Hillside Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility did not follow their policy when Resident #161signed out of the facility, did not return, and the facility failed to initiate a Code Purple (missing person) per policy. The resident's guardian did not give permission for the resident to sign him/herself out. Per facility policy, when the resident failed to return to the facility for dinner and evening medications and did not return all night, staff should have initiated a Code Purple. The resident signed out at 3:55 P.M. on 05/08/26 to go outside, with no expected return time listed. Staff found the resident's wheelchair outside and could not locate the resident. Staff did not document attempts to locate the resident from 05/08/26 through 05/11/26 and did not document their communication with law enforcement. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure allegations involving abuse were reported within the required two-hour time frame, following a resident-to resident altercation, resulting in an injury (Resident #131). The sample size was 15. The census was 149. Review of the facility's Abuse and Neglect Policy, revised 6/12/2024, 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 time frames;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health care services to address one resident's (Resident #84) known history of self-harming behavior. The facility failed to develop and implement care plan interventions related to the self-injurious behaviors, failed to develop a safety plan for the resident, and to timely refer the resident to psychiatric services, resulting in self-mutilating behaviors of biting off his/her fingers when he/she became frustrated or angry. The facility also failed to address one resident's aggressive behavior and pulling the facility fire alarm multiple times. (Resident #39) The sample was 33. The census was 149. The Administrator was notified on 4/23/26 at 10:06 A.M, of an immediate jeopardy (IJ) which began on 4/21/26. The IJ was removed on 4/23/26 as confirmed by surveyor on-site verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Residents #100, #49, and #111) were free from resident-to-resident abuse. Resident #1 had a documented history of behavior problems. On 4/14/26, Resident #1 displayed changes in behavior and hit Resident #100. The altercation resulted in injuries to Resident #1's face. On 4/17/26, Resident #1 hit Resident #49 and a physical altercation later took place, resulting in Resident #1 sustaining fractured ribs and Resident #49 sustaining a fractured hand. Resident #1 also hit Resident #111 in the face with a closed fist, resulting in Resident #111 experiencing pain. The sample was 333. The census was 149. Review of the facility's Abuse and Neglect policy, reviewed 6/12/24, showed:-Abuse: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly assess and monitor two residents after resident-to-resident altercations resulted in injuries (Residents #49 and #111). Resident #49 received an x-ray to the right hand on 4/18/26 with results reported on 4/19/26. The facility failed to review the x-ray results until 4/24/26, which showed a fracture to the right hand. The facility failed to follow physician's orders for a hand splint and ice. The facility failed to initiate neuro checks for Resident #111 after being struck on the head during an altercation. Resident #111 had complaints of pain as late as 4/24/26. In addition, the facility failed to provide wound treatment for two residents (Residents #120 and #113). The sample size was 33. The census was 149. Review of the facility's Intensive Monitoring policy, reviewed 4/30/24, showed:-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective pain management regimen when the facility failed to assess, monitor, and address pain for two residents (Residents #49 and #90). Resident #49 sustained a fracture to the right hand on 4/18/26, without documentation of pain monitoring and was not offered or administered pain medication between 4/18 through 4/24/26. The facility failed to ensure Resident #90's order for oxycodone (an opioid prescribed to treat moderate to severe pain) was filled and delivered timely for six days. As a result, Residents #49 and #90 had unrelieved pain. The sample size was 33. The census was 149. Review of the facility's Pain Management policy, revised 6/26/24, included:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect by failing to ensure staff communicated with residents in an appropriate and respectful manner for three residents (Residents #12, #71, and #73). The facility also failed to ensure privacy was provided for one resident during care (Resident #86). In addition, the facility failed to ensure staff followed the facility's cell phone policy, while providing care to one resident (Resident #133). The sample size was 33. The census was 149. Review of the facility's promoting resident dignity policy, dated 9/21/25, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident petty cash was available upon request, seven days a week, and to ensure requests were honored as soon as possible, no later than the same day for amounts less than $100.00 ($50.00 for Medicaid residents) or three banking days for amounts $100.00 ($50.00 for Medicaid residents) or more (Resident #133). This deficiency had the potential to affect all residents who had a resident trust account. The facility identified 124 residents with funds in the resident trust account. The census was 149. Review of the facility's Resident Trust policy, dated 3/1/17, showed:-The facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday;-The facility will maintain a resident petty cash fund for resident trust transactions only. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and maintain complete accounting records, including the petty cash kept on hand, for the resident trust account for 12 out of 12 months. The facility failed to ensure monthly bank statements were added and reviewed monthly during the reconciliation. In addition, the facility failed to ensure quarterly statements were accurate for all residents with a trust account after new bank accounts were established. The facility failed to include debits and credits for the entire month of December 2025, leaving residents without accurate and complete quarterly statements for 10/1/25 through 12/31/25 and 1/1/26 through 3/31/26. This affected 11 out of 11 residents sampled for funds (Resident #133, #155, #9, #123, #55, #66, #1, #108, #117, #120, and #14). The facility identified 124 residents with a resident trust account. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and homelike environment by failing to ensure the 300 south hallway shower room was clean, the 300 south sitting room had a broken television removed, the 200 hallway was free from odors and the floors were clean, the 300 south bathrooms had working soap dispensers and towel holders, and room [ROOM NUMBER] had broken floor tiles and a television on the floor removed. The sample size was 33. The census was 149. Review of the facility's housekeeping deep cleaning policy, dated 6/29/23, showed:-Purpose: To ensure all rooms are clean;-Policy: Deep cleaning is to be completed as scheduled. [...]

