Heisinger Bluffs Healthcare Western Campus

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered care plan to include use of compression stockings for edema for two residents (Residents #6 and #15), cleanliness and maintenance of oxygen equipment for two residents (Residents #15 and #81), and monitoring for risks of opioid administration for one resident (Resident #10) out of eight sampled residents. The facility census was 57.1. Review of the facility's policy titled Resident Centered Care Plan, dated 07/17/23, showed the facility will develop and implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and medical and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument process. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASARR) level II screen is required) as required for one resident (Resident #7) out of 16 sampled residents with a new mental health diagnosis. The facility census was 62.1. Review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, dated 09/24/24, showed a Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one staff member (Registered Nurse (RN) A) had the required documentation to work in a long term care facility in Missouri. The facility census was 63. 1. Review of the facility policy's did not contain information to direct staff in regards to verification to be eligible to work in Missouri. Review of Registered Nurse A's employee file showed a hire date of 7/3/2014 as the Director of Nursing (DON). Review of RN A employee file did not contain documentation he/she was eligible to work at the facility. Review of RN A's earning statement, dated 4/27/25 through 5/10/25, showed RN A was paid for thirty two hours regular pay. During an interview on 6/6/25 at 8:31 A.M., the interim DON said he/she was asked to step in as interim DON because RN A needed some time off. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement their grievance protocol for one resident (Resident #1) when he/she reported a missing cellular phone and staff did not document the results of the investigation for the missing cellular phone. The facility census was 59. 1. Review of the facility's Nursing Home Residents Rights policy, undated, showed staff were directed to provide prompt efforts to resolve grievances, and provide a written decision upon request. Review of the facility's Grievances Complaints, Recording and Investigating policy, undated, showed: -All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s); -The Grievance Officer/designee will record and maintain all grievance and complaints on the facility approved log; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings and failed to complete a Resident Inventory Listing for three residents (Resident #1, #2 and #3) out of three residents. The census was 59. 1. Review of the facility's Resident Personal Property policy, dated 11/2024, showe the resident is allowed to have personal belongings. Staff are directed to inventory and documented upon admission resident items and when replenished. Review of the facility's Resident Handbook policy, undated, showed the facility is not responsible for lost or missing items of any value. This includes, but is not limited to, personal effects such as jewelry, money, valuables, televisions, hearing aids, dentures, and eyeglasses. [...]

Inspectors wroteBased on observations and interviews, facility staff failed to maintain a professional standard of care when staff left medications at the dining room table and failed to ensure the resident took the medications for three residents (Resident #7, #19 and #26) of 17 residents. The facility census was 58. 1. Review of the facility's Medication Administration policy, undated, showed: -Medication will be administered by persons licensed or permitted by this state to prepare, administer and document the administration of medications; -Medications will be administered in accordance with the orders, including any required time frame; -Residents may self-administer their own medications only if the attending practitioner, in conjunction with the Interdisciplinary Care Planning team, has determined that they have the decision-making capacity to do so safely. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility staff failed to properly secure potentially hazardous chemicals and objects in three facility rooms on 100 hall and properly secure the medicine cart on 300 hall, in a manner to prevent accidents. Facility staff failed to transfer one resident (Resident #17) of three sampled residents safely in the mechanical lift. The facility census was 58. 1. Review of the facility's policies showed staff did not provide a storage of hazardous items policy. 2. Observation on 10/15/24 1:47 P.M. showed the 100 hall spa door open and unsecured and unattended. The spa contained a wound cleanser, adhesive remover and one tube of zinc oxide maximum strength cream. Observation on 10/15/24 at 2:03 P.M., showed the 100 hall laundry door open and unsecured and unattended. [...]

