Heritage Wellness & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to prevent psychosocial abuse for two sampled residents (Residents #2 and #3) out of 12 sampled residents. On 4/15/16 Resident #1 was rubbing his/her hands on Resident #2's arm, shoulder and knee. On 5/5/26 Resident #1 touched Resident 2 on the breast and inner thigh. On 5/11/26 Resident #1 kissed Resident #3, resulting in Resident #3 crying. The facility census was 63 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to self-report two instances of possible abuse of two sampled residents (Residents #2 and #3) out of 12 sampled residents. On 4/15/16 Resident #1 was rubbing his/her hands on Resident #2's arm, shoulder and knee. On 5/9/26 Resident #1 touched Resident #3's on the breast/upper chest area. The facility census was 63 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate two instances of possible abuse for two residents (Residents #2 and #3) out of 12 sampled residents. On 4/15/16 Resident #1 was rubbing his/her hands on Resident #2 arm, shoulder and knee. On 5/9/26 Resident #1 touched Resident #3's on the breast/upper chest area. The facility census was 63 residents. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for four of four sampled expired residents (Resident #2, #3, #4 and #5). The facility continued to receive Social Security money and withdraw room and board for two residents (Resident #3 and #5) after they expired. The facility failed to provide a final accounting of resident fund balances or refund Social Security money. The facility census was 50.1. Review of the facility maintained discharged and expired report titled Action Summary for the period [DATE] through [DATE], showed Resident #3 expired on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect three sampled residents (Resident #1, #6, and #9) from misappropriation of property out of nine sampled residents. The facility census was 48 residents. A facility policy for Theft and Misappropriation of Resident Property was requested and not provided. A facility policy for Controlled Substances was requested and not provided. A facility policy for Discarding and Destroying Medication was requested and not provided. A facility policy for Medication Administration and Documentation was requested and not provided. 1. Review of Resident #1's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE] with a diagnosis of chronic pain. Review of the resident's Brief Interview for Mental Status (BIMS) dated 7/15/25 showed the resident was moderately impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately account for narcotic medication reconciliation for three sampled residents (Resident #1. #6 and #9) out of nine sampled residents. The facility census was 48 residents. A facility policy for Medication Administration and Documentation was requested and not provided. 1. Review of Resident #1's admission Record showed the resident admitted to the facility on [DATE] and was re admitted to the facility on [DATE], with a diagnosis of chronic pain. Review of the resident's Brief Interview for Mental Status (BIMS) dated 7/15/25 showed the resident was moderately impaired. Review of the resident's Physicians Order Sheet (POS) dated 7/1/25-12/19/25 showed:-Percocet (Oxycodone w/Acetaminophen- Opioid, narcotic analgesic) Oral Tablet 5-325 Milligram (MG). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to meet the needs of a resident on hospice (end of life care) for one sampled resident (Resident #29) out of five sampled residents. The facility census was 55 residents. Review of the facility's Hospice Program Policy dated 2001, revised 7/2017 showed: -Hospice services are available to residents at the end of life. -It was the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: --Determining the appropriate plan of care. --Changing the level of services provided when it was deemed appropriate. --Providing medical direction, nursing and clinical management of the terminal illness. --Providing medications necessary for the palliation of pain and symptoms. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow facility policy for using mechanical lifts for one sampled resident, (Resident #24) out of five sampled residents. Facility staff failed to inspect the lift sling for safety on 5/10/25. During a transfer, the sling strap broke and the resident fell to the floor. The resident hit his/her head on his/her recliner causing two bumps on the back of his/her head. The facility census was 55 residents. Review of the facility's Safety Precautions, Lifting Policy dated 2001, revised on 12/2009 showed: -All personal shall follow safety precautions established by the facility when lifting of handling heavy objects. -When lifting or moving residents, makes sure that equipment is secure (wheelchair, beds, stretcher, etc.) -If there are mechanical devices available to assist in moving residents more safely, use them. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy and procedure and investigate an injury of unknown origin of a fractured (broken) arm for one sampled resident (Resident #35); and failed to investigate the cause of skin tears and bruises for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. The Administrator was notified on 2/14/25 at 9:00 P.M. of the Immediate Jeopardy (IJ) which began on 1/3/25. The IJ was removed on 2/18/25, as confirmed by surveyor onsite verification. Review of the facility policy titled: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed: -Residents had the right to be free from abuse, neglect, misappropriation of property and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week. This had the potential to affect all residents of the facility. The facility census was 55 residents. Review of the facility's Staffing, Sufficient and Competent Nursing policy, dated as revised August 2022, showed: -Licensed nurses and Certified Nursing Assistants (CNA) were available 24 hours a day, seven days a week to provide competent resident care services. -A RN provides services at least eight consecutive hours every 24 hours, seven days a week. -RNs may be scheduled more than eight hours depending on the acuity needs of the resident. 1. Review of the Facility Assessment, dated 1/16/25, showed: -The facility was licensed for 118 residents. -Current full-time staff was 41. -Part-time staff was 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to address areas of needed improvement by not developing and implementing Performance Improvement Plans (PIP - a process designed to help facilities address and fix deficiencies) which could affect all facility areas including residents quality of life. The facility census was 55 residents. Review of the facility's Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program - Governance and Leadership Policy, dated March 2020, showed: -The QAPI program was overseen and implemented by the QAPI committee and reported findings, actions and results to the administrator and governing body. -The Administrator was ultimately responsible for the QAPI program and for interpreting results, and findings to the governing body. -The QAPI committee was responsible for: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written procedures for its Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program which led to the inability to gather feedback for quality improvement. This practice had the ability to affect all residents. The facility census was 55 residents. Review of the facility's QAPI Program - Governance and Leadership policy, dated March 2020, showed: -The Administrator was ultimately responsible for the QAPI program. -The QAPI program was based on data, resident and staff input, and other information that measured performance. -The QAPI program focused on problems and opportunities that reflected processes, functions, and services provided by the residents. -The responsibilities of the QAPI committee were to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five sampled residents (Resident #3, #9, #30, #39, and #37) who should have been on Enhanced Barrier Precautions (EBP), a set of infection control measures that used personal protective equipment (PPE- specialized clothing or gear worn to protect the wearer from injury, infection, or illness) to reduce the spread of multidrug-resistant organism (MDRO - bacteria or microorganisms that have become resistant to multiple antibiotics) for residents who had wounds or indwelling medical devices. [...]

