Gregory Ridge Health Care Center

Inspectors wroteBased on interview, and record review, the facility failed to provide a safe environment for residents, staff and the public by ensuring commercial cooking equipment was maintained in safe operating condition to reduce the chance of fire, in accordance with State of Missouri rules and federal regulations. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 96 residents with a total licensed capacity of 116 residents at the time of the investigation. The Administrator was notified on 7/8/26 of the past noncompliance which began on 7/2/26. The facility immediately completed education to ensure commercial cooking equipment was maintained and in safe operating condition for all dietary staff. The deficiency was corrected on 7/3/26. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent resident-to-resident physical abuse for four sampled residents (resident #3, #5, #10, and #11) out of seven sampled residents. On 6/10/26 Resident #6 hit Resident #5 which caused the resident to land on the floor by the elevator. Resident #6 repeatedly hit Resident #5 in the head and stomped on his/her arm. Resident #5 was sent to the hospital for evaluation and remained afraid of Resident #6. On 6/13/26 Resident #3 lunged at Resident #4 and Resident #4 hit Resident #3. Resident #4 picked up Resident #3 and slammed Resident #3 to the floor and continued to hit and kick Resident #3 in the abdomen, chest and hand. Resident #3 had bruising on his/her abdomen and left hand which caused Resident #3 to be upset and angry. On 6/19/26 Resident #11 slapped/backhanded Resident #10 on the right side of his/her face. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure proper notification to the resident's guardian for one sampled resident (Resident #2) when on 6/8/26 the resident was transferred to the hospital for behavior type issues out of eleven sampled residents. The facility census was 101 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Ombudsman with a copy of one sampled resident's (Resident #1) 30-day discharge notice at the time the notice was issued, limiting the resident's opportunity to exercise his/her appeal rights out of eleven sampled residents. The facility census was 101 residents.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two sampled residents Resident #1and Resident #9 out of 10 sampled residents. On 5/23/26 Resident #2 had pulled Resident #1's hair and hit Resident #1 in the face resulting in bruising. On 5/29/26 Resident #2 hit Resident #9 in the face resulting in a small mark to the lower lip. The facility census was 101 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure Resident #1's physical, mental, and psychosocial well-being in accordance with the resident's identified needs related to mental health care needs and substance use disorders. The facility failed to implement interventions to reduce known hazards and risks to the resident. Facility staff were aware of the resident's family's concern the resident needed a legal guardian to assist them in making health care decisions in September 2025. The facility was aware of behaviors that were escalating and becoming dangerous with the resident leaving the facility all day, taking illicit drugs and drinking alcohol. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary behavioral health care and services to attain the highest practicable physical, mental, and psychosocial well-being in accordance with the resident's identified needs related to mental health care needs and substance use disorders. The facility failed to review, collaborate with the resident's interdisciplinary team (IDT), and create a plan of care after the resident receive an updated Preadmission Screening and Resident Review (PASRR) II (Level II - an in-depth assessment of resident's serious mental illness or related condition which evaluates the need for facility services, specialized services and confirms if nursing facility care is appropriate) to aid in preventing or relieving the residents behaviors, and help maintain the resident's safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #4) safe from abuse out of 11 sampled residents when on 5/11/26 at approximately 9:55 P.M., Resident #4 was hit by another resident with his/her fist while sleeping which caused a large bruise on Resident #4's right bicep area and a cut under his/her left eye. The facility census was 103 residents. Review of the facility Abuse and Neglect Policy, dated 11/28/16 and revised on 06/12/24, showed Physical Abuse is purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal of inhumane manner. Handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide sufficient and appropriate social services to meet one resident's needs (Resident #1). The facility failed to provide or obtain services from outside entities to determine if the resident needed a legal representative or guardian to assist in making health care decisions. Family, physicians, administrative staff, and a PASRR assessment identified the need for the facility to facilitate guardianship proceedings and coordinate communication with legal and community resources, however, steps were not taken to begin the process. The facility census was 103 residents. 1. Review of Resident #1's undated care plan showed problem identified as: -He/She had depression related to schizophrenia revised on 1/20/26: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect three sampled residents (Resident #1, #5 and #8) from physical abuse out of 15 sampled residents. On 4/18/26 Resident #6 choked Resident #5 around his/her neck which left scratch marks to Resident #5's neck. On 4/22/26 Resident #7 hit Resident #8 in the face that caused bruising to Resident #8's left eye. On 4/24/26 Resident #2 hit Resident #1 in the face that caused bruising to Resident #1's left eyebrow/forehead area and nose. The facility census was 104 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were met related to the documentation of blood glucose (sugar) checks (measures the amount of sugar in blood) and insulin (a hormone produced by the pancreas that regulates blood sugar levels) for three sampled residents (Resident #10, Resident #14, and Resident #15) out of 15 sampled residents. The facility census was 104 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize the facility practices and procedures to call a Code [NAME] (behavioral health response) at the start of a verbal escalation per facility policy for one sampled resident (Resident #2) resulting on 4/24/26 Resident #2 hit Resident #1 in the face causing bruising to Resident #1's left eyebrow/forehead area and nose out of 15 sampled residents. The facility census was 104 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for three sampled residents (Resident #6, #7 and #8) out of 16 sampled residents. On [DATE] Resident #6 hit Resident #7 and he/she fell to the ground. Resident #6 hit Resident #7 two more times while he/she was on the ground. Resident #7 was sent to the hospital and received a dissolvable suture to his/her bruised lip and swelling to the forehead. On [DATE] Resident #8 was standing in the hallway when Resident #6 approached Resident #8. Resident #6 then threw multiple closed fist punches at Resident #8's face then Resident #8 hit Resident #6. Resident #8's left cheek had swelling and redness. The facility census was 105 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #9) right to maintain his/her personal property out of 16 sampled residents. The facility census was 105 residents. Review of the facility's Resident Rights policy, revised 9/21/25 showed:-Residents have the right to voice grievances without discrimination or reprisal. -Prompt efforts will be made by facility to resolve grievances residents may have, including those with respect to the behavior of other residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect three sampled residents (Resident #1, Resident #2, and Resident #9) from physical abuse out of ten sampled residents. On 3/25/26 Resident #2 punched Resident #1, Resident #1 then punched Resident #2 which resulted in bruise to Resident #1's left eye. On 3/31/26 Resident #10 picked up an ashtray, threw it across the room and hit Resident #9 on the left eye which resulted in a bruise to the left eye and a swollen left check for Resident #9. The facility census was 106 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate, necessary behavioral health services for two sampled residents (Resident #2 and Resident #10) out of 10 sampled residents to maintain the highest practicable physical, mental and psychosocial wellbeing of each resident with supervision and the use of Crisis Prevention Intervention (CPI- behavioral techniques for de-escalation). On 3/25/26, Certified Nurse Aide (CNA) A failed to implement Resident #1's care plan for behavioral interventions on the smoke deck including supervision and the use of CPI with Resident #1 and Resident #2 which resulted in a resident to resident altercation where Resident #1 received a black eye. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two sampled residents (Residents #14 and #18) were free from abuse when on 2/26/26 Resident #8 struck Resident #14 on the back of the head and on 3/1/26 Resident #17 struck Resident #18 with a chair out of 22 sampled residents. The facility census was 104 residents. Review of the facility Abuse and Neglect Policy dated 6/12/24 showed:-It is the policy of the facility to report all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with activities to meet the residents' psychosocial well-being for two sampled residents (Resident #2 and Resident #16 out of 22 sampled residents. The facility census was 104 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functional and comfortable environment for residents by not maintaining inside resident room temperatures within acceptable parameters (71 to 81 degrees [ ] Fahrenheit [F] year-round) during outdoor temperature extremes in the event of a power outage and/or HVAC (heating, ventilation, and air conditioning) failure during those extremes; failed to develop a facility-specific, comprehensive climate control system outage policy and procedure; and failed to notify the proper agencies and entities of a failure in a timely manner, in accordance with State of Missouri rules and federal regulations. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, when the facility staff did not provide ordered 1 on 1 supervision in direct line of sight per policy for one sampled resident (Resident #2) who had a known history of self-harm. On 9/19/25, the resident was able to self-harm by cutting him/herself on the left arm with scissors which resulted in a 7cm x 3-centimeter (cm) laceration. The resident was afraid because he/she could not get the bleeding to stop and the laceration required 8 sutures. The facility census was 108 residents. The Administrator was notified on 10/8/25 at 11:30 A.M. of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 9/19/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #2) out of 16 sampled residents was free from abuse; when on 10/27/25 at approximately 12:00 P.M., Resident #1 approached Resident #2 from behind and struck Resident #2 in the head and neck areas. Resident #2 was knocked to the floor from the hit when Resident #1 then kicked Resident #2 multiple times in the head and body; resulting in bruising on his/her forehead and minor swelling on the back of his/her head and neck and a small scratch on his/her left cheek. The facility census was 106 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the State Agency (SA) physical abuse for one sampled resident (Resident #2); when on 10/27/25 at approximately 12:00 P.M., Resident #1 approached Resident #2 from behind and struck him/her in the head and neck areas. Resident #2 was knocked to the floor and Resident #1 kicked him/her multiple times in the head and body out of 16 sampled residents. The facility census was 106 residents. Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Any owner, operator, employee, manager, agent or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency without fear of retaliation.-Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse-Neglect Reporting Decision Tree to assess the particular incident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #8) out of 13 sampled residents, was free from misappropriation when facility staff Certified Nursing Assistant (CNA) A attempted to purchase and iPad from Resident #8 for $50. The facility census was 107 residents. On 6/5/25 the Administrator was notified of the potential failure and immediately began an investigation. The employee was placed on suspension pending the investigation. As a result of the investigation it was determined there was an attempt to engage in commerce and the employee was terminated. Training was completed on 6/10/25 for all staff related to the buying and selling of goods between staff and residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and behavioral health services for one sampled resident (Resident #204) who had a known history of self-harm. The resident admitted to the facility on [DATE], with a history of self-harm and recommendation of intensive monitoring. The facility staff failed to consistently implement recommendations made in the resident's Pre-admission Screening and Resident Review (PASRR) assessment and the plan of care related to behavioral health services to ensure highest practicable well-being. The facility failed to ensure the interdisciplinary team reviewed, updated, and implemented individualized approaches to care after incidents of self-harm including: hitting a wall until his/her hand was swollen and greenish on 3/21/25; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain one sampled resident's (Resident #99) dignity when Receptionist A opened the resident's package without permission and then verbalized to another resident that the resident got him/her in trouble out of six sampled residents. The facility census was 115 residents. Review of the facility policy for Resident's Rights revised 7/5/23 showed: -Residents had the right to a dignified existence, self-determination and communication with access to persons and services inside and outside the facility. -The facility was to have promoted the rights of each resident. -Residents had the right to voice grievances without discrimination or reprisal. -Residents had the right to prompt communication and resolution to their grievances. Review of the facility's policy titled Dignity and Respect, revised on 6/29/23 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their facility policy by opening one sampled resident's (Resident #99 ) personal package without the resident's permission, causing the resident to be upset and angry that he/she was not allowed to open his/her own package out of six sampled residents. The facility census was 115 residents. Review of the facility policy for Resident's Rights revised 7/5/23 showed: -Residents had the right to a dignified existence, self-determination and communication with access to persons and services inside and outside the facility. -The facility was to have promoted the rights of each resident. -Residents had the right to voice grievances without discrimination or reprisal. -Residents had the right to prompt communication and resolution to their grievances. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for one sampled resident (Resident #1). The facility failed to transcribe a physician's order for Eliquis (an anti-blood clotting medication) 5 milligrams (mg) twice a day (BID) orally (PO) from the resident's hospital discharge orders on 12/31/24 and subsequently failed to administer the medication as ordered out of four sampled residents. The facility census was 112 residents. Review of the facility's Transcription of Orders/Following Physician's Order policy revised on 5/18/24 showed: -The purpose of this policy was to outline procedures in accurately transcribing physician's orders and to ensure all physician's orders were followed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely de-escalation techniques for two sampled residents (Resident #9 and #43) with known mental health diagnoses out of 16 sampled residents. The facility census was 110 residents. Review of the Facility Assessment Tool dated 10/4/24 showed: -The facility accepts residents with Psychiatric/Mood Disorders, including: --Psychosis, Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder, Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that needs interventions, Personality disorder, Schizoaffective Disorder, Explosive Disorder. -Psychosocial/Spiritual Supports include: --Building relationship with the residents and engagement in conversation. --Determine resident references and routines are; what makes a good day for the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #9) free from abuse. On 12/8/24 Certified Nursing Assistant (CNA) K kicked at Resident #9. Resident #89 grabbed Resident #9 by the neck out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Abuse and Neglect policy dated 1/5/23 showed: -Physical abuse included purposely beating, striking, or injuring a resident. It included but was not limited to hitting and kicking. -Verbal abuse included using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples included yelling at a resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were using appropriate infection control practices during wound care for three sampled residents, (Resident #19, #1 and #14), failed to ensure Enhanced Barrier Precautions (EBP-strategy to decrease transmission of infections and/or cross-contamination during high-contact care activities for residents in nursing homes that include wearing gowns, gloves and at times a face mask) were used for one sampled resident with open wounds (Resident #19), failed to have appropriate EBP signage on the doors and Personal Protective Equipment (PPE) available near the rooms for three sampled residents (Resident #19, #1 and #14), failed to ensure the medication room on the Men's Locked Unit was kept clean and hand hygiene products were available for staff, and failed to ensure staff preformed hand hygiene during [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a manner that protected it from mice, failed to date items with the date opened, failed to perform hand hygiene, failed to store kitchen items on surfaces that were easily cleanable, failed to use clean gloves, and failed to maintain the sheet pan rack in a clean manner. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility census was 111 residents. Review of the facility's policy titled Dietary-Equipment Operations, Infection Control, and Sanitation Policy dated as last reviewed on 2/2/24 showed: -Tray carts should be washed and sanitized after each meal. -The policy did not address handwashing, glove use, food storage, and storage of items on surfaces that were not easily cleanable. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for four sampled residents (Resident #108, #43, #23 #35) out of 23 sampled residents, so that the facility remained free of pests and rodents. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside in or visit the facility. The facility census was 111 residents. Review of the facility's policy titled Pest Control Program Policy dated 5/14/24 showed: -It was the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. -Effective pest control program was defined as measures to eradicate and contain common household pests including mice. 1. Review of the facility pest control invoices showed: -On 9/24/24 - one mouse caught on a trap. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity for three sampled residents (Resident ##66, #78, and #98) by entering their room without knocking out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy Dignity and Respect revised 6/29/23 showed: -The facility was to ensure every resident was treat with dignity and respect. -Every resident had the right to be treated with dignity and respect. Review of the facility's policy Resident Rights revised 7/5/23 showed: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote rights of each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent commingling (the mixing of funds belonging to one person with funds belonging to another) of resident funds with any person other than the resident by allowing negative balances in the resident trust fund account for six supplemental residents (Residents #53, #58, #79, #100, #167 and #169) sampled for resident trust funds review and failed to complete or maintain reconciliation of the resident trust fund account to the bank statements. This deficient practice had the potential to affect all residents who have a resident trust fund. The facility census was 111 residents. Review of the facility's policy titled Resident Trust dated as reviewed on 2/2/24 showed: -Resident trust fund money would be safeguarded by the facility, using complete and separate accounting principles and prevent commingling of resident funds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for residents who wished to use the facility telephone for two sampled residents (Resident #19, Resident #112) out of 23 sampled residents. This had the potential to affect all residents who used the telephone in the facility. The facility census was 111 residents. Review of the facility's policy, Resident Rights, dated 7/5/23 showed: -Residents were to have been treated with consideration, respect, and in full recognition of his/her dignity and individuality, including privacy and in care for his/her personal needs. -The resident has the right to have reasonable access to the use of a telephone where calls could have been made without being overheard. --The policy included an undated handwritten notation use of phone if want privacy - may use administrator work phone. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to open mail privately for two sampled residents, (Resident #99 and #14) out of 23 sampled residents. This potentially affected all residents who receive mail at the facility. The facility census was 111 residents. Review of the facility's policy, Resident Rights, dated 7/5/23 showed: -Residents were to have been treated with consideration, respect, and in full recognition of his/her dignity and individuality, including privacy and in care for his/her personal needs. -The resident has the right to have reasonable access to the use of a telephone where calls could have been made without being overheard. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had a safe homelike environment by not ensuring the ceiling tiles were not damaged, the floor tiles were not damaged, the ceiling did not leak, failed to ensure there was not mouse excrement on the floor, for five sampled residents, (Resident #108, #23, #25, #102, #72) and for one supplemental resident (Resident #43) out of 23 sampled residents and 12 supplemental residents. The facility failed to ensure the medication room on the Men's Locked Unit was kept clean and hand hygiene products were available for staff. The facility census was 111 residents. Policy requested and not provided by the end of survey. 1. Review of Resident #108's Face Sheet showed he/she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least every 30 days for the first 90 days and then at least every 60 days thereafter for three sampled residents (Resident #9, #108, and #107 ) out of 23 sampled residents. The facility census was 111 residents. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Impulse disorder (a psychiatric condition that makes it difficult to control actions or reactions). -Borderline intellectual functioning (below average cognitive functioning). -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff, residents and visitors had access to daily staffing by not posting staffing data in a prominent and readily accessible area for all residents to have access. The facility census was 111 residents. Review of the facility's Nurse Staffing Posting Information Policy, dated 6/26/24, showed: -The purpose of the policy was to make sure nurse staffing information was readily available in a readable format to resident's and visitors at any given time. -The nurse staffing sheet was posted daily and contained: --The facility name. --Current date. --Current resident census. --Total number and actual hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA). -The facility posted the Nurse Staffing sheet at the beginning of each shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Narcotic (a substance used to treat moderate to severe pain) medication count was correct, and failed to ensure that two nursing staff were counting the narcotics at the beginning and end of each shift. The facility census was 111 residents. Review of the facility's Administration and Accountability Policy, dated 5/14/24 showed: -All controlled substances were accounted for in the following ways: -All controlled substances obtained were recorded on the designated usage form. -Written documentation must be clearly legible with all applicable information provided. -The controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration. -The Charge nurse or other designee should have conducted a daily visual audit of the required documentaion of controlled substances. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary medications and recommendations were addressed by the physician in a timely manner for four sampled residents (Residents #9, #108 and #19 and failed to ensure a medication that was prescribed had an associated diagnosis for one sampled resident (Resident #25) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Medication Regimen Review (MRR) policy dated 6/24/24 showed: -The drug regimen review should be completed by the pharmacist at least monthly. -Facility staff shall act upon the recommendations. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Impulse disorder (a psychiatric condition that makes it difficult to control actions or reactions). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic medications for five sampled residents (Residents #9, #108, #66 #102, and #7) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs updated 5/14/24, showed: -Residents who use psychotropic drugs received gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue those drugs. -Psychotropic drugs were defined as any drug that affects the brain activities associated with mental processes and behaviors. -Psychotropic drugs included but were not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics. -Rationale for clinical contraindications may be documented in the electronic health record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly by having a roll-off dumpster and the surrounding area over-flowing of trash, equipment, and furniture. The facility census was 111 residents. The facility did not have a policy related to this deficiency. 1. Observation on 12/16/24 at 8:30 A.M., 12/17/24 at 8:30 A.M., 12/18/24 at 10:00 A.M., 12/18/24 at 11:06 A.M., 12/18/24 at 1:08 P.M., and 12/19/24 at 9:55 A.M., showed: -One dumpster with two closing lids in the facility's south-east parking lot. -A roll-off dumpster north of the other dumpster in the facility's south-east parking lot. -The roll-off dumpster: --Was 23 feet in length, 7 feet in width, and 4 feet in height. --Was completely full of about two layers of trash bags visible over the top of the dumpster. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required 12 hours of nurse aide in-service training that included the topics of dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), and Abuse, Neglect and Exploitation (ANE) for four out of five sampled Certified Nursing Assistants (CNA) (CNA A, CNA B, CNA E and CNA G) for January 2024 through December 2024. The facility census was 111 residents. Review of the facility's Nurse Aide (NA) Training Program Policy, dated 5/18/24, showed: -The purpose of the policy was to maintain appropriate and effective NA in-service training, ensuring the continue competence of nurse aides. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written invitations and hold care plan meetings to ensure resident focused person-centered care for one sampled resident (Resident #26) out of 23 sampled residents. The facility census was 111 residents. Review of policy Comprehensive Care Plans revised 10/31/24 showed: -The facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. -Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was able to purchase items his/her family and/or guardian provided money to purchase in a timely manner for one sampled resident (Resident #108) out of 23 sampled residents. The facility census was 111 residents. 1. Review of Resident #108's face sheet showed he/she was admitted to the facility on [DATE] and he/she had a guardian. Review of the resident's Progress Notes dated 11/6/24 showed: -He/She had been in the administrator's office asking if the funds to purchase a tablet and earphones had been received. -No further documentation related to the resident's funds or the status of purchasing a tablet and earphones. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/20/24 showed he/she: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy by failing to provide the resident with an up-to-date accounting of his/her trust account balance and return the resident's funds timely for one supplemental resident (Resident #168) out of three supplemental residents sampled for discharged residents. The other two residents sampled had negative balances. The facility census was 111 residents. Review of the facility's policy titled Resident Trust reviewed on 2/2/24 showed: -Upon discharge, the facility shall provide an up-to-date accounting of the resident's trust account balance. -The resident shall be issued a check for all remaining personal funds in his/her account within five days of discharge. 1. Review of Resident #168's trust statement through 9/30/24 showed a balance of $2,406.51. [...]

Inspectors wroteBased on observation, interview and record review ,the facility failed to complete a thorough investigation for an allegation of employee to resident abuse and resident to resident abuse on 12/8/24 for two sampled residents (Resident #9 and #89) out of 23 sampled resident. The facility census was 111 residents. Review of the facility's Abuse and Neglect policy dated 1/3/23 showed: -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices such as dealing with aggressive residents, and recognizing signs of burnout, frustrations, or stress that may lead to abuse. -On a regular basis, supervisors will monitor the ability of staff to meet the needs of residents and staffs understanding of individual resident care needs. Situations such as inappropriate language, insensitive handling, and impersonal care will be corrected as they occur. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a nursing facility, including the reasons for the transfer in writing for two sampled residents (Residents #116 and #115) and failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the discharge for one sampled resident, (Resident #115), out of two closed record sampled residents. The facility census was 111 residents. Review of the policy Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave revised date of 5/14/24 showed: -The transfer referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility when resident expects to return to the original facility. -Notice of Discharge or Transfer: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess the resident's dental status on the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) on one sampled resident (Resident #27) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans dated as revised on 11/6/23 showed: -The purpose of the policy was to ensure that MDS 3.0 sections were completed accurately and in a timely manner by the assigned responsible parties. -The MDS addressed the holistic person, including functional status, quality of life and individual plan of care to address and meet the needs of the individual resident. -The MDS must be kept current and up to date. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for two sampled residents (Residents #27 and #72) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy titled Comprehensive Care Plans dated as revised on 10/31/24 showed: -The facility staff would develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medications that were prescribed by the physician were administered within the time frame the physician had ordered for one sampled resident (Resident #12) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy, Medication Administration Policy, dated 6/26/24 showed: -Medications were to have been administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Ensure that the six rights of medication administration were followed: -Right resident. -Right drug. -Right dosage. -Right route. -Right time. -Right documentation. -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary for one sampled resident (Resident #116) out of two sampled closed discharge record. The facility census was 111 residents. Review of the facility's policy, Resident Transfer/Discharge, Immediate Discharge and Therapeutic Leave Policy, dated 5/14/24 showed: -The purpose of the policy was to establish policy and procedure regarding the transfer/discharge of residents. -When a resident is discharged or transferred the interdisciplinary discharge summary (recapitulation) must be completed in Point Click Care. -When a resident is transferred or discharged , the resident's attending physician must document in the medical record with the reason for the transfer/discharge. 1. Review of Resident #116's admission Record showed: -The resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a communication device for one sampled resident, (Resident #66) to improve the ability to carry out activities of daily living related to communication out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Activities of Daily Living (ADL) policy revised 5/18/24 showed: -The facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. --Care and services would be provided for the following activities of daily living: ---Using speech, language, or other functional communication systems. -Tips for improving or maintaining ADL skills. -Evaluating reason for decline in ADL skills. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #51) was seen by a Dermatologist out of 23 sampled residents. The facility census was 111 residents. Policy requested from the facility and was not provided. 1. Review of Resident #51's admission Record showed: -He/She was admitted to the facility on [DATE]. -He/She had a guardian. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] showed: -He/She was moderately cognitively impaired. -Other skin problems was not checked. Observation and interview of the resident on 12/17/24 at 10:25 A.M. showed: -He/She had a golfball sized cyst on the left side of his/her face. -The cyst bothers him/her and should have been taken care of months ago. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly skin and/or wound assessments were completed each week for one sampled resident (Resident #21) out of 23 sampled residents. The facility census was 111 residents. A policy for skin and wound assessments was requested but not received at the time of exit. 1. Review of Resident #21's Face Sheet showed he/she had a diagnosis of a left heel Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) with a diagnosis onset date of 9/30/24. The resident also had a diagnosis of diabetes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment such as oxygen tubing, Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle) were cleaned and stored in a sanitary condition for two sampled residents, (Resident #72 and #27) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy, Oxygen Administration, dated 5/18/24 showed: -The facility was to follow the manufacturer recommendations for the frequency of cleaning oxygen equipment and filters. -Change oxygen tubing and mask, cannula (a medical device that provides supplemental oxygen to patients through two prongs that fit into the nostrils) weekly and as needed if it becomes soiled or contaminated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of abnormal laboratory values for one sampled resident, (Resident #19) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy, Diagnostic Testing Services Policy, dated 6/26/24 showed: -The facility would provide the appropriate diagnostic tests in accordance with the physician's orders. -Qualified nursing personnel would have received and reviewed the diagnostic test reports and communicated the results to the ordering physician within 24 hours of receipt unless the report results fall outside of clinical reference ranges and required immediate attention at which time the physician would have been notified upon receipt. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine and/or emergency dental services to meet the needs of residents were offered to two sampled residents, (Residents #26 and #98), out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy Dental Services dated 6/26/24 showed: -It is the policy of the facility to assist residents in obtaining routine and emergency dental care. -Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, minor partial or full denture adjustments, and limited prosthodontic procedures such as taking impressions for dentures and fitting dentures. -Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. [...]