Inspectors wroteBased on interview and record review, the facility failed to send the Office of the State Long-Term Care (LTC) Ombudsman a copy of the notice of resident discharges in January, February, and March 2026. The census was 149. Review of the facility's Resident Transfer, Discharge, Immediate Discharge, and Therapeutic Leave policy, last revised 4/28/25, showed:-Purpose: Establish policy and procedure regarding the transfer/discharge of residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served to residents at a safe and palatable temperature, affecting six out of 33 sampled residents (Residents #3, #5, #12, #78, #110, and #148). The census was 149. Review of the facility's dietary food preparation policy, dated 7/5/23, showed:-Food Temperatures: Foods will be served at proper temperature to ensure food safety;-If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature;-Warm foods should measure at 135 degrees Fahrenheit (F). 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/26, showed:-Diagnoses included type two diabetes;-Cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen equipment was clean and floors were free of trash and grime. The sample size was 33. The census was 149. Review of the facility's Dietary - Equipment operations, Infection Control, and Sanitation policy, dated 2/2/24, showed:-The dietary staff shall maintain the sanitation of the dietary department through compliance with written, comprehensive cleaning schedules developed for the facility by the Dietary Manager;-Refrigerator walk-in: Weekly cleaning. Thoroughly sweep all floor areas and corners. Mop floor and drain area. Scrub any hard-to-clean areas using a sanitizing solution and scouring pad;-Deep fryer: Once a month, or as needed, the cook with the assistance of the Dietary Manager will clean and disinfect the deep fryer. The grease will be drained from the deep fryer through the bottom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pest control program was effective in preventing mice, which affected three out of 33 sampled residents (Residents #48, #12, and #78). The census was 149. Review of the facility's pest control program policy, dated 5/14/24, showed:-Purpose: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Policy: Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were allowed to exercise their right to choose their attending physician when the facility discontinued services with Physician RR and failed to permit Physician RR to continue providing care within the facility, resulting in residents being required to transition to a different physician for two residents (Residents #133 and #139). The sample size was 33. The census was 149. Review of the facility's undated admission Agreement, showed:-Resident rights: Facility has delivered, and Resident acknowledges receipt of a document entitled ''Nursing Home Resident Rights that describes Resident's rights at Facility. Resident also acknowledges that Facility has orally explained these rights in terms Resident can reasonably be expected to understand. [...]

Inspectors wroteBased on interview and record review, the facility failed to routinely notify residents receiving Medicaid benefits when the amount in the resident's account was within $200.00 of the resource limit for seven residents (Resident #117, #66, #55, #1, #108, #120, and #155). The facility identified 124 residents with a resident trust account. The census was 149. Review of the facility's Resident Trust policy, dated 3/1/17, showed the resident trust clerk must monitor account balances. Missouri Medicaid residents are allowed to keep only a total of their state's allowable limit (Missouri is $6068.80, effective 7/1/2025) in non-exempt resources. Any Medicaid resident who is within $200.00 of these allowed amounts should be notified in writing that he/she is within $200.00 of the allowable non-exempt resource limit set forth and may lose their eligibility if they accumulate excess funds. [...]

Inspectors wroteBase on interview and record review, the facility failed to review and administer hospital admission orders for one resident (Resident #39), when staff failed to administer an ordered antibiotic to treat the resident's urinary tract infection (UTI). Additionally, staff failed to implement a physician's order for a protective boot for one resident (Resident #16) and failed to follow up on physician's referrals for skilled therapy for two residents (Residents #16 and #90). The sample was 33 and the census was 149. Review of the facility's Transcription of Orders/Following Physician's Orders policy revised on 05/24, showed: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents requiring assistance with activities of daily living (ADLs) received necessary services when staff left one resident soiled for an extended period (Resident #155), and failed to provide hygiene assistance for one resident (Resident #6), and supervision during meals for one resident (Resident #110). The sample was 33. The census was 149. Review of the facility's ADL policy, dated 5/18/24, showed:-Purpose: The facility will, 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;-Cares and services will be provided for the following ADLs;--Bathing, dressing, grooming and oral care;--Transfer and ambulation;--Toileting;--Eating to include meals and snacks. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care to prevent pressure ulcers for one resident (Resident #90). Staff did not provide a treatment to the resident's wound as the physician ordered and left the wound exposed to air. Staff also did not update the resident's care plan after they discovered the resident had a pressure wound. The sample size was 33. The census was 149. Review of the facility's Pressure Ulcer Management policy dated 05/24, showed:-Purpose: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries;-Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to use a gait-belt (specialized device utilized to assist during transfers) during a transfer for two residents (Resident #143 and #86 ). The sample size was 33. The census was 149. Review of the facility's Gait Belt policy, dated 6/23, showed:-Purpose: The purpose of this policy is to ensure precautionary and safe measures are taken during the application and use of gait belts;-Procedure:--Safe usage of a gait belt can prevent potential risk of injury to residents that could be caused by pulling on their arms, shoulders and wrists during ambulation, transfers or repositioning;--Safety Measure: Never transfer any resident by lifting them under their arms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a pre-assessment and post assessment communication form to the dialysis center for two out of two dialysis residents sampled (Resident #2 and Resident #5) receiving hemodialysis (a treatment to clean the body's blood supply of impurities). The sample size was 33. The census was 149. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #12) of 33 sampled residents received follow-up trauma-informed care after a shooting incident occurred at the facility. The census was 149. Review of the facility's behavioral health services policy, dated 10/31/24, showed:-Purpose: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;- The facility will consider the acuity of the resident population. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication was stored properly by failing to ensure medications in the 300 south unit medication refrigerator were secured behind a lock. The sample size was 33. The census was 149. Review of the medication storage policy, dated 5/18/24, showed:-Purpose: It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Observation on 04/20/26, of the 300 south medication storage room, showed:-At 12:17 P.M., the door to the medication storage room was open with no staff present. The refrigerator was unlocked. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were provided to two of 33 sampled residents (Residents #12 and #113). The census was 149. Review of the facility's Dental Services policy, dated 6/26/24, showed:-Purpose: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care;-Dental services: The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location;-Documentation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards during perineal care (peri-care, cleaning of the genitals and rectal area) for two residents (Resident # 155 and Resident #108). The sample size was 33. The census was 149. Review of the facility's Peri Care policy, last revised on 6/29/23, showed:-Purpose: The purpose for this policy is to ensure that the female and male resident genital area is kept clean and proper techniques are used to prevent skin break down, infections or any other impairments that can be caused from not using proper aseptic (non-sterile) technique;-Procedure for giving peri-care to the male resident:--Gather necessary equipment;--Wash our hands;--Put on gloves;--Explain what you are going to do;--Provide privacy;--Resident should be back-lying or side-lying position;--Fill basin with warm water; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents of the facility. The sample was 8. The census was 147. Review of the facility's Sufficient Staffing Policy, dated February 2023, showed the following:-Purpose: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe following a physical altercation between two residents (Residents #1 and #2). The sample was eight. The census was 147. Based on interview and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe following a physical altercation between two residents (Residents #1 and #2). The sample was eight. The census was 147. Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed the following:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse involving a physical altercation between two residents (Residents #1 and #2). The sample was eight. The census was 147. Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed the following:-Purpose: [...]

