Ignite Medical Resort Carondelet LLC

Inspectors wroteBased on interview and record review, the facility failed to develop an ongoing person-centered discharge plan, when the facility issued a 30-day discharge letter to one sampled resident (Resident #2), discharging the resident to a homeless shelter who required medication and care oversight out of five sampled residents. The facility census was 111 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) received physician ordered pain medications when the resident's narcotic pain medication was not administered for four consecutive days out of five sampled resident. The facility census was 125 residents. The Administrator and the Director of Nursing (DON) was notified of the past noncompliance which began on 4/7/26. The facility immediately completed education to ensure physician orders were complete with all nursing staff. The deficiency was corrected on 4/7/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an appropriate discharge plan, when the facility issued a Notice of Medicare (a federal health insurance program) Non-Coverage (NOMNC - a mandatory document provided to beneficiaries by skilled nursing facilities when their covered services are ending) to one sampled resident (Resident #1) out of seven sampled residents. The facility census was 134 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medical related social services by not planning for and referring one resident (Resident #1) out of three sampled residents, to potential community services necessary for the resident to have a successful and appropriate discharge back to the community. The facility census was 134 residents. Review of the facility's Discharges policy, dated April 2023, showed:-A resident's discharge potential was assessed by Social Services upon admission.-When the Interdisciplinary Team (IDT - a group of facility staff, including nursing, medicine, therapy, and social work, work together with the resident to develop and implement a person-centered discharge plan) meet to discuss the discharge. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling vents in the A Hall shower room free from a heavy buildup of dust; and failed to maintain the table top fans in the following areas free from a heavy buildup of dust: Resident room B10, Resident #33's room, Resident room B4, Resident room C5, and Resident #101's room. This practice potentially affected at least 30 residents who used the shower room and resided in those areas. The facility census was 105 residents. 1. Observation on 1/13/26 at 11:22 A.M., with the Facility Maintenance Director showed a heavy buildup of dust on two ceiling vents in the A Hall shower room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's food preferences were honored, and alternative menu choices were provided for three sampled residents (Resident #95, #110, and #112), out of 21 sampled residents and had the potential to affect all residents who were bed bound, did not eat in the dining room area, and who ate meals in their room. The facility census was 105 residents. Review of the facility policy titled Meal Service revised dated May 2024 showed:-Meals were served three times per day. [...]

Inspectors wroteBased on observation and interview, the facility failed to remove the dust on the vents and ceiling lights all throughout the kitchen and over-serving area; failed to ensure the walls did not have holes in them and the metal trim was falling off on a corner; failed to ensure there was a drain cover over the drain in the dish machine room; failed to ensure a large bag of bread crumbs was not open and the flour bin door was open; and failed to ensure the dining room floors were mopped. This deficient practice potentially affected all residents who ate the food from the kitchen and ate or walked through the dining room. The facility census was 105 residents. 1. Observation on 1/11/26 1:20 P.M., of the dining room showed there was dried spilled residue all throughout the sitting area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP, infection control measures, primarily in long-term care, requiring gowns and gloves for all high-contact care activities for residents with multidrug-resistant organisms (MDROs), wounds, or indwelling devices, expanding beyond standard precautions to prevent transmission while allowing residents more freedom than contact precautions.) were implemented for two sampled residents (Resident #4 and #14) who were on EBP; failed to ensure handwashing was done after completing dirty tasks during resident care for two sampled residents (Resident #4 and #14); [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the inner area of the climate control units in resident rooms A9, A1, B11, D3, free from debris; failed to ensure the restroom ceiling vent covers in the restrooms of resident rooms A14, C8, C3, and D11, were firmly attached to the ceiling; failed to ensure the hand rail in the restroom of resident room A5, was firmly attached to the wall; and failed to ensure the wall guard in C12 was firmly attached to the wall. This practice potentially affected at least 15 residents who resided in or used those areas. The facility census was 105 residents. 