M., Activity Director/Human Resources/Medical Records said: -He/She was in school now, getting an associate degree in human resources. -He/She had not had any training in activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Restorative Aide (RA-Assist residents with exercises designed by rehabilitation staff to help improve the use of limbs and body functions) services were provided as ordered to prevent further decline of Range of Motion (ROM - the range on which a joint can move) in accordance with therapy recommendations to for three sampled residents (Resident #2, #61, and #37) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Restorative Nursing Services, dated July 2017 showed: -Residents would have received restorative nursing care as needed to help promote optimal safety and independence. -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed weekly and stored in sanitary condition with the date it was changed written on it for two sampled residents, (Residents #268 and #17); to ensure a nebulizer (machine that converts medications into a mist to be inhaled by a patient) masks/pipes and tubing were cleaned, and stored in a sanitary condition for three sampled residents (Residents #33, #268, and #267) out of 17 sampled residents. The facility census was 67 residents. A policy was requested and not received at the time of exit. 1. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block air flow and make it difficult to breathe). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was providing services at least eight consecutive hours a day, seven days a week. The facility census was 67 residents. The RN Coverage policy was requested and not provided at the time of exit. Review of the facility's Staffing policy, dated April 2007, showed: -The facility maintained adequate staffing for each shift to ensure that resident's needs and services were met. -Licensed RN staff were available to provide and monitor the delivery of resident care services. 1. Review of the Center for Medicare and Medicaid Services (CMS) Staffing Report dated April 1 - June 30, 2023 showed the facility triggered for the following areas: -One Star Staffing Rating. -Excessively Low Weekend Staffing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) was responded to for four sampled residents (Resident #42, #19, #24 and #41) out of 5 residents reviewed for MRR out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Medication Regimen Reviews dated as revised in April 2007 showed: -The Consultant Pharmacist was responsible for performing a MRR for every resident in the facility monthly. -The Consultant Pharmacist would document his/her findings and recommendations on the monthly drug/medication regimen review report. -The Consultant Pharmacist would provide a written report to physicians for each resident with an identified irregularity. -Copies of MRR reports, including physician responses, will be maintained as part of the permanent medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the medication refrigerator temperatures and to remove expired medications which had no open dates from the Rehabilitation Unit medication refrigerator. The facility census was 67 residents. The facility policy titled Administering Medications dated December 2012 showed: -Medications shall be administered in a safe and timely manner, and as prescribed. -The expiration/beyond use date on the medication label must be checked prior to administering. -When opening a multidose container, the date opened shall be recorded on the container. 1. Observation on 4/18/24 at 6:33 A.M., of the Rehabilitation Unit medication refrigerator showed: -A paper refrigerator temperature log was laying on top of the medication refrigerator. -The log was dated 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four sampled residents, (Resident #37, #268, # 267, and #32) who had broken or missing teeth were seen by a dentist out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Dental Services dated December 2016 showed: -Routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and 24-hour emergency dental services were provided to residents through a contract agreement with a licensed dentist that comes to the facility monthly. -Social services representatives would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement measures to adequately respond to situations raised by two sampled residents (Resident #37 and #33) in the resident council meetings regarding receiving cold food out of 17 sampled residents; failed to ensure hot foods were at or close to 120 ºF (degrees Fahrenheit) and cold foods were served at a temperature of 41 ºF at the time of room tray service on the 500, 300 and the 200 Hall; and failed to ensure hot foods were served at or close to a temperature of 120 ºF who received room trays on the 200 and 300 Hall. The facility census was 67 residents. 1. Review of the resident council minutes dated 3/19/24, showed the residents raised the issue of cold food. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for five sampled residents (Resident #33, #48, #60, #61, and #173) out of five sampled residents. The facility census was 67 residents. Review of the facility's Tuberculosis, Screening Residents for, policy, dated July 2013, showed: -The facility screened all residents for TB. -The facility screened referrals for admission and readmission for information regarding exposure to or symptoms of TB. -TB skin tests (TST) completed within the last 12 months were reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to offer pneumococcal (lung inflammation caused by bacterial or viral infection) and/or influenza (flu-a highly contagious viral infection of the respiratory passages causing fever, severe aching, and often occurring in an epidemic) vaccines for five sampled residents (Resident #33 #48, #60, #61 and #173) out of five residents sampled for immunizations. The facility census was 67 residents. Review of the facility's Vaccination of Residents policy, dated August 2017, showed: -All resident were offered vaccines that aided in preventing infections diseases unless the vaccine was medically contraindicated, or the resident had already been vaccinated. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide the COVID-19 (an acute disease in humans caused by a virus, which caused fever, cough and could progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccine for three sampled residents (Resident #60, #61 and #173) out of five residents sampled for immunizations. The facility census was 67 residents. Review of the facility's Vaccination of Residents policy, dated August 2017, showed: -All resident were offered vaccines that aided in preventing infectious diseases unless the vaccine was medically contraindicated, or the resident had already been vaccinated. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one sampled resident's (Resident #61) code status was changed from a full code (if a person's heart stopped beating and or or they stopped breathing, all resuscitation procedures would be provided to keep them alive) to a Do Not Resuscitate (DNR - a legal document that means a person has decided not to have cardiopulmonary resuscitation attempted on them if their heart stops or they stop breathing) status, out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Advance Directives, dated December 2016 showed: -Upon admission, the resident would have been provided with written information concerning the right to refuse or accept medical treatment and to formulate an advance directive if he or she choose to do so. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident with a written summary of a baseline care plan that included instructions needed to provide the resident with care until the comprehensive care plan was developed for two sampled residents (Resident #41 and #60) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Care Plans - Baseline dated as revised December 2016 showed: -A baseline care plan would be developed within the first 48 hours of the resident's admission. -The interdisciplinary team would implement a baseline care plan to meet the resident's immediate care needs. -The baseline care plan would be used until the staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document the administration of pain medication for one sampled resident (Resident #41) and failed to ensure one sampled resident (Resident #33) had taken his/her prescribed medications out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Administering Pain Medication dated as revised October 2010 showed the policy did not address where to document the administration of opioids (pain medications used to treat severe pain). Review of the facility's policy, Administering Medications, dated December 2012 showed: -The Director of Nursing Services would supervise and direct all nursing personnel who administer medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing/showers were completed at least once weekly and at the resident's preference for two sampled residents (Resident #13, and #54) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's shower policy dated October 2010 showed: -No indication of how often a shower/bath should be offered or given. -The purposes of the procedure. -General guidelines. -Equipment and supplies. -Steps in the procedure. -Information recorded on the residents' Activity of Daily Living (ADL) record and/or the residents medical record as: --The date and time the shower was performed. --The name and title of individual who assisted the resident with the shower. --All assessment data pertaining to the resident's skin condition obtained during the shower. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered weekly weights were completed for one sampled resident (Resident #61) who had lost weight and was receiving tube feeding out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Weighing and Measuring the Resident, dated March 2011 showed: -The purposes of the procedure were to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status of the resident. -Weight was usually measured upon admission and monthly. -The following information should have been recorded in the resident's medical record: --The date and time the procedure was preformed. --The name and title of the individual who had performed the procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to have ongoing communication and collaboration with the dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) center regarding dialysis care and services for one sampled resident (Resident #18) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Care of a resident with end-stage renal (kidney) disease dated as revised September 2020 showed the policy did not address communication between the facility and the dialysis center. 1. Review of Resident #18's care plan dated 3/7/23 showed the resident received dialysis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications were administered for a specific condition and as needed orders were limited to 14 days without review at 14 days and without documented physician rationale for one sampled resident (Resident #41); and to ensure the resident received a gradual dose reduction (GDR) for psychotropic medications after it was recommended by a pharmacist in a Medication Regimen Review (MRR) for one sampled resident (Resident #24) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Medication Utilization and Prescribing - Clinical Protocol dated as revised in July 2016 showed: -The physician and the staff would identify the indications for a prescribed medication. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the lids of the dumpster were closed after facility staff place trash the dumpsters. This practice affected one outdoor area. The facility census was 67 residents. 1. Observation on 4/15/24 at 9:59 A.M. and 11:21 A.M., showed both outdoor dumpsters were left open. 2. Observation on 4/16/24 at 2:20 P.M, showed two lids of one dumpster were left open. 3. Observation on 4/17/24 at 12:36 P.M,, showed the lids of both dumpsters were left open. During an interview on 4/17/24 at 12:38 P.M., the Dietary Manager (DM) said he/she expected all departments within the facility who used the dumpsters to place items in to keep the dumpsters closed and keep the raccoons out.