Inspectors wroteSee F686 cited under Event ID 4F7E12 Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145.

Inspectors wroteSee F697 cited under Event ID 4F7E12 Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. [...]

Inspectors wroteSee F684 cited under Event ID 4F7E12 Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers; -Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot; -Procedure: Assessment: -A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a wound the licensed nurse will: -Measure the wound (length, width and depth); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policies for Transfer and Discharge & Elopement and Wandering for one resident (Resident #1), when facility staff failed to provide written discharge notice to the resident and his/her legal guardian- when the resident eloped (left the premises without authorization and/or any necessary supervision to do so) from the facility. The facility considered the resident leaving Against Medical Advice (AMA), although the resident had a legal guardian and was unable to make medical decisions on their own. Facility staff did not have a consistent understanding of the difference between a resident having a leave of absence, elopement, and against medical advice, to ensure policies and procedures were followed accordingly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers; -Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot; -Procedure: Assessment: -A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a wound the licensed nurse will: -Measure the wound (length, width and depth); -Initiate a wound monitoring record sheet: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for Elopement and Wandering for one resident (Resident #1) when the resident eloped (left the premises without authorization and/or any necessary supervision to do so) from the facility. The facility considered the resident leaving Against Medical Advice (AMA), although the resident had a legal guardian and was unable to make medical decisions on their own. Facility staff did not have a consistent understanding of the difference between a resident having a leave of absence, elopement, and against medical advice, to ensure policies and procedures were followed accordingly. The resident sample was 13. The census was 144. Review of the facility's Discharge Against Medical Advice policy, last revised 10/24/22, showed: -A resident may discharge themselves from the facility against the advice of his/her physician; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the respiratory services provided were consistent with professional standards of practice for one resident (Resident #3) when staff failed to ensure the oxygen was in working order when it was administered to the resident who had shortness of breath. The facility called Emergency Medical Services (EMS), who found the resident hypoxic (low level of oxygen) and the oxygen was not turned on. In addition, the facility failed to ensure staff followed physician's orders for the rate of oxygen and failed to properly change and date oxygen tubing (Resident #2). The facility identified three residents with orders for oxygen. The sample size was 13. The census 144. Review of the facility's oxygen administration policy, revised 10/24/22, showed: -Initiation of Oxygen: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the handrails on each resident hall were properly maintained. This deficient practice had the potential to affect all residents on these halls. The facility census was 145. 1. Observation of 100 South unit on 11/4/24 at 10:25 P.M., showed: -Loose handrail outside of room [ROOM NUMBER]. The handrail was detached from the wall on one side; -Missing handrail between rooms [ROOM NUMBERS]; -Loose handrail outside of room [ROOM NUMBER] and 104. The handrail was missing screws; -Loose handrail outside room [ROOM NUMBER]; -Loose handrail outside of room [ROOM NUMBER]; -Loose handrail outside of the soiled utility room and nurse's station; -Loose handrail outside of the shower room; -Loose handrails on both left and right side outside the TV room. 2. Observation of 100 Main unit on 11/4/24 at 10:37 A.M., showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for two of three dining rooms in use by residents and several common areas. The 300 main dining room had leaks, broken chairs, trash bags stored on the floor, and soiled curtains. The 200 main dining room had a leak. The 200 main day room with water leaks on the carpet. The 200 hall had cracks in the floor. In addition, the 100 hall had a Personal Protective Equipment (PPE) container in use that was soiled. The facility census was 145. 1. Observation of 300 Main dining room, showed: -On 11/4/24 at 10:53 A.M., large brown stains covered the lower half of the curtains that hung up in the windows. There was a wet spot located on the floor and a yellow substance underneath the curtains; -On 11/4/24 at 11:30 A.M., six chairs with torn or detached seats. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #5) after staff failed to close the door and pull the privacy curtain before providing incontinence care. The sample size was eight. The census was 145. Review of the resident bill of rights, showed: -Right to privacy: Residents have the right to privacy in their treatment and care, and to have their personal affairs kept confidential; -Right to dignity: Residents have the right to be treated with dignity and respect at all times. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/9/24, showed: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and follow physician orders for wound care for two sampled residents (Residents #89 and #72). Both residents required hospitalization for assessment and treatment of wound conditions, including amputations. The census was 151. The Administrator was notified on 7/12/24 at 10:49 A.M., of an immediate jeopardy (IJ) that began on 7/1/24. The IJ was removed on 7/12/24 as confirmed by surveyor on-site verification. Review of the wound management policy, revised 10/24/22, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including non-pressure ulcers; -Definitions: -Arterial Ulcer- an ulceration that occurs as the result of arterial occlusive disease when no pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (death). [...]