Inspectors wroteBased on observation, interviews, and record review facility staff failed to protect resident's private medical information by not closing the computers screens on two medication carts and one nurse desk. The facility census was 58. 1. Review of the facility's Resident Rights, dated 11/22/24, showed residents have the right to personal privacy and confidentiality of his or her personal and medical records. 2. Observation on 10/15/24 at 1:15 P.M., showed Licensed Practical Nurse (LPN) A left a medication cart on 200 hall unattended to administer medications. The computer screen on the medication cart open and visible to the public with residents medical information. During an interview on 10/15/24 at 1:30 P.M., LPN A said he/she should not have left the screen open on the computer. He/She staff are required to close the screen or lock it to protect resident's private medical information. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete cognitive assessments for one resident (Resident #1) of two sampled residents who had unwitnessed falls. Facility staff failed to complete wound assessments for one (Resident #1) of two sampled residents. The facility census was 60. 1. Review of the facility's Falls Protocol Policy, undated, showed staff are directed for a post fall to conduct an assessment of the resident to include but not limited to physical, behaviors, cognitive and functional status. Review of the facility's Pressure Ulcer and Injury Prevention and Management policy, undated, showed staff are directed to assess the pressure ulcer or injury weekly. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to notify one resident's (Resident #1) physician or representative in a timely manner of an unwitnessed fall and a room change for one resident (Resident #1). The facility census was 58. 1. Review of the facility's fall protocol policy and procedure, undated, showed facility staff are directed the physician or practitioner and the resident representative will be notified of the fall and any change of condition of the resident. Review of the facility's room change policy and procedure, undated, showed facility staff are directed to inform the resident and the resident representative with issuance of notice for a room or roommate change arrangements and will be documented in the resident's record. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to maintain the kitchen in a clean and sanitary manner, to cover kitchen trash cans when not in use, to utilize hair restraints appropriately, and to properly store open food to prevent cross contamination and outdated usage. This failure had the potential to affect all residents. The census was 53. 1. Review of the facility's daily Kitchen Cleaning List, undated, showed: - Sweep under all storage racks in dry storage; - Clean and organize freezer; - Clean seals around walk-in cooler; - Clean both ovens including the racks and doors; - Sweep under all tables and coolers; - Wipe under slicer and the shelf under slicer. Review of the facility's End of Shift Cleaning Checklist, undated, showed: - Sweep and mop kitchenette; - Wipe steam table and lids; - Wipe off all countertops; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to properly screen six new employees out of ten employee files reviewed in accordance with their policy, prior to employment to determine if any had a Federal indicator with the Nurse Aide Registry (NAR), Employee Disqualification List (EDL), the Criminal Background Check (CBC) and/or the Family Care Safety Registry (FCSR). The facility census was 53. 1. Review of the facility's Residents rights to freedom from abuse, neglect, and exploitation policy and procedure, dated 2022, showed, it is the purpose of this facility to ensure that all of the facility residents are free from abuse, neglect, misappropriation of their property, and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide written notice to a resident (Resident #68) or the resident's representative regarding the resident's transfers to the hospital. In addition, the facility staff failed to provide the resident a 30-day prior written notice of a date of discharge from the facility with the resident's appeal rights, failed to find appropriate placement for the resident, and refused to readmit the resident after a hospital stay. Further, the facility staff failed to provide written notice to residents or the residents' representatives regarding resident transfers to the hospital for three additional residents (Resident #54, #69, and #70). The facility census was 53. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store razors, an oxygen tank, personal care chemicals and alcoholic beverages. In addition, staff failed to properly propel three residents (Resident #11, #29, and #34) in wheelchairs in a manner to prevent accidents. The facility census was 53. 1. Review of the facility's policies showed the facility did not provide a policy for oxygen storage. The Occupational Safety and Health Administration (OSHA) requirement, CFR 1926.350(a)(1) 6-7 and 9, securing compressed gas cylinders , shows: (a) Transporting, moving, and storing compressed gas cylinders. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to assess for risk of bed rail entrapment, or obtain informed consent for bed rails for four residents (Resident #23, #33, #45, and #60). In addition, facility staff failed to obtain bedrail orders for one Resident (Resident #23). The facility census was 53. 1. Review of the facility's Bed Rails policy, undated, showed: This organization will take measure to develop and implement a strategy to minimize the possibility of resident entrapment and or injury while using bed rails. This will include an evaluation of the residents who have a need for or desire to use bed rails and that may have characteristics that place them at special risk for entrapment. The evaluation will also include inspection of the bed, mattress, and bed rail for risk of entrapment. A. [...]