Inspectors wrote2. Review of Resident #201's admission record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Anxiety Disorder, 12/10/24. -Restlessness (a feeling of unease, or an inability to stay still) and Agitation (the state of anxiety or nervous excitement) 12/10/24. -Unspecified Intellectual disabilities (significant limitations in reasoning, learning, problem solving and also adaptive behavior which covers a range of everyday social and practical skills) 12/10/24. Review of the resident's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact. -Had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing,) occurred one to three days in the seven-day look back. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #9) out of seven sampled residents, was free from abuse when on 8/6/24 Licensed Practical Nurse (LPN) G was verbally and physically abusive. LPN G called the resident names, pulled the resident's hair and kicked the resident while the resident was laying on a mattress on the floor which resulted in a contusion to the resident's right hip and pain to his/her left knee. The resident was heard yelling and crying during the altercation and needed an injection to calm his/her agitation after the incident. Multiple staff witnessed the altercation and did not intervene. The facility census was 109 residents. The Administrator was notified on 8/29/24 at 11:29 A.M. of an Immediate Jeopardy (IJ) which began on 8/6/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to appropriately de-escalate one sampled resident with known triggers and mental health needs (Resident #9). On 8/6/24, the resident displayed behaviors of agitation, yelling, throwing items, kicking, hitting the wall, nightstand and mattress. Staff failed to provide calm redirection; decrease stimulation; use a firm and calm approach; and avoid getting into a power struggle with the resident. Staff argued with the resident, became defensive, called the resident derogatory names, and failed to respect his/her personal space. Staff failed to utilize de-escalation techniques appropriately and to involve the interdisciplinary team and guardian per the resident's care plan. The resident was not encouraged to express emotions in a safe environment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #29's belongings were sent to the resident's current facility after discharging from the facility on 2/8/24. This affected one out of 34 sampled residents. The facility census was 109 residents. Review of the facility's policy, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 5/14/24, showed: -Transfer and Discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. -Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility was not expected. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #9) was free from abuse. On 7/12/24 a Certified Nursing Assistant (CNA) E pushed the resident into a corner and pinned him/her so he/she could not move out of 26 sampled residents. The facility census was 109 residents. On 7/24/24, the facility Administration was notified of the past noncompliance which occurred on 7/12/24. Facility staff were educated on abuse and neglect protocols and customer service. The deficiency was corrected on 7/14/24. Review of the facility's Abuse and Neglect Policy, reviewed and revised on 6/12/24, showed: -Abuse was defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for two sampled resident (Resident #12 and Resident #13) out of 26 sampled residents. The facility census was 109 residents. Review of the facility's Medication Administration dated 4/6/17, revised on 6/26/24 and Reordering policy dated 5/18/24 showed: -Medications are to be given per doctor's orders. -All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications. -The nurse or Certified Medication Technician (CMT) will check each medication to the MAR noting the correct name of the medication, correct resident name, correct dose, correct time, and correct route of administration. -Report and document any adverse side effects or if the medication is refused. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep one sampled resident (Resident #5) free from physical abuse when on 6/26/24 the facility Dietary Manager (DM) hit the resident in the head out of 9 sampled residents. The facility census was 110 residents. On 6/27/24, the facility Administration was notified of the past noncompliance which occurred on 6/26/24. Facility staff were educated on abuse and neglect protocols and customer service. The deficiency was corrected on 6/26/24. Review of the facility policy titled, Behavioral Emergency Policy, revised 1/5/23 showed: - Provide safe treatment and humane care to the resident in a behavioral crisis to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was appropriate documentation in the medical record for one sampled resident (Resident #2) related to his/her transfer and discharge out of seven sampled residents. The facility census was 108 residents. 1. Review of Resident #2's Pre admission Screening and Resident Review (PASRR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 10/22/21, showed: -The resident was evaluated for placement in a long term care nursing facility. -Public Administrator was the resident's legal guardian. -The resident had psychiatric symptoms of delusions, hallucinations, paranoia, disorganized thoughts, agitation, irritability and was uncooperative with cares. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #2) or his/her guardian received a notice of the bed hold policy out of 7 sampled residents. The facility census was 108 residents. Review of the facility Bed Hold policy and procedure dated 7/27/2018, showed: -When a resident is admitted to the facility, they receive a copy of the bed hold policy. -When a resident is discharged to the hospital or goes on therapeutic leave, the facility will provide to the resident or legal representative, a copy of the bed hold policy. -Following a hospitalization or therapeutic leave, the resident will be admitted if they require the services of the facility and is eligible for Medicare or Medicaid services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #23) was free from physical abuse from facility staff and other residents out of six sampled residents, when on 4/14/24 11:00 A.M. Housekeeper B used physical force to take the resident from his/her feet to the ground. While on his/her back, Resident #16 ran up the hall and kicked three times at Resident #23 with no staff intervention and then grabbed Resident #23's right arm. CNA D, Dietary Aide A, and Housekeeper B drug the resident across the hallway, flipped the resident over and had the resident's arms outstretched with Housekeeper B on the right arm, CNA A had the resident's left arm, Dietary Aide A had his/her knee on the resident's lower back buttocks area with the resident on his/her stomach. LPN A and CMT A watched the entire events and did not intervene. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility staff had the competencies and skills to assure resident safety for one sampled resident (Resident's #23), when on 4/14/24 at about 11:00 A.M., Housekeeper B failed to utilize non-physical crisis intervention and de-escalation techniques in accordance with facility policy, resulting in physical abuse and psychosocial harm to the resident. About 12:20 P.M., Hall Monitor C made derogatory statements to the resident, based on their behavioral health symptoms and engaged in a physical altercation with the resident against facility policies and training for a behavioral intervention resulting in abuse of the resident. Six residents were sampled for review. The facility census was 109 residents. Review of the facility policy titled, Behavioral Emergency, dated 1/5/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to report physical abuse for one sampled resident (Resident #23). Facility staff Housekeeper B, Hall Monitor C, Certified Nursing Assistant Aide (CNA) D, Dietary Aide A, Licensed Practical Nurse (LPN) A and Certified Medication Technician (CMT) A watched the abuse and did not make a report. The facility census was 109 residents. On 4/23/24, the facility Administration was notified of the past noncompliance which occurred on 4/14/24. Facility staff were educated on Elder Justice Reporting Requirements. The deficiency was corrected on 4/15/24. Review of the facility's policy titled Abuse and Neglect Policy dated 1/5/23 showed: -Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane way. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #1, #17 and #22) were free from abuse, out of 26 sampled residents. On 2/24/24, Resident #2 pushed staff aside and pulled Resident #1 from his/her chair to the floor. Resident #2 struck Resident #1 in the face and on the head multiple times. Resident #2 then stomped on Resident #1's head. Resident #1 sustained a bump and discolored area on his/her forehead. Resident #2's physical and aggressive behavior resulted in six sampled residents (Resident #3, #6, #9, #13, #4, and #15) verbalization of fear for their safety from Resident #2. Additionally, on 2/27/24, Resident #19 struck Resident #17 in his/her face resulting in Resident #17 having a bloody nose and mouth. On 4/3/24, Resident #18 wrapped his/her hand around Resident #22's neck and squeezed until staff intervention. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with an appropriate discharge plan before an immediate involuntary discharge when one sampled resident (Resident #2) was transferred to the hospital and not allowed to return to the facility out of three sampled residents. The facility census was 112 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 7/12/22, showed: -A facility-initiated transfer or discharge was a transfer or discharge which the resident objected to, which did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent abuse for three sampled residents (Resident's #19, #10 and #11). On [DATE] Resident #19 pushed Resident #20 and then punched him/her in the face, resulting in a blackened left eye. On [DATE] Resident #10 and Resident #11 hit and scratched each other resulting in bruising to Resident #11's left upper posterior arm and superficial scratches on Resident #10's face and neck out of 19 sampled residents. The facility census was 113 residents. Review of the facility policy titled, Abuse and Neglect Policy, dated [DATE] showed: -The facility was committed to protecting residents from abuse by anyone. -Physical Abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or humane manner. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately investigate a resident to resident altercation that occurred on [DATE] between two sampled residents (Resident #10 and #11) out of 19 sampled residents. The facility census was 113 residents. Review of the facility policy titled, Abuse and Neglect Policy, dated [DATE] showed: -The facility must ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury, to the State Survey Agency. -If the abuse involved alleged suspicion of a crime, it must also be reported to local law enforcement within those time frames. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and coordination for resident transfer for one sampled resident (Resident #4). On 1/3/24 at approximately 11:50 P.M., the resident returned from the hospital and there was no staff at the door to receive the resident resulting in him/her walking away unescorted from the facility out of 19 sampled residents. The facility census was 113 residents. On 1/29/24, the facility Administration was notified of the past noncompliance which occurred on 1/3/24. Facility staff were educated on elopement protocols, customer service and coordination of transfer. The deficiency was corrected on 1/5/24. Review of the facility policy titled, Elopement Protocol, dated 1/19/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility staff had the competencies and skills to assure resident safety for one sampled resident (Resident's #9) when on 1/12/24 Licensed Practical Nurse (LPN) A failed to monitor the resident closely after a behavior crisis and Hall Monitor A failed to use proper Crisis Alleviation Lessons and Methods (CALM) technique during the resident's behavioral crisis out of 19 sampled residents. The facility census was 113 residents. On 1/29/24, the facility Administration was notified of the past noncompliance which occurred on 1/12/24. Facility staff were educated on customer service, Elder Justice Reporting Requirements, Code [NAME] and CALM techniques and behavioral health interventions. The deficiency was corrected on 1/17/24. Review of the facility policy titled, Behavioral Emergency, dated 1/5/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain residential areas in a repaired, clean and in a sanitary manner, specifically in areas of toilet rooms and resident rooms, for three sampled residents (Resident's #2, #39 and #108) out of 23 sampled residents. The facility census was 111 residents. 1. Record review of Resident #108's undated admission Record showed he/she was admitted to the facility on [DATE] and was his/her own responsible party. -Had the following diagnoses: - -Hypertension (blood pressure that is higher than normal). - -Gastroesophageal Reflux Disease (GERD - a common condition in which the stomach contents move up into the esophagus toward your mouth, automatically as a reflex or burp). [...]