Inspectors wroteBased on observation, interview and record review, the facility to failed to provide appropriate administration of enteral (passing through the intestine) nutrition for a resident who was dependent upon a gastrotomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) (Resident #22). Resident #22's physician's orders showed 40 milliliters (ml)/hour (hr) via g-tube continuously and water flushes 175 ml every four hours. On 7/9/24, the tube feeding machine was not set in the English language and infused at a rate of 140 ml/hour. Staff failed to ensure the g-tube machine settings were accurately set at 40 ml/hour during medication and treatment administrations and failed to report its language settings to management. The resident received approximately 400 cubic centimeters (cc) of feeding between 7:56 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep one resident with epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures) free from a significant medication error, when the facility failed to administer the ordered Keppra (used to prevent seizures). The resident experienced a grand mal seizure (a tonic-clonic seizure, causing the loss of consciousness and violent muscle contractures) with fall at the facility and he/she sustained a fracture of the right proximal fibular shaft (lower leg outer bone) (Resident #14). In addition, staff administered Ambien (a sedative) to Resident #69, for which he/she had a known medication allergy. The census was 151. The Administrator was notified on 7/12/24 at 12:45 P.M., of an immediate jeopardy (IJ) which began on 4/17/24. The IJ was removed on 7/12/24 as confirmed by surveyor on-site verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident received care consistent with professional standards and facility policy to prevent and/or treat pressure ulcers (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility failed to ensure wound treatments were completed as ordered, and failed to notify the attending wound Nurse Practitioner (NP) of the missed treatments. The resident was sent to the hospital and received a surgical debridement of a sacral (tailbone) wound. The facility failed to administer ordered antibiotics for a 6 week time frame, which were ordered by the hospital infectious disease (ID) physician (Resident #72). The sample size was 30. The census was 151. Review of the wound management policy, dated 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify one resident's significant weight loss of -24.93% in a timely manner, resulting in delayed identification of interventions to support the resident's nutritional status (Resident #127). The facility failed to ensure three residents with significant weight loss were provided with therapeutic diets, supplemental food items, alternative food items, and/or feeding assistance to address weight loss (Residents #127, #123, and #50). The sample was 30. The census was 151. Review of the facility's Nutrition/Hydration Management policy, revised 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with chronic obstructive pulmonary disease (COPD, a chronic lung disease which airflow is constricted and makes it difficult to breathe) symptoms, received ordered oral steroids. The resident continued to have audible wheezing and the facility obtained a STAT (immediate) chest x-ray. The facility did not obtain or report the results to the physician and the x-ray results reflected pneumonia. The resident experienced a change in condition on 7/13/24, was sent to the hospital, where he/she received steroids. He/She was diagnosed with a COPD exacerbation and ordered steroids and two separate antibiotics (Resident #4). [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 151. Review of the facility's Nursing Department, Staffing, Scheduling, and Postings policy, revised 10/24/22, showed the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week, unless a waiver applies. Review of the facility's staffing sheets, dated 6/1 through 7/9/24 showed no RN coverage for the following dates: -6/1, 6/2, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/29, 6/30, 7/6, and 7/7/24; During an interview on 7/10/24 at approximately 12:00 P.M., the Staffing Coordinator said the facility currently has one as needed (PRN) RN but can utilize agency staff to cover the RN vacancy on the schedule. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate certification. This had the potential to affect all residents who consumed food prepared by the facility. The census was 151. Review of the facility's Dietary Manager job posting, undated, showed: -Job Requirements: you are certified by the Association of Nutrition and Food Service Professionals, you completed a dietary manager exam. During an interview on 7/16/24 at 9:18 A.M., the Dietary Manager said he does not currently have any certifications. He went through the course but never took the test. During an interview on 7/16/24 at 9:27 A.M., the Administrator said the Registered Dietician comes to the facility once a week and is not employed full-time with the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not include staffing ratios required per shift to meet the needs of residents, the need for a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, or the facility's use of locked units for residents identified with cognitive impairments and behaviors. The census was 151. Review of the facility's Facility Assessment, updated 12/13/23, showed: -Persons involved in completing assessment: Administrator, Director of Nursing (DON), Medical Director, Governing Body Representative (representative from facility's corporation); [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and a system to monitor antibiotic use. The census was 151. Review of the facility's ASP, revised 10/24/22, showed: -Purpose: To limit antibiotic resistance in the post-acute care setting, improve treatment efficacy and resident safety, and reduce treatment-related costs; -Policy: ASP is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain a tracking system for Certified Nursing Assistant (CNA) 12 hour training requirements for five out of five sampled CNAs. The census was 151. A policy related to CNA 12-hour training was not provided by the facility. Review of the five sampled CNAs' (CMT HHH, CMT OO, CNA E, CNA T, and CNA M) employee training records showed: -Multiple dated in-services and education sheets signed by the CNAs. The signed in-service and education sheets did not list the amount of time each in-service had taken. -No further documentation of tracking the in-services for each CNA provided by the facility. During an interview on 7/10/24 at 4:10 P.M., CNA T said the facility was always in- servicing and providing education, but didn't think the facility was officially tracking the mandatory 12 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs and preferences by failing to ensure three residents had wheelchairs that were in good condition and properly fit the residents (Resident #1, #87, and #127). The facility also failed to provide side rails to assist one resident with bed mobility, positioning, and transfers (Resident #42) and ensure one resident had his/her call light in reach (Resident #89). In addition the facility failed to provide access to community rooms on the third floor, therefore limiting access for the residents to the TV and vending machines for three residents (Resident #46, #138 and #45). The sample was 30. The census was 151. Review of the facility's admission Packet, revised 7/2022, showed the facility shall offer personal care, room, board, dietary services and laundry services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the first floor dining room was free from leaks (Resident #45), failed to ensure furniture and second floor common areas were clean and in good repair (Residents #86 and #106), failed to provide a homelike