Inspectors wroteBased on observation and interview, the facility failed to maintain the siding located on the outside of the former dementia unit and the siding on the outside wall behind the kitchen in good repair, which created openings that pests could get into. This practice potentially affected an unknown number of residents. The facility census was 67 residents. 1. Observation on 4/15/24 at 8:36 A.M., showed the siding on the outside wall of the dementia unit with a bird that went into one of the gaps in the missing siding. 2. Observation on 4/16/24 at 2:17 P.M., with the Maintenance Director showed an approximately 6 feet (ft.) wide by 2 ft. high section of siding behind the air conditioning unit outside the kitchen that was damaged with the insulation that was under the siding visible. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) with a facility acquired pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) that became infected requiring antibiotic therapy had weekly assessments of his/her skin and to ensure assessment, staging and measurements and description of the wound bed and drainage, and that the resident's care plan was revised to address his/her coccyx (tailbone) pressure and his/her pressure ulcer infection, and failed to ensure weekly licensed nurse skin assessments and weekly wound documentation for one sampled resident (Resident #8) admitted to the facility with two unstageable (not stageable due to coverage of the wound bed with slough - tan/yellow dead tissue or eschar - dry, black hard dead [...]

Inspectors wroteBased on observation, interview and record review, dietary staff failed to follow the recipe directions for Egg Salad Sandwich to maintain the temperature at or below 41 degrees Fahrenheit (ºF) in the kitchen before the time of service. This practice potentially affected 63 residents who ate food from the kitchen. The facility census was 67 residents. 1. Record review of the directions for the Egg Salad Sandwich showed: - Chill all ingredients prior to use. - Boil boil eggs till hard, then refrigerate at 41 ºF for several hours. - Peel eggs and chop. - Combine all remaining ingredients (relish, mayonnaise, mustard, red peppers) in a bowl and mix well. Observation on 8/21/22 from 3:37 P.M. through 6:21 P.M. showed: - Eggs were placed in boiling water. - Dietary [NAME] (DC) B placed the eggs in ice to cool them off cooling off eggs. - Between 5:17 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure paper towels were available at the handwashing sink next to the food preparation table; to ensure the handwashing sink next to the food preparation table was not blocked by boxes; to ensure the handwashing sink next to the automated dishwasher was not obstructed by a food cart and a red washing bucket; to discard 12 containers of half and half dairy product was discarded by the use by date; to discard two gallons of milk by the use by date; to remove an area of mildew or mold form the upper part of the ice machine; to maintain the gasket (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects), to store one bag of onions off the floor; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that items stored in the resident use refrigerator were labeled with a date they were placed in the fridge, a resident's name to identify who the items belonged to; to remove items that had expired according to the date on the package;and to maintain the resident use refrigerator free of food stains within the refrigerator and along the gasket which went around the inside part of the refrigerator. This practice potentially affected an unknown number of residents whose food was stored in that refrigerator. The facility census was 67 residents. Record review of the Policy entitled Foods Brought by Family/Visitors revised in 2/14, showed: - Family members should inform nursing staff of their desire to bring foods into the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to include the following in their Water Management Plan: diagrams from hot water heaters and the destinations of water from those hot water heaters, corrective actions that the facility would implement as a result of changes in municipal or facility water quality and members of the water management team; to ensure documentation of the most previous backflow testing (using valves on the backflow testing device, known as backflow preventers to ensure they're working properly to prevent contaminated water from going back into the building) was conducted. The facility also failed to follow appropriate infection control practices during wound care for one sampled resident (Resident #27); [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen steam table in working order; to maintain two washers and two clothes' dryers in the laundry in working order; and to have a system to indicate that the clothes' dryers were not working. The facility census was 67 residents. 