1. Observation on 1/13/26 between 11:02 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of the following resident rooms H7, H6, H5, H4, H2, H1, G8, G5, G7, G9, G12, G14, D8, D7, D4, D5, D3, D2, and D1. This practice potentially affected 23 residents who resided in those rooms. The facility census was 105 residents. *Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent. 1. Observation on 1/12/26, with the Facility Maintenance Director and the Senior [NAME] President of Facility Services showed the following:-At 2:31 P.M. there was the absence of negative air flow in the restroom of resident room H7.-At 2:33 P.M. there was the absence of negative airflow in the restroom of resident room H6.-At 2:36 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice when administering insulin (a hormone that regulates blood sugar), without cleansing the insulin pen rubber septum with alcohol prior to applying the pen needle and injecting insulin for two supplemental residents (Resident #75 and #115) out of 6 supplemental residents. The facility census was 105 residents. Review of the facility's Injections Policy last reviewed/revised in May 2023 showed there was no instruction given to clean pen septum prior to drawing up insulin.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multiple shower refusals were reviewed and documented for a potential reason for the shower refusals, and failed to review and document preferences for bathing or shower days and preferred shower times, for one sampled resident (Resident's #19), who refused 5 out 5 showers since his/her admission; and failed to ensure one sampled resident (Resident #12) who required staff assistance with activities of daily living (ADL's) had the call light placed within his/her reach out of 21 sampled residents. The facility resident census of 105 residents. The facility's Bathing/Shower Program policy was requested and not received at time of exit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #93) had access to an adaptive call light device and that the call light was within reach; and failed to implement ordered pressure injury prevention interventions, including the application of Prevalon boots while in bed. This failure placed the resident at risk for unmet needs, delayed assistance, and increased risk for pressure injury development out of 21 sampled residents. The facility census was 105 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were physician orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that treats sleep disorders by delivering a steady stream of air through a pressurized mask) for one sampled resident (Resident #18) out of 23 sampled residents. The census was 105 residents. Review of the facility policy titled Physician Orders revised dated May 2023 showed:-Orders may be called, handwritten, fax, or electronically generated by physician. -The physician's orders must be documented completely with sufficient content to clearly convey the provider's intent. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dialysis (a medical treatment that filters waste products and excess fluid from the blood when the kidneys fail, acting as an artificial kidney to keep the body in balance) orders for monitoring the dialysis site were complete to show the thrill (the buzzing vibration felt on the skin over a vascular access (like an AV fistula) from rapid blood flow), and bruit (the whooshing sound heard with a stethoscope, both indicating the access was working properly) would be checked daily; failed to monitor the resident's dialysis site according to the facility protocol; failed to document that the monitoring was completed; and failed to develop a care plan that included how the facility would monitor the resident's dialysis site for one sampled resident who received dialysis (Resident #57) out of 21 sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure follow-up dental appointments were made, which resulted in delay in dental treatment for one sampled resident (Resident #77) who was at risk for dental pain and infection out of 21 sampled residents. The facility Census of 105 residents. Review of the facility's Physician Order Policy dated May 2023 showed:-To clarify requirement and assure that all physicians orders were valid and safe for resident care. -Licensed nursing staff were responsible to promptly and accurately transcribe all written order. Review of the facility's Dental Services policy revised on April 2023 showed:-The admitting nurse performs a dental assessment on each resident upon admission. -If dental care is needed the nurse informs the resident and responsible party. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment for 64 sampled residents out of 73 sampled residents with room temperatures ranging from 81.8 degrees Fahrenheit (°F) to 87.0 °F and halls A, B, C, D and F temperatures ranged from 81.5 °F to 82.8 °F. The facility had failed to have a comprehensive monitoring system including documentation for the air temperatures to maintain documentation for all ongoing maintenance for cooling units in the facility and to conduct random monitoring. This had the potential to affect all residents in the building. The facility census was 116 residents. Review of the facility's Emergency Operations Plan policy dated 4/1/23 showed: -Temperature thresholds: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #316) received timely perineal care (peri-care: washing of a person's genitals and anal area) to keep the resident dry and repositioned to prevent the development of an open area to his/her tailbone and failed to ensure a resident who admitted to the facility with pressure ulcers had an admission skin assessment to include a description of the wounds, wound measurements, appropriate type and stage of wounds, and treatment orders for all wounds within six hours of admission and failed to administer antibiotics (a medicine that stops the growth or destroys bacteria) for an infected wound as ordered by the physician for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate staffing numbers to adequately provide resident care and meet resident needs. This had the potential to affect all residents who resided at the facility. The census was 122 residents. A policy regarding staffing by acuity was requested and not received at time of exit. 1. Review of the working staff schedules, dated 1/1/24 to 1/30/24 showed: -The facility had seven halls where residents resided; A-D were long term care, F-H were rehabilitation. -Each hall was assigned one Certified Nursing Assistant (CNA) each shift. -Nurses were each assigned to two halls per shift. -On 1/1/24 (holiday), two halls (F and G) did not have a CNA assigned during the day, and one hall (G) did not have a CNA at night. -On 1/2/24, two halls (D and G) did not have a CNA assigned at night. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing sheets were posted daily, visible, and accessible to residents and visitors at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 122 residents. Review of the facility's policy, dated April 2023, titled Posting of Nursing Hours showed: -Each day staff were to post, at the facility entrance, the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) scheduled; the name of the facility; the census of the facility; and the total number of hours for each position. -Staff were to post the staffing sheet to be accessible for residents, family members, and visitors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate medication storage throughout the entire facility which had the potential to affect all residents within the facility. The facility census was 122 Residents. Review of the facility's policy titled Medication Storage dated January 2020 showed: -All drug containers will be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirements. -Each prescription medication label includes: --Resident's name. --Specific direction for use, indicating route of administration. --Medication name. --Strength of medication. --Physician's name. --Date medication was dispensed. --Quantity. --Expiration date if medication not used within 24 hours. --Expiration time if medication expires in less than 24 hours. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floors under the automated dishwasher free of broken dishes, grime and debris; failed to prevent a buildup of dust on the fan blades in the dishwasher area; failed to repair a leak from one of the sinks of three-compartment sink across form the food preparation table; failed to maintain the floor under the convection oven and the six-burner stove keeping it free of grease, grime and food debris; failed to ensure there was an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage pipe from the ice machine and the drainage hole in the floor; failed to ensure the mops and brooms were stored properly in the mop closet; failed to ensure three light fixtures in the kitchen area illuminated; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure handwashing to prevent cross-contamination was completed prior to and during incontinence care for two sampled residents (Resident #90 and #69); failed to ensure appropriate hand hygiene was completed during medication administration for one sampled resident (Resident #367) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube is passed into a resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate); and failed to ensure appropriate hand hygiene was completed during wound care for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen steam table (a type of food-holding equipment designed to keep hot foods at a safe holding temperature in high-volume businesses such as kitchens) in a safe operating manner by not maintaining one well (a section of the steam table) in a working manner. This practice potentially affected 119 residents who ate food from the kitchen. The facility census was 122 residents. 1. Observation on 1/23/24 at 10:53 A.M., during the initial kitchen observation, showed one well of the steam table well not operating due to the burner of that steam table not properly connected and loosely hanging under the steam table. During an interview on 1/25/24 at 12:38 P.M., the Dietary Manager (DM) said: - A service technician came to the facility back in 11/23 to work on the steam table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system operated as per the manufacturing guidelines and with the exception granted to the facility on [DATE], by failing to ensure that all Certified Nurse's Aide (CNAs) had pagers, failed to ensure the pagers operated properly, failed to ensure the call light activation devices in the resident rooms operated properly, and failed to ensure call lights were being answered timely for three sampled residents (Resident #23, #96 and #69) out of 33 sampled residents. This practice potentially affected all residents. The facility census was 122 residents. 