Inspectors wroteBased on interview and record review, the facility failed to have anyone in the position, or performing the tasks and responsibilities of the Infection Preventionist. The facility census was 55 residents. Review of the facility's policy ,Infection Preventionist, dated September 2022 showed: -The Infection Preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program. -The Infection Preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners. -The Infection Preventionist has obtained specialized training beyond initial professional training or education prior to assuming the role including antibiotic stewardship. -The Infection Preventionist was employed on site and at least part time. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain authorization forms for three sampled residents (Residents #5, #2, and #39) out of four residents sampled for the resident trust review. The facility census was 55 residents. Review of the facility's policy entitled Resident Trust Policy and Procedures, dated March 2023, showed: -Purpose: Baptist Homes and Healthcare Ministries need to be good stewards of the money entrusted to us by our residents and their families. -This policy and procedures document outlines a general guide and specific steps on how to handle resident trust funds across the organization. -General Information regarding responsibilities of holding Resident Funds: --Personal Funds of the resident shall be used exclusively for the resident, which must be authorized in writing. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain records of reconciled (a process that takes place when the deposits, credits and interest that are on record but were not accounted for on the final bank statement; are added to the final amount on the bank statement, then checks and charges that are on record, but were not listed on the bank account statement, are subtracted from the adjusted final amount) banks statements dated January 2024 to September 2024; failed to maintain the monthly ending petty cash (small amount of discretionary funds in the form of cash used for small cash disbursements) amounts from January 2024 to December 2024; failed to maintain signatures or receipts of withdrawals from one sampled resident's (Resident #5's) account; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) (SNF/ABN-form Centers for Medicare and Medicaid Services (CMS)-10055) was provided to the resident or their representative for three sampled residents (Residents #41, #43, and #56) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 55 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling vent in the dining room free of a heavy buildup of dust; failed to maintain the 80 Hall free of a persistent urine odor; failed to ensure the hot water in resident rooms 86, 84, 82 was at or above 105 ºF (degrees Fahrenheit); failed to ensure there was not a buildup of dust and debris on the floor in resident rooms [ROOM NUMBERS]; failed to prevent a heavy buildup of dust in the ceiling vents in 50 Hall Shower Room A, 20 Hall Shower Room A, and in the restroom of resident room [ROOM NUMBER]. This practice potentially affected at least 40 residents who resided in, or used those areas in the facility. The facility census was 55 residents. 1. Observation on 1/28/25 at 11:45 A.M., with the Maintenance Director showed a heavy buildup of dust in the ceiling vent in the dining room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the resident's status on Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessments for three sampled residents (Resident #9, #40, and #3) out of 14 sampled residents. The facility census was 55 residents. Review of the facility MDS 3.0 Process policy, dated 1/1/24, showed: -The facility should complete an accurate MDS. -The MDS should be signed by everyone completing any portions of the assessment to certify the accuracy of the portion of the assessment he/she completed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans for four sampled residents (Resident #15, #28, #39, and #9) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated March 2022, showed: -A comprehensive care plan was developed for each resident. -The care plan was developed within seven days of the completion of the resident's required Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and no more than 21 days after admission. -Assessments of residents were ongoing and care plans were reviewed and revised as information about the resident and resident's conditions change. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain personal hygiene by not helping residents complete Activities of Daily Living (ADL), bathing/showering, causing poor hygiene and physical discomfort for six sampled dependent residents (Resident #12, #44, #109, #3, #39, and #50) out of 14 sampled residents. The facility census was 55 residents. A policy regarding ADLs was requested but not provided. Review of the facility's Bath, Shower/Tub policy, undated, showed: -The purpose of the policy was to provide a step-by-step procedure that promoted cleanliness, provided comfort to the resident and to observe the condition of the resident's skin -Document the date and time the shower/tub bath was performed with the name, title of the individual who assisted the resident. -Document all assessment data regarding skin condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional when the staff person identified as the Life Enrichment Coordinator reported he/she did not complete the state approved training course. The facility census was 55 residents. An Activities policy was requested and not received. 