1. During an interview on 8/21/22 at 5:48 P.M., Dietary [NAME] (DC) B said: - No pans could be placed in the middle well of the steam table because it would not shut off. - The dietary staff were going to serve meals that needed to be kept cold that day. - There have been four maintenance persons that have tried to fix the steam table, but were unsuccessful. Observation on 8/21/22 at 5:50 P.M. showed the absence of a switch from the middle well of the steam table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that openings that could let pests in, the attic area above the dry goods storage area and the Memory Care Unit hot water heater room, were maintained in good repair; and to clean up dead insect carcasses in the 300 Hall soiled utility room, the 400 Hall medication room, and the 200 Hall climate control unit room. This practice potentially affected at least 40 residents who resided in or used those areas. The facility census was 67 residents. 1. Observations of the attic area over the kitchen dry goods storage room, with the Maintenance Director on 8/22/22 at 10:27 A.M. and 11:22 A.M., showed the presence of wasps which flew around in the attic, bird and mouse droppings, dried vegetation, and a dead carcass of an animal that was not identifiable. During an interview on 8/22/22 at 10:34 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation that change was returned to two sampled residents (Residents #23 and #24), after money was spent on their behalf during a shopping trip. The facility also failed to provide records pertaining to the following areas within resident trust: reconciled bank statements for [DATE], [DATE], [DATE] and [DATE]; a listing of the residents' transactions over the past few months ([DATE] through [DATE] at least); a list of residents who were discharged with resident funds; a list of residents who were deceased with resident funds; and quarterly statements from [DATE] through [DATE]. This practice affected 29 residents who allowed the facility to manage their funds. The facility census was 67 residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain bed sheets free from stains and to change those sheets for five days of the survey for one sampled resident (Resident #40) out of 17 sampled residents. The facility also failed to maintain ceiling fans in the Golden Meadows dining room, the Memory Care Unit and the Social Worker's Office, free of a heavy buildup of dust; to maintain the floors of the resident rooms 110, 105, 310, 208, 201, free of a grime buildup; to maintain a stand up lift used on 400 Hall, without grime and food crumbs on its base; and to maintain a shower chair in the Memory Care Unit shower room in good repair. This practice potentially affected at least 40 residents who resided in or use these areas. The facility census as 67 residents. A request for the bed linen policy was made to the Corporate Liaison on 8/26/22; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dinner meal was served in a timely manner according to the listed meal schedule, on 8/21/22. This practice potentially affected 63 residents who ate food from the kitchen. The facility census was 67 residents. 1. Record review of the undated document which stated the facility meal times, showed dinner was supposed to be served at 5:00 P.M. Record review of the resident council minutes dated 5/12/22 showed late meals was one of the concerns raised during that meeting. Record review of Resident Council minutes dated 6/9/22, showed there was not any written followup to the concerns raised in the meeting on 5/12/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all the necessary items were available for the dinner meal on 8/21/22; to notify the Registered Dietitian (RD) when the dietary department changed from one entrée to another entrée on 8/21/22; and to ensure the recipe for super cereal was available for dietary staff to use while making the super cereal, for one observed resident (Resident #42). This practice potentially affected 62 residents who ate food from the facility kitchen. The facility census was 67 residents. 1. Record review of the weekly menu entitled Week at a Glance for General/Regular Week 1, dated 3/7/2022 showed the meal that was to be served on 8/21/22 was Philly style turkey burger, seasoned green beans, strawberries and whipped topping hamburger bun, 2% milk, and hot beverage. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the hot foods (sausage and eggs) of breakfast meal was at or close to 120 degrees Fahrenheit (ºF) at the time of service to residents on the Memory Care Unit on 8/25/22. This practice potentially affected 12 residents who resided on the Memory Care Unit. The facility census was 67 residents. 1. Observation of the breakfast food at the steam table on 8/25/22 at 7:52 A.M., showed the temperatures for the food served was scrambled eggs were 156.4 ºF, oatmeal cereal was 183 ºF, sausage was 142 ºF, and hot cereal was 175.3 ºF. Observation on 8/25/22 at 8:28 A.M., showed the food cart was delivered to the Memory Care Unit. Observation on 8/25/22 from 8:29 A.M. through 8:32 A.M., showed Certified Medication Technician (CMT) A provided assistance to Resident #21, in getting that resident dressed. [...]