Inspectors wroteBased on interview and record review,the facility failed to accurately code the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) for six sampled residents (Resident's #86, #47 #2 #31, #21,and #61) out of 23 sampled residents. The facility census was 111 residents. Review of facility policy MDS 3.0, Care Assessment Summary and Individualized Care Plans revised 2/6/2021 showed: -Sections of the MDS should be completed accurately and in a timely manner by the assigned responsible parties. 1. Record review of Resident # 86' s quarterly MDS dated [DATE] showed the resident was marked yes to further evaluate for BIMS (BIMS-brief interview for mental status score) to determine his/her cognitive status and this was not completed. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the follow-through of the Pre-admission Screening and Resident Review (PASRR-a federal program implemented in 1987 to: Prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care) recommendations and to integrate the recommendations into the care plan for four sampled residents (Resident #61, #76, #54, and #55) out of 23 sampled residents. The facility census was 111 residents. 1. Record review of resident #61's PASRR dated 6/12/19 showed the resident: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for five sampled residents (Resident #86, #47, #2, #91, and #76) out of 23 sampled residents. The facility census was 111 residents. Record review of facility Policy and Procedure Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning purposes) Care Assessment Summary and Individualized Care Plans revised 2/26/21 showed: -All CAT (Care Area Assessment Triggers) must be addressed in the individualized plan of care for residents. 1. Record review of Resident #86's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's 3/24/23 quarterly MDS showed current tobacco use was not marked. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of practice related to documentation of medications administration for six sampled residents (Residents #12, #24, #61, #16, #108, and #1) out of 23 sampled residents. The facility census was 111 residents. Record review of facility policy entitled Transcription of Orders/Following Physician's Orders dated 4/6/17 last revised 7/9/21 showed: -The Unit Director/Designated Nurse would review all Medication Administration Records (MAR) and Treatment Administration Records (TAR) daily to monitor for medications that were not administered to a resident. [...]

Inspectors wroteBased on interview, and record review, the facility failed to identify, assess and provide supportive interventions for three sampled residents (Resident #61, #76, and #91), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 23 sampled residents. The facility census was 111 residents. Record review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess, monitor, document and provide treatment that includes ongoing appropriate interventions for target behaviors; to ensure supportive services were in place and to have an individualized care plan based on the resident's behaviors for three sampled residents (Resident #61, #76, and #91) out of 23 sampled residents. The facility census was 111 residents. A policy for behaviors was requested and was not received by the facility. 1. Record review of Resident #61's admission Record showed the resident: -Was admitted to the facility on [DATE]. -Had the following diagnoses: --Borderline Personality Disorder (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #108), who was his/her own legal representative, out of 23 sampled residents had his/her code status preferences accurately reflected on his/her admission Record, Code Status Care Plan, and Physician Orders to accurately reflect the resident's choice at the time of his/her admission. The facility census was 111 residents. Record review of the facility's Advanced Directives (AD - a legal document that states a person's wishes about receiving medical care if the person is no longer able to make medical decisions because of a serious illness or injury) policy/procedure, updated [DATE] showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for surgical wound care and treatment to the resident's left buttock wound, document in the resident's Treatment Administration Record (TAR) that wound treatments had been completed as ordered by the physician and document all surgical wounds on the facility weekly skin assessment for one sampled resident (Resident #2) out of 23 sampled residents. The facility census was 111 residents. Record review of the facility policy and procedure for Wound Management revised on 4/9/21 showed: -Treatments will be set up per physician's order. -Any deviance from set protocols must be approved by physician. Record review of the facility policy and procedure for Following Physician Orders revised on 7/9/21 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #21) was assessed to be able to self- care for an ileostomy (a surgical operation in which a piece of the small intestine is diverted to an artificial opening in the abdominal wall to remove body waste-feces), and to monitor the ileostomy site and to ensure that one sampled resident (Resident #2) had appropriate treatment and services for nephrostomy tube (a tube that is put in the kidney to drain urine directly from the kidney)out of 23 sampled residents. The facility census was 111 residents. A policy for nephrostomy care was requested and not received prior to exit. 1. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) had orders for cares and monitoring of the PEG tube insertion site and to document the assessment and/or cleaning of the PEG insertion site for one sampled resident (Resident #24) out of 23 sampled residents. The facility census was 111 residents. Record review of facility policy entitled G-tubes dated 11/28/17 last revised 1/19/22 showed: -Infection could occur if aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) practices were not followed. -The G-tube might become dislodged from the stomach or the skin might become irritated at the site of insertion. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor, assess, and follow physician's orders to provide adequate pain management for two sampled residents (Residents #108 and #21) out of 23 sampled residents. The facility census was 111 residents. Record review of the facility's Pain Management policy/procedure, revised 7/5/22 showed: -All residents who are receiving routine pain medication or PRN (pro re nata - as needed) pain medication on a frequent basis will have their pain evaluated and assessed prior to pain medication administration and within an hour after the medication was given to determine if the current pain medication regimen is effective to adequately manage the resident's acceptable pain level. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #21) who received dialysis services (a process of purifying the blood of a person whose kidneys are not working normally) communication between the facility and the dialysis center was documented and to ensure the dialysis catheter (an access point, meaning an entrance and exit point, for the blood during dialysis treatment) was monitored out of 23 sampled residents. The facility census was 111 residents. Record review of the facility's dialysis policy revised 3/18/23 showed: -The facility shall monitor a resident on dialysis using professional standards including: --On-going assessments and oversight before and after dialysis treatment. --On-going communication and collaboration with the dialysis facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL) form (a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to MO Health Net after the death of one supplemental resident (Resident #1000), and failed to ensure the remainder of funds was sent to four discharged supplemental residents (Resident's #1001, #1002, #1003, and #111) after they were discharged to other facilities. The facility census was 109 residents. 1. Record review of Resident #1000's face sheet printed on [DATE] showed the resident died on [DATE] with a balance of funds of $16.00. Record review of the TPL form showed the form was mailed on [DATE], 61 days after the resident's death. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure two light fixtures in the 3rd floor south dining room illuminated during the lunch meal; to maintain the headboard of two beds in resident room [ROOM NUMBER] in good condition, and to maintain the shower chair in the 2nd floor south shower room in good condition. This practice potentially affected at least 14 residents using the 3rd floor south dining room and at least 20 residents who resided on 2nd floor south. The facility census was 109 residents. 