1. During an interview on 1/28/25 at 1:22 P.M., the Life Enrichment Coordinator said: -He/She did not complete the state approved training course. -He/She started it but with the changes in facility Administration it just didn't get done. -The previous Administrator was going to help pay for the course, but it was not paid for before he/she left the facility. During an interview on 1/28/25 at 1:42 P.M., the Human Resources (HR) Director said: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and document weekly wound assessments that described the type and characteristics of the resident's coccyx wound (documented as non pressure) and face wound on the cheek, failed to complete wound treatments as ordered, failed to have a system in place to review the progress of wounds, and failed to keep the resident's cheek, neck, and chest free of dried drainage from the resident's facial wound for one sampled resident (Resident #9), and failed to ensure a follow-up surgical appointment was made per discharge orders to remove surgical staples for one sampled resident (Resident #29) out of 14 sampled residents. The facility census was 55 residents. Review of the facility wound care policy, dated 1/1/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen and nebulizer equipment was stored in a sanitary condition for two sampled residents (Resident #40 and #3) and one supplemental resident (Resident #51) out of 14 sampled residents and one supplemental resident. The facility census was 55 residents. Review of the facility's policy titled Oxygen Administration, dated as revised 6/8/23, showed: -Tubing and nasal cannula (tube in the nose) should be placed in a baggies when not in use. -Replace tubing and nasal cannula if they are on the floor. -The tubing and cannula should be changed weekly every Sunday night. 1. Review of Resident #40's care plan, dated 4/22/24, showed: -The resident had altered respiratory status with shortness of breath. -The resident was on hospice (end of life care). [...]

Inspectors wroteBased on interview and record review, the facility administrative staff failed to plan for and provide a sufficient number of nursing staff over a 48-hour period to relieve overworked staff that stayed on shift and worked over during a winter storm which caused the working nursing staff to not feel safe in administering routine medications to seven sampled residents (Residents #8, #2, #9, #40, #29, #35, and #50) out of seven sampled residents for medications administration. The facility census was 55 residents. Review of the facility's staffing, sufficient and competent nursing policy, dated revised August 2022, showed: -Licensed nurses and certified nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including: --Assuring resident safety. [...]

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information, which included the facility census, the total number of each staff and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view at each nursing station. The facility census was 55 residents. A copy of the facility policy regarding posting of nursing staff type, hours worked by each discipline, and facility census was requested and not received at the time of exit. 1. Observation on 1/22/25 at 2:17 P.M., showed a staffing sheet was posted at the far right of the reception desk, but was not visible to residents or visitors who did not stop at the desk. During an interview on 1/22/25 at 2:17 P.M., the receptionist said: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain hot meal items on room trays at or close to 120 ºF (degrees Fahrenheit) for five sampled residents (Resident #11, #159, #4, #19, and #109) out of 10 residents who received room trays. The facility census was 55 residents. Review of the facility policy titled The dining experience, staff roles dated 2020 showed: -The Dietary Services Manager or designee would be present in the dining room for all meals to ensure that the meals served: --Were palatable. --Were served at the appropriate temperatures. 1. Review of the resident council minutes, dated January 2025, showed the residents mentioned the food was cold and the food was not good. During an interview on 1/31/25 at 12:21 P.M., the Life Enrichment Coordinator said: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an Antibiotic Stewardship program and a system to monitor antibiotic usage. The facility census was 55 residents. Review of the facility's policy ,Infection Preventionist, dated September 2022 showed: -The Infection Preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program; -The Infection Preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners; -The Infection Preventionist has obtained specialized training beyond initial professional training or education prior to assuming the role including antibiotic stewardship; -The Infection Preventionist was employed on site and at least part time. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) and influenza (flu - an infection of the respiratory system: nose, throat and lungs) vaccines for four sampled residents (Resident #44, #109, #2, and #9) out of five residents sampled for immunizations. The facility census was 55 residents. Review of the facility's Influenza Vaccine policy, dated March 2022, showed: -All residents who have no medical contraindications to the vaccine were offered the flu vaccine annually. -The facility provided information about the significant risks and benefits of vaccines to residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide COVID-19 (a highly contagious respiratory disease caused by a new coronavirus that emerged in December 2019) vaccines for three sampled residents (Residents #2, #9, and #109) out of five residents sampled for immunizations. The facility census was 55 residents. Review of the facility policy titled Coronavirus Disease - Vaccination of Residents dated as revised June 2022 showed: -Residents who were eligible to receive the COVID-19 vaccine were strongly encouraged to do so. -The resident or resident representative could accept or refuse a COVID-19 vaccine and to change his/her decision. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Automated External Defibrillator (AED a portable device that can be used to treat a person whose heart has suddenly stopped working by delivering an electrical shock) was in working condition. The facility census was 55 residents. Review of the facility's policy, Cardiopulmonary Resuscitation, dated February 2018 showed: -Early delivery of a shock with a defibrillator within three to five minutes of collapse can further increase chances of survival. -Maintain equipment and supplies necessary in the facility at all times. Review of the facility's policy, In House Maintenance for Defibrillators - AED dated [DATE] showed: -Maintenance should have been done monthly. -Verify electrodes (pad that delivers a shock) were connected to the AED and sealed in their package. -Replace if pads were expired. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a consistent code status (a medical directive that specifies the type of resuscitation and medical interventions a patient wishes to receive in the event of a cardiac or respiratory arrest) in the resident's medical record for one sampled resident, (Resident #54); and did not have a code status listed in the electronic health record for one sampled resident (Resident #209) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Code Status Designation policy, dated [DATE], showed: -A code status would have been identified and supported by a physician's order to facilitate providing emergency care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's family for one sampled resident (Resident #35) of a change in condition out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Accidents and Incidents-Investigating and reporting policy, dated revised July 2017, showed: -All accidents or incidents involving residents shall be investigated and reported to the administrator. -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The following data, as applicable, shall be included on the report of incident/accident form: --The date and time the accident or incident took place. --The nature of the injury/illness (e.g., bruise, fall, nausea, etc.). --The circumstances surrounding the accident or incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin timely to the physician as per policy and to the State Agency for one sampled resident (Resident #35) out of 14 sampled residents. The facility census was 55 residents. Review of the facility policy titled: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed: -Investigate and report any allegations within time frames required by federal requirements. Review of the facility policy titled: Recognizing signs and symptoms of abuse/neglect dated April 2021 showed: -All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing (DON). -The following are signs and symptoms of abuse/neglect that should be promptly reported. --Injuries that are non-accidental or unexplained. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the discharge notification for one sampled resident (Resident #29) out of 14 sampled residents. The facility census was 55 residents. A copy of the facility's Ombudsman notification policy was requested and none was provided. 1. Review of Resident #29's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic Kidney Disease, stage 3A (CKD- is a condition characterized by a moderate loss of kidney function over time) 1/16/24. -Chronic Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should) 1/5/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of the facility's bed-hold policy before transferring or discharging the resident to the hospital for one sampled resident (Resident #29) out of 14 sampled residents. The facility census was 55 residents. 1. Review of Resident #29's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic Kidney Disease, stage 3A (CKD- is a condition characterized by a moderate loss of kidney function over time) 1/16/24. -Chronic Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should) 1/5/24. -Fracture of base of neck of unspecified femur (fracture at the top of the femur [thigh bone] near the hip joint with the exact location not specified) 11/14/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to create a baseline care plan within 48 hours of admission for one sampled resident (Resident #209) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Baseline policy, dated March 2022, showed: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. -The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: --Initial goals based on admission orders and discussion with the resident/representative. --Physician orders. --Dietary orders. --Therapy services. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide continuity of resident care by not developing and implementing resident comprehensive care plans for one sampled resident (Resident #109) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated March 2022, showed: -A comprehensive care plan was developed for each resident. -The care plan was developed within seven days of the completion of the resident's required Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and no more that 21 days after admission. -Each resident and/or their representative had the right to participate in care plan development. -Each care plan included: --Measurable objectives and time frames. --Description of services to be provided. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were changed and transcribed correctly when the physician agreed with the pharmacists review for changes for two sampled residents (Resident #40 and #29 ) out of 14 sampled residents. The facility census was 55 residents. 1. Review of Resident #40's Medication Regimen Review (MRR) by the pharmacist, dated 12/2/24, showed: -The resident had an order for Fluticasone 110 microgram (mcg) inhaler one puff every six hours as needed for shortness of breath. -The pharmacist documented that Fluticasone was not a rescue medication to be used as needed and that having it scheduled would decrease the inflammation and help with breathing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the interests as well as the physical, mental, and psychosocial well-being for one sampled resident (Residents #109) out of 14 sampled residents. The facility census was 55 residents. A policy regarding resident activities was requested and not received. 1. Review of Resident #109's face sheet, undated, showed the resident was admitted to the facility 12/31/21 with the following diagnoses: -Muscle weakness. -Morbid (severely overweight) obesity. -Heart failure. Review of the facility activity log dated October 2024 showed: -On 10/8/24, 10/9/24, 10/16/24,10/17/24, 10/22/24, 10/23/24, 10/24/24,10/25/24, 10/28/24, and 10/31/24 the resident did not attend activities. Review of the facility activity log dated November 2024 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure skin and wound assessments were completed for residents who were at high risk for and had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), failed to provide pressure ulcer treatments as prescribed by the physician, and failed to provide interventions to reduce pressure ulcers for two sampled residents, (Resident #3 and #39) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Wound Care Policy, dated 1/1/24, showed: -The purpose was to identify factors that placed the residents at risk for the development of pressure ulcers and to implement appropriate