Inspectors wroteBased on interview, and record review the facility staff failed to communicate pharmacy recommendations to the physicians for six residents (Resident #2, #6, #13, #29, #34, and #41) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 53. 1. Review of the facility's Monthly Medication Regimen Review policy, not dated, showed: -The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent and minimize adverse consequences related to medication therapy to the extent possible; -The Consultant Pharmacist will perform a Medication Regimen Review (MMR) for every resident in the facility; -Routine reviews will be done monthly; [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for three residents (Resident #18, #34, and #41). The facility census was 53. 1. Review of the facility's Gradual Dose Reduction policy, undated showed the following: -After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic medications shall be referred to as gradual dose reduction. Residents who use psychoactive drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to ensure medications were stored in a safe and effective manner for two out of three medication carts, and for one resident (Resident #18). The facility census was 53. 1. Review of the facility's Storage of Drugs and Biologicals, undated, showed staff were directed as follows: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. Observation on 7/17/23 at 11:56 A.M., showed the medication cart for the 300 hall, contained the following loose pills: -One small oval blue pill stamped with RDYL493; -One small oval white pill stamped with G4; -One small oval red pill; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for one resident (Resident #11), failed to perform appropriate incontinent care by wiping multiple times with the same area of the wipe for one resident (Resident #28), and when staff failed change and/or store oxygen tubing in a manner to prevent the spread of bacteria for three residents (Resident #7, #55 and #63). [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide one resident (Resident #68) a 30-day prior written notice of a date of discharge from the facility with the resident's appeal rights, failed to find appropriate placement for the resident, and refused to readmit the resident after a hospital stay. The facility census was 53. 1. Review of the facility's Notice of Resident Transfer or Discharge Notice Form, undated, showed: -A fill-out line of the location for the transfer/discharge; -A fill-out line of the date of the transfer/discharge; -Checkboxes of the reason for the transfer/discharge; -A paragraph stating the physician was discussed and agreed upon by the physician, the right to appeal the decision and how to obtain assistance or appeal; -A signature line for the facility representative; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekend for four residents (Resident #6, #23, #42 and #45). The facility census was 53. 1. Review of the facility's Activities Program policy, undated, showed the following: Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Individualized and group activities are provided that: -Reflect the schedules, choices, and rights of the residents; -Are offered at hours convenient to the residents, including evenings, holidays, and weekends. Review of the facility's Activity Calendar, dated July 2023, showed the following: -Saturday, 7/1/23: Ask staff about activity cart; -Sunday, 7/2/23: Weekend activity cart, Community services worship; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 53. 1. Review of the facility's Nursing Staff Posting policy, undated, showed the following: -The facility will make nurse staffing information readily available in a readable format to residents and visitors at any given time; -Nurse staffing information will be posted in a readily accessible location to residents and visitors; -Staffing information will be posted and/or updated at the beginning of each shift by the designated staff member; -Staffing information will include: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. The facility census was 53. 1. Review of the facility's Resident Census and Condition of Residents form, dated 7/17/23, showed a census of 53 and the following resident characteristics: -Indwelling or external catheter: 3; -Occasionally or frequently incontinent of bladder: 34; -Occasionally or frequently incontinent of bowel: 7; -Documented psychiatric diagnosis: 2; -Bedfast all or most of time: 2; -Behavioral healthcare needs: 5; -Pressure Ulcers: 2; -Hospice care: 8; -Mechanically altered diets: 6; -Rehabilitative services: 26; -Any psychoactive medication: 33; -Antibiotics: 9; -Pain management program: 51. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for four residents (Resident #54, #68, #69, and #70) out of four sampled residents. The facility's census was 53. 1. Review of the facility's Facility Initiated Transfer and Discharge Requirements policy, undated, showed: -When sending a resident to the Emergency Department (ED) - the medical record should include demonstration that the resident and/or resident representative was provided written copy of bed hold policy. 2. Review of Resident #54's medical record showed the following: -Moderately cognitively impaired; -discharged from the facility on 7/01/23 and readmitted to the facility on [DATE]; [...]