environment by serving meals with plastic utensils to residents on the second floor (Residents #106, #15, #50, and #126), failed to ensure the third floor shower room was clean and the toilet was in working order (Residents #87), failed to ensure Resident #120's bedroom wall was free from damage, failed to ensure the Air Conditioning (AC) units were free from dust and debris (Rooms 301, 303, 305, and 307), failed to ensure Resident #45 had a closet door. The sample was 30. The census was 151. Review of the facility's Maintenance Services policy, revised 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to perform criminal background checks (CBC) on newly hired employees prior to the employee's start date, in accordance with the facility's policy, for three of 10 employees hired since the last survey. The census was 151. Review of the facility's Staff Screening policy, revised 10/24/22, showed: -Purpose: To ensure the highest quality of care through the utilization of qualified staff, consultants and volunteers; -Policy: The Facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five residents who required assistance with activities of daily living (ADL) received personal care, nail care, and facial hair hygiene in accordance with their needs and preferences (Residents #37, #22, #88, #51, and #124). The sample was 30. The census was 151. Review of the facility's Care and Services policy, dated 10/24/22, showed: -Policy: Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to fully implement the restorative therapy program for residents with limited mobility. The facility failed to ensure appropriate services and assistance to maintain or improve mobility for three residents (Residents #88, #4 and #123 ). Resident #88's therapy was discontinued due to insurance and restorative services was not recommended. Resident #88 also had a hand contracture, with therapy recommendations for a hand splint that was not ordered. The sample was 30. The census was 151. Review of the facility's Restorative Nursing Program policy, dated 10/24/22, showed: -Purpose: The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient number of staff to meet the residents' needs. In addition, the facility failed to provide wound treatments for two residents (Resident #89 and #2) due to lack of nursing staff. The sample size was 30. The census was 151. Review of the facility's Staffing, Scheduling and Posting policy, revised 10/24/22, showed: -Purpose: To ensure an adequate number of nursing personnel are available to meet resident needs; -Procedure: -The facility will employ sufficient Nursing Staff on an 24 hour basis that meet the appropriate competencies, skill set, and required qualifications to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents food at a safe and appetizing temperature for three residents (Residents #30, #58, and #111). The sample was 30. The census was 151. Review of the facility's food temperatures policy, revised 10/24/22, showed: -Purpose: To provide the dietary department with guidelines for food preparation and service temperatures; -Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Acceptable serving temperatures: Eggs should be greater than 135 degrees Fahrenheit (F), meat entrees should be greater than 135 degrees F, cereal or oatmeal should be 135 degrees F. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/12/24, showed: -Cognitively Intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen equipment clean and floors free of dust, grease, and grime. In addition, staff failed to wear a beard net when preparing food. The census was 151. Review of the facility's weekly cleaning list, dated 1/21/24, showed: -Weekly cleaning: prep table, floors swept and mopped, cook station floors behind the fryers, walk in freezer, and fans and duct work. 1. Observation 7/8/24 of the kitchen, showed: -At 8:31 A.M., the walk-in freezer with trash and food debris on the floor in multiple areas; -At 8:34 A.M., the flour and sugar bulk bins observed to have lids caked with a white powder substance; -At 8:35 A.M., the deep fryer observed with a sticky, dried grease build-up on the sides; -At 8:35 A.M., the floor under the tilt skillet observed with a dark liquid with other debris spilled and puddled; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed and demonstrated the ability to safely self-administer medications when the resident self-administered medications via a gastric tube (g-tube, tube surgically inserted into the stomach to administer food, fluid, and nutrition) and did not follow acceptable standards of practice. Staff present at the time failed to provide education on safe medication administration as the medications were being administered (Resident #45). The census was 151. Review of the facility's Medication-Self Administration policy, dated 10/24/22, showed: -Policy: Residents who request to perform medication self-administration will be assessed for capability. The assessment of medication self-administration will ensure a clinically appropriate, effective process for the resident to provide self-care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update records of residents' personal possessions per facility policy for two sampled residents (Resident #42 and #39). Resident #42 purchased dresses and socks that were not documented on the resident's inventory sheet and were missing after being sent to laundry. Resident #39 purchased shirts and pants that were not documented on the resident's inventory sheet and were missing after being sent to laundry. The sample was 30. The census was 151. Review of the facility's admission policy, revised July 2022, showed: -Laundry services: The facility will clean the resident's laundry (in commercial machines with industrial detergent) at no additional charge to the Resident. The family will pick up and clean the resident's laundry and the family will provide a covered, plastic laundry container to the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address behaviors related to pulling the call light out of the wall, on the care plan for one sampled resident (Resident #96). The sample was 30. The census was 151. Review of Resident #96's medical record, showed his/her diagnoses included Alzheimer's disease, muscle weakness, insomnia, depression, low blood pressure, high cholesterol, anxiety disorder and difficulty in walking. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/30/24, showed: -Severe cognitive impairment; -Required supervision or touching assistance from staff with eating, oral hygiene, upper body dressing, putting on or taking off footwear and personal hygiene; -Required partial to moderate assistance from staff with toileting, showering, lower body dressing; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a resident's involvement in discharge planning for one resident (Resident #299), who was transferred to another facility. The census was 151. Review of the facility's Transfer and Discharge Planning policy showed: -Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility; -Policy: Social Services staff will conduct a Discharge Planning Assessment and will help orient the resident to the impending discharge. -Procedure: -Social Services staff will document the discharge planning, preparation, and the resident's post-discharge needs in a Discharge Planning Assessment, or similar form in the electronic health record; -The Discharge Planning Assessment will be filed in the resident's medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary was completed for one resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge (Resident #299). The census was 151. Review of the facility's Transfer and Discharge Planning policy showed: -Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility; -Policy: Social Services staff will participate in assisting the resident with transfers and discharges and preparing the