1. Observations on 6/8/21 at 12:36 P.M., showed two light fixtures in the 3rd floor south dining room, were not illuminated during the lunch meal. Observation on 6/10/21 at 1:02 P.M., showed two light fixtures in the 3rd floor south dining room, were not illuminated in a time period just after the lunch meal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the instructions of the recipe to maintain the temperature of ambrosia (a dessert made with tropical fruits, marshmallows, and at times, shredded coconut) at or below 41 degrees Fahrenheit (ºF ). This practice potentially affected at least 21 residents who ate the lunch meal in the 3rd floor South Dining room. The facility census was 109 residents. Record review of the 2021 recipe for ambrosia showed the following directions: -Chill all ingredients before preparation Maintain at 41 ºF or below. -Toss diced fruit with pineapple until bananas are coated with juice. -Drain thoroughly, add canned mandarin oranges and marshmallows. -Fold in whipped topping and sour cream. Chill overnight. Cover, label and date. -Keep chilled and maintain at a temperature of 41 ºF or below. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the window unit air conditioner outflow vent free of a heavy dust buildup; to maintain the upper nozzle of the dishwasher spray wand free of debris inside the nozzles; to maintain 10 cutting boards in an easily cleanable condition and without numerous grooves; to install a light fixture at the area where the coffee was prepared; and to maintain the coffee filter holder in good repair. This practice potentially affected at least 100 residents who ate food from the kitchen. The facility census was 109 residents. 1. Observations on 6/8/21 from 9:09 A.M. through 1:15 P.M. showed: - A heavy buildup of dust on the window air conditioner unit. - The absence of a light fixture over the area where the coffee was made and the sliced bread was toasted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the trash container located at the food preparation area, had a lid on it when it was not being used and to ensure the outdoor dumpster was closed on 6/8/21, 6/9/21, 6/10/21, and 6/11/21. The facility census was 109 residents. 1. Observations on 6/8/21 showed the following: - From 8:33 A.M., through 9:00 A.M., the trash container at the food preparation area, was uncovered. - At 9:08 A.M., Dietary [NAME] (DC) A dumped a wax paper in the trash container; no cover was placed on the trash container. - At 9:12 A.M. Dietary Aide (DA) A dumped food into trash container; no cover was placed on the trash container. - At 9:22 A.M. DC A dumped gloves and plastic bag into trash container; no cover was placed on the trash container. - At 9:28 A.M., DA A dumped the remnant of hot cereal into trash container; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling over the three compartment sink area in the kitchen without leaks; to maintain a metal bar which held a section of tile in place in the 3rd floor south dining without a sharp, jagged edge; to maintain the area under the ice machine in the 3rd floor Main Dining Room kitchenette free of debris; to maintain the area under the vending machines close to the elevators free of debris; to maintain the cabinet in the clean utility room free from a leaky drainage pipe; and to ensure that water from a leaky water pump in the boiler room was drained properly. The facility census was 109 residents. 1. Observation on 6/8/21 at 9:09 A.M., showed a leak from the ceiling over the three compartment sink in the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to take necessary measures to prevent the presence of roaches in the kitchen, the 3rd floor south dining room and a housekeeping closet; to prevent the occurrence of gnats in the kitchen and in the 2nd floor South Clean Utility room; and to prevent the presence of mouse droppings in several resident rooms and offices. This practice potentially affected at least 40 residents. The facility census was 109 residents. 1. Observations on 6/8/21, showed: - At 8:46 A.M. many gnats flew around within the dishwashing room. - At 9:16 A.M., gnats flew around within the hot water heater section of the dishwashing room. During an interview on 6/8/21 at 1:43 P.M., the Dietary Manager (DM) said the gnats were horrible. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the resident's dignity by failing to provide privacy during cares for one sampled resident (Resident #100) and to ensure the Foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid, that drains into a collection bag) bag was kept covered for two sampled residents (Resident #100 and #1) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's catheter care policy dated 2/26/21 showed catheter bags are to be placed in privacy bags to promote the resident's dignity. 1. Record review of Resident #100's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide in writing the facility's bed-hold policy to the resident and/or the resident's representative prior to transfer/discharge for one sampled resident (Resident #69) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy revised 4/29/21 showed: -Notice of Bed Hold Policy: --When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative a written copy of the bed hold policy. --This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan reflective of the resident's immediate health and safety needs for one sampled resident (Resident #109) out of 25 sampled residents. The facility census was 109 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -The resident enters the nursing home with a set of physician-based treatment orders. Nursing home staff should review these orders and begin to assess the resident and to identify potential care issues/ problems. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough discharge summary was completed to include documentation showing the recapitulation of the resident's stay at the facility, the resident's health status at discharge, and what supportive care/services he/she would need at the receiving continuing care facility. The facility also failed to ensure documentation of the disposition of the resident's medications (reconciliation) and the disposition of the resident's belongings upon discharge for one closed record resident (Resident #111) out of three sampled closed record residents. The facility census was 109 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy revised 4/29/21 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and document a fall and follow the facility policy for one sampled resident (Resident #16) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's Post Fall Protocol policy revised 2/26/21 showed: -The purpose of the policy is to ensure that all residents who had a fall had accurate assessment and follow through to prevent further injury and recurrence of falls. -A fall is defined as any event, not purposeful and not from external force, which results in a resident coming in contact with the next lower surface. -Procedure: --The Licensed Practical Nurse (LPN)/Registered Nurse (RN) on duty will perform a full head to toe assessment of the affected resident immediately when informed of a fall. --Immediate vital signs are to be taken and include: ---Temperature. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep a urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid, that drains into a collection bag) bag below the level of the bladder (causing urine to flow back into the bladder which has the potential for infections) during mechanical lift (device used to lift and move a resident from one surface to another surface) transfers for two sampled residents (Resident #38 and Resident #100) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's catheter care policy dated on 2/26/21 showed: -The facility will ensure any resident with a urinary catheter will be maintained to prevent infection. -Catheter care procedures are as follows: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain was managed for one sampled resident (Resident #67) and to ensure appropriate documentation related to the resident's pain on the Medication Administration Record (MAR) and in Nurse's Notes out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's Medication Administration and Monitoring policy revised 2/26/21 showed medications were to be given according to physician's orders. 1. Record review of Resident #67's Face Sheet showed he/she: -admitted to the facility on [DATE]. -Was his/her own responsible party. -Had diagnoses which included: --Schizophrenia (a serious mental disorder in which people interpret reality abnormally, often leading to decreased independence in daily functioning). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for a gradual dose reduction of psychotropic medications (also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of other psychotic disorders. They are also the mainstay together with mood stabilizers in the treatment of bipolar disorder) for one sampled resident (Resident #90) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's monthly drug regimen review policy dated 2/26/21 showed: -The consultant pharmacist or his agent will review the drug regimen of each resident at least monthly and report, in writing any irregularities. [...]