interventions to prevent the development of clinically avoidable wounds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate a fall, failed to assess a resident after a fall, and failed to implement new interventions after a fall for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, dated as revised July 2017, showed: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the facility property shall be investigated and reported to the Administrator. -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The Report of Incident/Accident form shall include: --The date and time the accident or incident took place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident who had a feeding tube (a medical device inserted into the stomach to provide nutrition when a person could not eat) by not checking placement of the feeding tube or checking for residual (withdrawing stomach contents from a feeding tube to determine how much formula was left after a feeding) before administering medications and a liquid feeding; failed to ensure documentation was completed when tube feeding was administered; and failed to ensure nursing staff had received education for taking care of a resident with a feeding tube for one sampled resident (Resident #3) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Enteral Nutrition (liquid nutrition for persons who could not eat) policy, dated November 2018, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and implement interventions related to pain management for one sampled resident (Resident #9) who expressed pain during a wound care treatment out of 3 sampled residents. The facility census was 57 residents. Review of the facility's Wound Care and Pain Management Policy, dated 4/10/25, showed: -The purpose of the policy was to ensure wound care was delivered in a manner that minimized pain, promoted healing and enhanced the resident's comfort, dignity and quality of life. -All residents who received wound care had associated pain assessed, managed and documented as part of the wound care process. -Pain management was individualized, evidence-based and in accordance with the resident's care plan (a document the provides services designed to meet a resident's health or personal care needs). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely assistance was provided to two sampled residents (Residents #35 and #29) who were Medicaid pending (a person has applied for Medicaid, but had not yet been approved or denied benefits) out of four residents reviewed, in the procurement of Medicaid (a government program that provides health insurance for adults and children with limited income and resources) to assist with their expenses at the facility. The facility census was 55 residents. Review of the Medicaid Nursing Home Application- Helpful Information showed items often needed for Nursing Home Application include the following: -Bank Statements (any/all checking and Savings -Last 3 months to the current; -Life Insurance Policies (Cash Surrender Value & is the policy revocable or irrevocable -Stocks, Bonds, IRAs (Individual Retirement Accounts); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the narcotic (a class of drugs that produce insensibility or stupor due to their depressant effect of the central nervous system) medications were counted and signed by two nurses at the beginning and end of each shift, failed to ensure residents' narcotic medications were counted correctly for one supplemental resident (Resident #49), and failed to ensure narcotic medications were documented correctly when administered for one sampled resident (Resident #39) out of 15 sampled residents. The facility census was 55 residents. The facility narcotic drug count policy was requested and not received. 1. Review of The Controlled Substance Key Exchange Record, dated December 22, 2024 to December 31, 2024, with Licensed Practical Nurse (LPN) C showed: -There should have been two nurses signatures for two shifts per day. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) Pharmacy recommendations were followed and the Physician responded for two sampled residents (Residents #209, and #2) out of five residents sampled for medication review. The facility census was 55 residents. Review of the facility's Medication Regimen Reviews policy, dated as revised May 2019, showed: -The consultant pharmacist performed a MRR for every resident in the facility receiving medications. -MRR's were done upon admission and at least monthly. -Within 24 hours of the MRR, the consultant pharmacist provided a written report to the attending physicians for each resident identified as having non-life-threatening medication irregularity. -The MRR included the resident's name, the name of the medication, the identified irregularity and the pharmacist's recommendation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' medications that needed to be refrigerated were refrigerated, failed to ensure there were no loose pills in the medication cart, failed to ensure the temperature was checked daily for the medication refrigerator which stored the resident's prescribed medications, failed to ensure there was soap in the only soap dispenser in the medication room, and failed to ensure the only sink in the medication room was clean. The facility census was 55 residents. Review of the facility's Storage of Medications policy, dated November 2020, showed: -Drugs and biologicals used the the facility were to have been stored in locked compartments under proper temperature, light and humidity controls. -Only persons authorized to prepare and administer medications had access to locked medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's orders pertaining to the diet texture were correct and followed, and failed to discontinue a diet order after the resident was reassessed for a change in diet texture for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. 1. Review of Resident #30's admission Face Sheet showed the resident was admitted with the following diagnoses: -High blood pressure. -Hyperlipidemia (condition in which there are abnormally high levels of lipids (fats) in the blood). -Malignant neoplasm (an abnormal mass of tissue that forms when cells grow and divide uncontrollably. of unspecified site. Review of the resident's physician's orders, dated 5/8/24, showed a physician's order for a regular diet with a regular texture. [...]