Discharge Summary and Discharge Care Plan as part of the interdisciplinary team (IDT); -Social Services staff will assist in developing the Discharge Summary and Discharge Care Plan that is developed with the IDT; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's room was free from hazardous chemicals at the bedside (Resident #124). The sample was 30. The census was 151. Review of the Material Safety Data Sheet (MSDS) for Odoban (disinfectant cleaner), dated 2/10/2022, showed: -Regulatory information: immediate health hazard; -Hazard statement: may cause respiratory irritation. Causes serious eye irritation. Review of the MSDS for Raid Ant and Roach Killer, dated 9/6/2016, showed: -Precautions for safe handling: avoid contact with skin, eyes and clothing, do not enter places where used or stored until adequately ventilated, flammable. Review of the MSDS for Febreeze Air Effects, dated 2/24/2014, showed: -Advice on safe handling: use personal protective equipment as required. Keep container closed when not in use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident #93), diagnosed as having dementia with depression and exhibiting symptoms/behaviors, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. The facility failed to follow the recommendations from his/her psychiatric Nurse Practitioner (NP) and there was no Social Service documentation of the resident's behaviors and individualized interventions provided by Social Services. The census was 151. Review of the facility's policy titled, Physician Orders, revised 10/24/22, showed: -Purpose: This will ensure that all physician orders are complete and accurate; -Other orders will include a description complete enough to ensure clarity of the physician's plan of care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and facility policy in two of two medication rooms and three of five medication/treatment carts. The census was 151. Review of the facility's Medication Storage Policy, dated 1/2021, showed: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents received mechanically altered diets in accordance with physician orders (Residents #127 and #15). The census was 151. Review of the facility's Therapeutic Diets policy, revised 10/24/22, showed: -Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders; -Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian; -Procedure: -The nursing staff is responsible for communicating the physician's order for a therapeutic diet to the dietary department in writing; -The therapeutic diet will be reflected on the resident's tray card. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that are complete and accurately documented in accordance with acceptable professional standards and practices and with the facility's policies, when staff revised an assessment completed three months ago for one resident (Resident #45). The sample was 30. The census was 151. Review of the facility's Falsification and Omission policy, revised 10/24/22, showed: -Purpose: To ensure entries in the medical records provide an accurate description of the services provided; -Policy: Entries in a medical record at the facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided; -Procedure: -The original entry in a record is not to be destroyed or removed from the record; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection prevention and control, when staff failed to utilize Enhanced Barrier Precautions (EBP), an infection control method that uses personal protective equipment (PPE), gowns and gloves, to reduce the spread of multidrug-resistant organisms (MDRO, a germ resistant to many antibiotics), for one resident (Resident #22). In addition, the facility failed to use proper infection control techniques when obtaining blood glucose and administering insulin to one resident (Resident #133). The sample was 30. The census was 151. Review of the facility's Standard and Enhanced Precautions policy, revised 4/1/24, showed: -Purpose: To ensure the use of appropriate protective equipment to improve infection control as required in the care of the residents; -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure beds in three shared rooms were equipped with curtains to assure full visual privacy for each resident (Residents #37, #126, and an unidentified resident). The census was 151. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/24, showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease. Observation on 7/8/24 at 10:08 A.M., showed no privacy curtain hung around the resident's bed. Observation on 7/9/24 at 8:33 A.M., showed no privacy curtain hung around the resident's bed. The resident stood next to his/her bed while Certified Nurse Aide (CNA) E assisted him/her in getting undressed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the nurse staffing information daily in a prominent place, readily accessible to residents and visitors. In addition, the daily staffing sheets maintained by the facility did not include the facility name. The census was 151. Review of the facility's Nursing Department Staffing, Scheduling, and Postings policy, revised 10/24/22, showed: -Posting requirement: -The facility will post the following information on a daily basis: -Facility name; -The current date; -The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift; -Facility census; -The facility will post the nurse staffing data specified above, on a [NAME] basis at the beginning of each shift; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of eight sampled residents, in writing, of a facility-initiated immediate discharge in a language understood by the resident (Resident #8). The census was 156. Review of the facility policy titled, Transfer and Discharge, revised 10/24/22, showed the purpose of the policy was to ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. The facility may transfer or discharge a resident for reasons which include that the health and/or safety of individuals in the facility would otherwise be endangered by the resident's presence. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident #7) was free from physical abuse. On 9/21/23, Resident #4 hit Resident #7, resulting in small laceration (cut) to left eye brow, bottom lip and left upper and bruising with some swelling under left eye and bridge of nose. The sample was 10. The census was 146. Review of the facility's Abuse Prevention and Prohibition Program policy, dated revised: October 24, 2022, showed: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; [...]

Inspectors wroteSee T2XB12 Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing Assistant (CNA), threatened him/her. Appropriate staff and resident interviews were not conducted. The sample was 10. The census was 146. Review of the facility's abuse policy, dated 10/24/22, showed: -Purpose includes: To ensure the facility established, operationalized, and maintained an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the investigation of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -The investigator may take some or all of the following steps: -Reviews all relevant documentation; [...]

Inspectors wroteSee T2XB11 Based on interview and record review, the facility failed to ensure services provided met professional standards when one resident (Resident #2) with a head laceration, related to a fall, did not receive neurological checks (neuro checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); and failed to ensure one resident (Resident #7 ) received neuro checks after another resident hit him/her in the head with their fist. The sample of residents with head injuries or unwitnessed falls was four. The census was 146. Review of the facility Neurological Assessment Policy, dated revised 10/24/22, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Policy: Nursing will perform a neurological assessment in the following circumstances: [...]