Inspectors wroteBased on interview and record review, the facility failed to update the authorization to manage resident funds for one sampled resident (Resident #23) by failing to obtain a signature of authorization from the resident's legal guardian, when the status of that resident was changed from having self determination to needing a guardian. The facility census was 67 residents. 1. Record review of Resident #23's paperwork showed: - The resident signed to allow the facility to manage his/her funds when he/she was admitted on [DATE]. - The resident became a ward (a person, usually a minor or of unsound mind, for whom a guardian has been appointed by a court or one who has become directly subject to the authority of that court) of the County Public Administrator on 9/23/19. During an interview on 8/24/22 at 9:56 A.M., the Business Office Manager (BOM) said: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a current copy of each resident's Advanced Directive (legal document which allows you to plan and make your own end-of-life wishes known in the event you are unable to communicate) for one sampled resident (Resident #61) out of 17 sampled residents. The facility census was 67 residents. Record review of Revisor.mo.gov's article Title XII Public Health and Welfare-Chapter 190 dated [DATE] showed: -An Outside the Hospital Do-Not-Resuscitate Order (OHDNR) requires a written physician's order signed by the patient and the attending physician, or the patient's representative and the attending physician, in a form promulgated by rule of the department which authorizes emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation from the patient in the event of cardiac or respiratory arrest. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and follow a complete detailed physician's order for type, care and monitoring of a Suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis); and to follow infection control practices by ensuring a Suprapubic catheter drainage bag (a bag that holds drained urine) was kept off the floor for one sampled resident (Resident #18) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system); out of 17 sampled residents. The facility census was 67 residents. Record review of Missouri Certified Nursing Assistant (CNA) Manual Nursing Assistant in Long term Care Facility Student Reference, Revised 2010 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were detailed for a colostomy (ostomy, an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen stoma) care to include the type of appliances, skin barriers and skin care; to obtain physician orders for self-care of colostomy; to complete a self-care assessment for the residents ability to perform own care; and to document a detailed skin assessment of the colostomy site for one sampled resident (Resident #1) out of 17 sampled residents. The facility census of 67 residents. The facility colostomy care policy was requested and was not received at the time of exit. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's dietary orders were transcribed to the Medication Administration Record (MAR) monthly, to ensure physician's dietary supplement orders were followed, and to ensure dietary interventions were being monitored and documented to prevent gradual weight loss that became significant for one sampled resident (Resident #42) out of 17 sampled residents. The facility census was 67 residents. Record review of the Facility's Nutrition/Unplanned Weight Loss policy and procedure dated 9/2012, showed the facility will monitor and document the weight and dietary intake of the residents which permits readily available comparisons over time. The threshold for significant unplanned weight loss/undesired weight loss included a 10 percent weight loss within six months was considered significant. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were complete for the resident's tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store the oxygen nasal cannula/tubing (used to deliver oxygen through the resident's nose) and nebulizer mask/tubing (used for aerosol breathing treatments) in a manner to prevent the spread of infection for two sampled residents (Resident #70 and #40) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's policy titled Oxygen Administration dated October 2010 showed facility staff were to document in the resident's electronic chart when tubing was changed. Record review of the facility's policy titled Administering Medications through a Small Volume Nebulizer dated October 2010 showed: -Facility staff were to store the nebulizer mask and tubing in a plastic bag with the resident's name and the date the mask/tubing was opened. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and transcribe detailed physician orders for dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) care and monitoring of dialysis line (port) or dialysis shunt monitoring and care; to obtain diet order, transcribe and follow-up on recommended dialysis nutrition orders; to document ongoing observations and monitoring for the resident before, and after dialysis treatments; and to provide ongoing management of nutritional and fluid intake including documentation of weights, resident compliance with food and fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered for one sampled resident (Resident #1) out of 17 sampled residents. [...]