Inspectors wroteBased on interview and record review, the facility failed to account for one sampled resident (Resident #1) funds within 30 days of the resident's death and to return the funds to the designated family members out of three sampled residents. The facility census was 55 residents. Review of the facility's Resident Trust Policy and Procedures dated 3/23 showed: -The following must be adhered to by the resident trust clerk upon the death of a resident who received aid or assistance from the Department of Social Services: -The operator shall submit in writing on form MO [PHONE NUMBER] a complete accounting of the resident remaining personal funds. This must be submitted within 30 days from the date of the resident's death; and also included on this form should be the name and address of the resident's guardian, conservator, legal representative or fiduciary of the resident's estate. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the misappropriation of one sampled resident's (Resident #1) monies when Business Office Manager (BOM) A wrote a check in the amount of $7279.74 to him/herself from the resident trust account out of three sampled residents. The facility census was 55 residents. Review of the facility's Check Signing and Management Policy dated 8/23 showed: -All checks and orders for the payment of money greater than $5000.00 must be signed by 2 approved signers as designated by board resolution. -In no case may one of the signatures be the same as the payee. Review of the facility's Resident Trust Policy and Procedures dated 3/23 showed: -The following must be adhered to by the resident trust clerk upon the death of a resident who received aid or assistance from the Department of Social Services: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a respectful and dignified manner when Certified Nursing Assistant A (CNA) forcefully pushed Resident #1 into his/her recliner out of three sampled residents. The facility census was 55 residents. On 4/22/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 4/15/24. The facility administration had all staff in-serviced on abuse and neglect, customer services, resident rights and dignity. The deficiency was corrected on 4/15/24. Review of the facility policy titled Dignity, dated 2/2001 showed: -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect for residents by honoring resident goals, choices preferences, values and beliefs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program that included tracking and trending of facility resident infections and to use proper hand hygiene between glove changes; to ensure perineal care was completed per facility policy to prevent Urinary Tract Infections(UTI) and placed soiled linen directly on floor for one sampled resident (Resident #7) out of three sampled residents. The facility census was 59 residents. 1. Review of the facilities policy Surveillance for Infections revised 9/2017 showed: -The Infection Preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 59 residents. Review of the facility's policy Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. -As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotic will undergo, review by the Infection Preventionist (IP), or designee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nursing staff had the appropriate competencies and skills sets to use a mechanical lift prior to use for two sampled residents (Resident #6 and #1) out of 16 sampled residents. This had the potential to effect any resident that required the use of a mechanical lift for transferring. The facility census was 55 residents. A copy of the facility's policy on staff training was requested and not received at time of exit. A copy of the facility's mechanical lift policy and procedure, as well as staff training policy, was requested but not received at time of exit. Review of the Food and Drug Administration's undated article titled Patient Lifts Safety Guide showed: -Staff were to receive training and practice before operating a lift. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the last three quarters which had the potential to affect all residents. The facility census was 55 residents. Review of the facility's policy, dated October 2017, titled Reporting Direct-Care Staffing Information (PBJ) showed: -As of 7/1/16, the facility was to electronically report direct care staffing and census information to the Centers for Medicare and Medicaid (CMS) through the PBJ system. -Staffing information was to be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. 1. Review of the facility's PBJ Quarter Three (2022) from 4/1/22-6/30/22 showed no data submitted for the quarter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for a COVID-19 breakout by having two supplemental residents (Resident #4 and #40) share a bathroom out of seven supplemental residents; by not performing COVID-19 tests correctly for one sampled resident (Resident #19) and two supplemental residents (Resident #33 and #8) out if 16 sampled residents and seven supplemental residents; by placing used Personal Protective Equipment (PPE) outside of COVID-19 positive resident rooms which had the potential to affect all residents; and not notifying the families of two sampled COVID-19 positive residents (Resident #30 and #12); and failed to ensure handwashing was completed to prevent cross-contamination during wound care for one sampled resident (Resident #27) out of 16 sampled residents. The facility census was 55 residents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for three sampled residents (Resident #19, Resident#6, and Resident #12) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated March 2022, titled Care Plans-Comprehensive Person-Centered showed: -A comprehensive care plan was to be developed within seven days of the completion of a significant change in status Minimum Data Set (MDS-a federally mandated tool used for care planning). -The comprehensive, person-centered care plan: --Includes measurable objectives and timeframes. --Describes he services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. --Includes the resident's stated goals upon admission and desired outcomes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing was completed per the resident's preference for three sampled residents (Resident #3 and #27) and one supplemental resident (Resident #36) who needed assistance or were dependent on staff for bathing, out of 16 sampled residents and eight supplemental residents. The facility census was 55 residents. Review of the facility's policy, dated 1/1/23, titled Safe Bathing and Showering Policy showed staff were to: -Offer each resident a shower at least twice a week. -Complete a bath sheet on every resident. 