Inspectors wroteSee T2XB11 Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facility. The census was 146. Review of the facility's Competency Evaluation Policy, revised dated December 2006, showed the following: -Policy Statement: Nurse aides employed for a period greater that four months must successfully pass a state approved competency evaluation; -Policy Interpretation and Implementation: -Persons completing the training program must successfully pass the competency evaluation test within four months (120 days) of their date of employment. Failure to do so will result in the student having to retake the training program. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent roaches, mice and gnats in resident rooms (Residents #19, #16, #10, #5 and #18) and common areas. The census was 160. Review of the facility's Pest Policy, revised 10/24/22, showed: -Purpose: To ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors; -The Administrator arranges for a pest control company (Company) to visit and inspect the facility at least once a year; -The company representative will inspect the facility and grounds for insects, termites, rodents, and any other pests that may cause damage to the facility; -Submit a written report to the Administrator detailing its findings; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident was free from physical restraint when, Certified Nurse Aide (CNA) D, pinned the resident's wrists to his/her chest to provide care (Resident # 13). The sample was 20. The census was 160. Review of the facility's Restraint policy, revised June 2020, showed: -Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used; -Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body; [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing Assistant (CNA), threatened him/her. Appropriate staff and resident interviews were not conducted. The sample was 10. The census was 146. Review of the facility's abuse policy, dated 10/24/22, showed: -Purpose includes: To ensure the facility established, operationalized, and maintained an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the investigation of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -The investigator may take some or all of the following steps: -Reviews all relevant documentation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards when one resident (Resident #2) with a head laceration, related to a fall, did not receive neurological checks (neuro checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); and failed to ensure one resident (Resident #7 ) received neuro checks after another resident hit him/her in the head with their fist. The sample of residents with head injuries or unwitnessed falls was four. The census was 146. Review of the facility Neurological Assessment Policy, dated revised 10/24/22, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Policy: Nursing will perform a neurological assessment in the following circumstances: --Upon Attending Physician order; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice when staff failed to follow their policy to obtain one resident's wound care orders timely (Resident #6). The sample was 20. The census was 160. Review of the facility's Wound Care Policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -Preparation: Verify that there is a physician's order for this procedure; -Documentation: The following information should be recorded in the resident's medical record: the type of wound care given; any change in the resident's condition; all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; if the resident refused the treatment and the reason(s) why; -Reporting: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facility. The census was 146. Review of the facility's Competency Evaluation Policy, revised dated December 2006, showed the following: -Policy Statement: Nurse aides employed for a period greater that four months must successfully pass a state approved competency evaluation; -Policy Interpretation and Implementation: -Persons completing the training program must successfully pass the competency evaluation test within four months (120 days) of their date of employment. Failure to do so will result in the student having to retake the training program. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to prevent and implement appropriate interventions for one resident who experienced a fall resulting in a fractured wrist and shoulder (Resident #8) due to the staff leaving the resident's side. In addition, the facility failed to provide adequate supervision for an elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) from a secured unit (Resident #32). In addition, the facility failed to provide oversight for one resident with a history of falls (Resident #82). The facility failed to ensure the residents environment remained free of accident hazards when staff failed to ensure the soiled utility room, where hazardous material is stored, was locked and inaccessible to residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed by failing to provide explanations for discrepancies noted during monthly resident trust fund reconciliations for two accounts, and by failing to complete monthly account reconciliations for a third account in which resident funds were held. In addition, the facility failed to follow up on outstanding checks, and failed to provide quarterly statements to residents and their representatives. This affected 110 residents whose funds were handled by the facility. The census was 121. Review of the facility's Cash Disbursement Procedure policy, undated, showed no guidance regarding resident trust account reconciliation, outstanding checks, or quarterly statements. 1. Review of the facility's Trust Account Reconciliation from January through December 2021, showed: -January 2021: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected five residents who expired and had money in their account (Residents #323, #322, #350, #321 and #320). The census was 121. 1. Review of Resident #323's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $866.38; -No documentation of TPL completed. 2. Review of Resident #322's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $2,441.22; -No documentation of TPL completed. 3. Review of Resident #350's resident fund account, showed the following: -His/her account closed on [DATE]; -He/she had a balance of $90.00; -No documentation of TPL completed. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they maintained an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 121. Review of the facility's Cash Disbursement policy, undated, showed no instructions on how to monitor the facility's surety bond to ensure it was sufficient. Review of the resident trust account for the past 12 months, from January 2021 to December 2021, showed an average monthly balance of $187,000. (This would yield a required bond in the amount of $280,500 (one and one half times the average monthly balance)). Review of the bond report for approved facility bonds by Department of Health and Senior Services (DHSS), showed an approved bond of $270,000, dated 12/17/21. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide reasonable accomodations of resident needs and preferences by not serving meals in a timely manner and at the posted times. This deficient practice affected all residents who ate at the facility. The census was 121. During an interview on 1/18/22 at 8:30 A.M., the Dietary Manager said breakfast was served at 8:00 A.M., lunch was served at 12:00 P.M. and dinner was served at 5:00 P.M. There were three cooks and six dietary aides (DA) working in the kitchen. The main dining room was in use and some residents received meals delivered to their room. Observations of the lunch meal service in the main dining room on 1/18/22, showed: -At 12:02 P.M., eight residents sat in the dining room; -At 12:16 P.M., approximately 10 residents sat in the dining room. No drinks or food were served; [...]

Inspectors wroteBased on interview, the facility failed to ensure the Business Office Manager (BOM) had access to all resident funds, and to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day by not assuring residents had access to their trust account on the weekends. This deficient practice affected all the residents who had a resident trust account. The census was 121. During an interview on 1/25/22 at 10:52 A.M., the BOM said she became employed with the facility in November, 2021. Resident funds are held in the resident trust fund account. In October 2021, the facility changed ownership and opened a new resident trust fund account, Account B. The BOM did not have access to the old account, Account A, until late in December 2021. Funds were held in both accounts until Account A was closed last week. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean and comfortable, homelike environment. The facility failed to repair pipes leaking outside of the facility's dining room and to address the sound levels of a heating unit in one resident's room (Resident #111). In addition, the facility failed to serve resident meals with appropriate dishware and utensils. The census was 121. 1. Observations on 1/18/22 at 1:08 P.M., 1/19/22 at 8:38 P.M., 1/20/22 at 12:34 P.M., and 1/21/21 at 7:20 A.M., showed two ceiling tiles missing in the hall leading to the dining room. Pipes leaked from the missing ceiling tiles, with mop buckets placed underneath them. During a group meeting on 1/20/22 at 2:00 P.M., four out of six residents said the plumbing has been an issue in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one on one (1:1) activities for six of 23 residents who were identified as receiving 1:1 activities (Residents #45, #89, #82. #101, #115, #20, and #9). In addition, the facility failed to provide 1:1 activities for one resident identified by staff as having the desire to participate in 1:1 activities. The sample was 24. The census was 121. 1. Review of Resident #45's medical record, showed: -admission date of 7/16/18; -Diagnoses included traumatic brain injury, aphasia (impairment of expression and understanding of language), seizures, dementia, and quadriplegia (paralysis affecting all four limbs). Review of the resident's quarterly activity participation review, dated 9/6/21, showed: -Resident is on 1:1 with activity staff. Resident will refuse any activity offered, but will socialize with staff; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately store non-expired medications and equipment in two of three facility medication storage rooms and in one of five nurse treatment carts. Staff also failed to secure narcotic medication. The facility census was 121. Review of the facility's Storage of Medications policy, revised April 2007, showed: -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; -The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Five out of six residents attending the Resident Council meeting complained about the food temperatures. The census was 121. Observation of the lunch meal service on 1/24/22 at 11:53 A.M., showed the prepared food on the warm server in the kitchen. Styrofoam plates sat on top of the server. Three wheeled carts held beverages. Dietary Aide (DA) D began placing food onto the Styrofoam plates. DA E took the plates and placed them onto the wheeled cart, with the beverages, to deliver to the units. The cart did not have any components to keep the meals warm while in transport. Further observation on 1/24/22, showed: -At 1:00 P.M., the cart which held the lunch trays was delivered to the second floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an inspection of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four of 24 sampled residents to reduce the risks of accidents (Residents #93, #112, #8, and #45). The facility identified 27 residents who utilized bed rails. Of the 27 residents, four were sampled and problems were identified with all four. The census was 121. Review of the facility's Bed Rail Policy, dated 7/20/20, showed: -Preface: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenances and individual bed rail evaluations. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain resident dignity by failing to sit while assisting two (Residents #93 and #115) of 28 sampled residents with meals. The census was 121. Review of the facility's Resident's Right policy, revised 8/2021, showed: -Policy Statement: Employees shall treat all residents with kindness, respect and dignity; -Policy Interpretation and Implementation: -Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness and dignity. 1. Review of Resident #93's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/21, showed: -admitted on [DATE]; -Exhibited moderate cognitive impairment; -No behaviors; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of one resident (Resident #55) out of 24 sampled residents, for unrestricted visitation, when the facility prevented the resident's care and financial power-of-attorney (POA, a person with the legal authority to make decisions regarding another person's medical care and financial matters) from entering the facility, contacting the resident by phone and did not set up visits via a virtual video teleconferencing platform. The census was 121. Review of the facility's policy titled, Resident's Rights, effective 9/2015, showed federal and state laws guaranteed certain basic rights to all residents of the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' responsible parties were notified in the event of a significant change for 1 of 24 sampled residents (Resident #55). The census was 121. Review of the facility's Notification of Change policy, revised November 2017, showed the following: -In an emergency situation, the physician is contacted at the same time or will be notified following 911 and once the resident is transferred to the hospital; -In a non-emergent, but acute medical situation (including critical lab values and other diagnostic results) the physician will be paged and if there is no return call in 15 minutes the physician will be notified again. If there is no return call in 5 minutes the Medical Director will be notified; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing and grooming assistance for two residents dependent on staff for assistance with hygiene maintenance (Residents #82 and #45). The sample was 24. The census was 121. 1. Review of Resident #82's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/21, showed: -admission date of 6/16/21; -Moderate cognitive impairment; -No behaviors exhibited; -Required extensive assistance of one person physical assist for bed mobility, dressing, toilet use and personal hygiene; -Total dependence of two (+) person physical assist for transfers; -Upper and lower extremity impairment on one side; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident identified with a rash on his/her feet. The facility failed to clarify physician orders for treatment, to administer treatments as needed, and to notify the physician upon a change in condition when the resident developed an abrasion on his/her feet (Resident #45). The sample was 24. The census was 121. Review of the facility's Non-Pressure Skin Evaluation policy, revised 12/2019, showed: -General: To provide guidance on the evaluation of skin tears, bruises, and rashes; -Responsible party: Licensed Nursing Staff, Wound Care Coordinator, Treatment Nurse; -Policy: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately support the nutritional status of 1 of 24 sampled residents by not following RD (Registered Dietician) recommendations and physician orders (Resident #115). The facility census was 121. Review of Resident #115's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, updated 12/20/21, showed: -Moderate cognitive impairment. -Resident dependent on staff for all Activities of Daily Living (ADLs). -Diagnoses included dementia, hemiplegia (the functional use of the upper limbs only), seizure disorder, anxiety, depression, and psychotic disorder. Review of the resient's care plan, updated on 12/20/21 and in use during the survey, showed: -Focus: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident of 24 sampled residents (Resident #55), diagnosed as having dementia with behavioral disturbance and exhibiting symptoms/behaviors which contributed to a pattern of falls with injury, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being by failing to fully inform his/her psychiatric nurse practitioner (NP) of behaviors which included the following: standing unassisted from his/her wheelchair and bed, wandering throughout the secured unit at night with an unsteady gait, screaming and attempting to enter other residents' rooms. The facility failed to obtain a urine specimen as ordered in a timely manner, failed to ascertain urinalysis results and report them to the NP. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers/discharges for three of three residents sampled for emergency transfers (Residents #45, #2 and #78). The sample was 24. The census was 121. 1. Review of Resident #45's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed: -admission date of 7/16/18; -discharged to the hospital 10/18/21; -readmission to the facility 10/25/21. 2. Review of Resident #2's MDS admission and discharge assessments, showed: -admission date of 9/27/21; -discharged to the hospital 11/3/21; -readmission to the facility 11/5/21. 3. Review of Resident #78's MDS admission and discharge assessments, showed: -admission date of 1/23/17; -discharged to the hospital 12/15/21; [...]