1. Review of Resident #3's face sheet showed he/she was admitted with the following diagnoses: -Major depressive disorder. -Pain. -Urinary Tract Infection (UTI). Review of the resident's care plan, last updated 11/28/22, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (an air mattress covered with tiny holes that are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) remained inflated and in working order for one sampled resident (Resident #28), who had pressure ulcers (damage to an area of the skin caused by constant pressure on the area) and to ensure the mattress settings were documented in the resident's medical record out of 16 sampled residents. The facility census was 55 residents. Review of the undated facility Low Air Loss Mattress policy and procedure showed: -A low air loss mattress will be provided for residents as ordered by the physician or indicated on the care plan. -Check low air loss mattress every 2 hours while doing care by placing hand under the resident's thighs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facemask for a Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BiPAP) (a machine that provides air at a consistent pressure level at all times (CPAP) or provides air at two different pressure levels, one for breathing in and one for breathing out (BiPap) and the mouthpiece for a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) machine were kept covered when not in use for three sampled residents (Resident #27, #12, and #1) and two supplemental residents (Resident #25 and #53); and to update respiratory care interventions in the care plan for one sampled resident (Resident #27) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated 6/8/23, titled Oxygen Administration showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a cold food (cucumber tomato salad) at or below a temperature of 41 ºF (degrees Fahrenheit) throughout the lunch meal service on 6/1/23 and to ensure the hot meal (a meatball sandwich) was served at a temperature of or close to 120 ºF when the meal was served to two sampled residents (Residents #16 and #39) who chose to eat in their rooms on 6/1/23. This practice potentially affected 54 residents who ate food from the kitchen. The facility census was 55 residents. 1. Observations on 6/1/23, showed: - At 10:01 A.M. Dietary Aide (DA) A finished slicing the cucumbers and tomatoes for the cucumber tomato salad. - At 10:05 A.M. the large bowl of cucumber/tomato salad was placed into a reach-in refrigerator. - At 11:06 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an authorization form signed by the Public Administrator (PA- a court appointed Personal Representative guardians and/or conservators for individuals who are unable to care for themselves or their property and in cases when there is no one else available to serve) for one sampled resident (Resident #2) and to have a legible authorization form for one sampled resident (Resident #1) out of four residents who were sampled for the purposes of reviewing the resident fund procedures at the facility. The facility census was 55 residents. 1. Review of Resident #2's resident fund paperwork showed: - Court Documents dated 2/8/16, from the local county circuit court, which stated the resident was appointed the Public Administrator as the guardian for the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to list transactions for May 2023 on the ledger sheet of one sampled resident (Resident #1) out of four residents sampled for the purposes of reviewing the resident fund procedures at the facility. The facility census was 55 residents. 1. Review of the Resident #1's ledger sheet printed on 6/2/23 showed: -He/she had a balance of $6,890.67 on 5/4/23. - No transactions for the month of May 2023 were listed on the ledger sheet. During an interview on 6/5/23 at 9:04 A.M., the Business Office Manager (BOM) said he/she missed entering in the resident's transactions for 5/23, by failing to take out the payment for 5/3/23 and he/she took out two payments for 5/23 and 6/23, on 6/2/23.

Inspectors wroteBased on interview and record review, the facility failed to notify one sampled resident (Resident #1) and/or the resident's responsible parties, of the resident's resident fund balances remaining above $5,101.85 (the limit which should trigger a notification) for the months of 2/23, 3/23, 4/23 and 5/23. Four residents were sampled for the purposes of reviewing the resident fund procedures at the facility. The facility census was 55 residents. 1. Review of Resident #1's ledger sheet printed on 6/2/23 showed the following balances for the following months: - On 2/28/23, the resident's fund balance was $5,153.76. - On 3/7/23, the resident's fund balance was $5,399.76. - On 4/17/23, the resident's fund balance was $5,533.97. - On 5/4/23, the resident's fund balance was $6,890.67. Further review, showed the absence of notifications that the resident was within $200 of over the limit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate assessment and monitoring for one sampled resident (Resident #42) who utilized a seatbelt when sitting in his/her wheelchair out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy titled Identifying Involuntary Seclusion and Unauthorized Restraint: dated September 2022 showed: -Physical restraint is defined is defined as any manual method, physical, or mechanical device, equipment, or material that meets all of the following criteria: --Is attached or adjacent to a resident's body. --Cannot be easily removed by the resident (in the same manner as it was applied by the staff). --Restricts the resident's freedom of movement or normal access to his/her body. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a thorough investigation of a resident's bruise of unknown origin and a left arm fracture to rule out abuse and neglect for one sampled resident (Resident #1) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated July 2017, titled Accidents and Incidents-Investigating and Reporting showed the following information was to be included in the investigation report: -The date and time the incident took place. -The nature of the injury. -The circumstances surrounding the accident or injury. -Where the accident or incident took place. -The names of witness and their account of the accident or injury. -The condition of the injured person, including their vitals (essential body functions, including heartbeat, breathing rate, temperature, and blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and/or responsible party were informed of and signed a bed hold for one sampled resident (Resident #28) out of 16 sampled residents. The facility census was 55 residents. A copy of the facility's Bed Hold policy was requested but not provided. 1. Review of Resident #28's Face sheet showed he/she was admitted on [DATE], with diagnoses including cognitive deficit, stroke, muscle wasting, urine retention, and pressure sores. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/18/22, showed the resident: -Had cognitive incapacitation and significant memory loss. -Needed extensive to total assistance with bed mobility, transfers, bathing, dressing and incontinence care and did not walk. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment when the resident had a change in condition and was admitted to hospice services (a type of health care for end of life care) for two sampled residents (Resident #19 and Resident #6) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated March 2022, titled Comprehensive Assessments showed: -Staff were to complete a comprehensive assessment in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. -Staff were to complete a Significant Change in Status Assessment when it was determined that the resident met the significant change guidelines for major decline. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for one sampled resident (Resident #9) out of 16 sampled residents. The facility census was 55 residents. A policy related to PASARR was requested and not received at the time of exit. 1. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Down syndrome (a genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21). Review of the resident's Electronic Medical Record (EMR) a PASARR or DA-124 could not be found. A copy of the PASARR was requested on 5/31/23 from the Social Services Director (SSD). During an interview on 6/1/23 at 9:23 A.M. the Business Office Manager (BOM) said: -Upon admission to the facility a PASARR was not requested for the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete thorough fall investigations per facility policy for two sampled residents (Resident #9 and #27) who had multiple falls out of 16 sampled residents. The facility census was 55 residents. Review of the facility's Fall and Fall Risk, Managing policy and procedure dated March 2018, showed: -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that hold drained urine) with bed in lowest position and placement under wheelchair for two sampled residents (Resident #2 and Resident #30) who was at risk for Urinary Tract Infections (UTI - an infection of one or more structures in the urinary system), failed to obtain an physician orders for indwelling catheter for one sampled resident (Resident #30) out of 16 sampled residents. The facility census was 55 residents. Review of the facility Indwelling Catheter Care Policy and Procedure dated 1/1/23 showed: -Keep the resident catheter bag of the floor at all times and in a dignity bag. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen reviews were completed for four sampled residents (Resident's #6, #3, #12, and #13) out of 16 sampled residents. The facility census was 55 residents. A copy of the facility's Monthly Medication Review policy was requested and not received at time of exit. 1. Review of Resident #6's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Pain. -Unspecified heart failure. -History of Urinary Tract Infection (UTI). -Major depressive disorder. -Other anxiety disorder. Record review of the monthly MMR from 6/2022 through 6/2023 showed: -No documentation of a review for July 2022. -No documentation of a review for August 2022. -No documentation of a review for September 2022. -No documentation of a review for November 2022. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's controlled substance medication that had been prescribed by a physician were dated when they were opened and failed to ensure safe secure safe storage controlled substance medication and other resident medication which were in an unlocked and open door of one medication room out two and the medication refrigerator were left unlocked with Schedule Controlled substance medication in side. The facility census was 55 residents. Review of the product insert for Ativan (an antianxiety medication) revised June 2016 showed to discard opened bottle after 90 days. Review of the Facility Policy and Procedures for Medication Administration revised on 4/2019, showed when opening a multi-dose medication container, the date opened were to be recorded on the container. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was an air gap (a vertical space usually one inch or more between the end of a drainage pipe which creates a separation between the drainage pipe and the drainage hole in the ground) between a drainage pipe from the automated dishwasher and the drainage hole in the floor of the kitchen and to ensure the gasket (a material such as rubber or a part used to make the area between two pieces of a material resist the flow of fluid such as air or water) of one refrigerator was in good repair. The facility census was 55 residents. Review of the 2015 Uniform Plumbing Code Chapter 801.2 Air Gap or Air Break Required, showed: Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed the annual tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) screening for one sampled resident (Resident #19) and three supplemental residents (Residents #10, #22, and #24) out of five residents sampled for tuberculosis screening. The facility census was 30 residents. Review of the undated facility Screening Residents for Tuberculosis policy showed: -The facility will screen all residents for TB infection and disease. -Individuals identified with active TB disease shall be isolated from other residents and ancillary staff and transported to an appropriate care facility as soon as possible. -Screening New Admissions or Readmissions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the two Automatic External Defibrillator (AED) machines (a portable electronic device that automatically diagnoses the life-threatening heart rhythms) by not ensuring the AEDs were checked monthly, by not ensuring the battery/pads pack were not expired, by not ensuring the battery/pads pack had not been opened, and by not ensuring the staff knew where the AEDs were located, for two out of two sampled AED machines. The facility census was 30 residents. Record review of the facility's undated policy, AED - Care and Use of the Automatic External Defibrillator, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff kept urinary catheter tubing (a sterile tube inserted into the urinary bladder to drain urine), drainage bag (a bag that is attached to the urinary catheter tubing) and privacy bag off (a cover to conceal the urine drainage from view) off the floor which has the potential to cause infection for two sampled residents (Resident #9 and #13) out of 13 sampled residents. The facility census was 30 residents. Catheter Care (Indwelling) guidelines dated March 2015 did not list any guidance for keeping the urinary drainage bag whether in or out of a privacy bag off of the floor. 1. Record review of Resident #9's admission Record showed he/she admitted to the facility on [DATE] with following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy Medication Regimen Reviews with the pharmacist's recommendation notes were in the resident's medical record monthly for two sampled residents (Resident #1 and #20) out of 13 sampled residents. The facility census was 30 residents. Record review of the facility's undated Medication Regimen Reviews (MRR) Policy showed: -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. -The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. -The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors, and other irregularities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly post daily staffing in a visible area for all staff, residents and visitors to see. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 30 residents. Record review of the undated daily staffing sheets showed: -The daily staffing sheet should include: --The facility census (number of residents). --The number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) on duty for each shift. 1. During an interview on 8/3/21 at 10:50 A.M. the Administrator said the daily staffing sheet was posted on the wall outside of the Director of Nursing's (DON) office, or on the board on the wall across from the nurses station. Observation on 8/3/21 at 10:53 A.M. [...]