1. Review of the Exception letter dated 10/13/21, showed: -19 CSR 30-85.012 paragraph (124) Facilities shall provide an electrically powered nurses' call system with indicator lights at the corridor entrance of each bedroom. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third-Party Liability (TPL) form to Missouri (MO) Health Net, for three deceased residents (Resident #118, #117, and #166) within 30 days after the deaths of those three residents; and to submit a written notice to one resident (Resident #57) when his/her fund balance remained above the limit of $5,726.00 for three months. The facility census was 122 residents. 1. Review of the Closed Account Summary Report dated 9/23 through 12/23 showed: - Resident #118 passed away on [DATE], (a period of 56 days before the resident trust fund review on [DATE]) with a balance of $855.40 in his/her resident trust account. - Resident #117 passed away on [DATE], (a period of 75 days before the resident trust fund review on [DATE]) with a balance of $1,992.87 in his/her resident trust account. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the floors of resident rooms D4 and C8, free of a buildup of tube feeding debris on the tube feeding poles and the floors in those rooms; to maintain the floors in many resident rooms, free of dust and debris on the floors; to maintain ceiling vents of resident rooms and showers free of a dust buildup and on those vents; to maintain the mattresses in resident rooms D4 and D11, and G3 in an easily cleanable condition; to maintain resident rooms B2 and B12, free of urine odors; to ensure that used adult briefs were picked up from the floors of resident room B7; and to ensure that trash containers in resident room D4 were cleaned to be free of a grime buildup. The facility census was 122 residents. Record review of the facility's undated policy entitled Room Cleaning procedure, showed: Pull trash recycle. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the screening section of the abuse prevention policy, by failing to conduct Federal Indicators (FI) through the Nurse Aide (NA) Registry and to ensure they were completed prior to hire in accordance with State requirements and facility policy to ensure potential employees did not have a history of abuse or neglect or a disqualifying crime against persons registry check on 6 of 10 employees selected for the background review. This practice potentially affected all residents in the areas the staff worked. The facility census was 122 residents. Review of the Screening section the facility's policy updated 11/23 showed the following: The facility will not knowingly employ any individual who has been found guilty of abusing, neglecting or mistreating residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the admission Minimum Data Set, (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) was accurate for four sampled residents (Resident #23, #96, #366, and #369) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Coordination and Certification of Assessments dated April 2023 showed each individual assessor was responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish an activity care plan for six sampled residents (Resident #23, #96, #75, #76, #366, and #369); and to establish a comprehensive care plan for two sampled residents (Resident #75 and #76) out of 33 sampled residents. The facility census was 122 residents. Review of the National Kidney Foundation's webarticle, dated 2015, titled Hemodialysis Access (hemodialysis-the process of removing excess water, solutes, and toxins from the blood of people whose kidneys can no longer perform these functions); access-a way to reach the blood to perform dialysis) showed the proper care of an arteriovenous fistula (AV fistula-a surgical connection between a vein and artery to allow for increased blood flow) included ensuring: -Blood pressures were not obtained using the arm with the access. [...]

Inspectors wrote8. Review of Resident #366's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Muscle weakness (generalized). -Need for assistance with personal care. -Metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). Review of the resident's Care Plan dated January 2024 showed: -The resident had an Activities of Daily Living (ADL) self-care performance deficits and limitations in physical mobility related to his/her Metabolic Encephalopathy. -The resident was completely dependent on staff for showering/bathing. Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was completely dependent on facility staff for showering/bathing. Observation on 1/24/24 at 12:10 P.M. of the resident showed: -He/she was in a hospital gown. -He/she had body odor. [...]

Inspectors wrote4. Review of Resident #369's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Displaced Intertrochanteric Fracture of Left Femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), Subsequent Encounter for Closed Fracture with Routine Healing. -Metabolic Encephalopathy. -Need for Assistance with Personal Care. -Muscle Weakness (Generalized). Review of the resident's Care Plan dated January 2024 showed: -The resident had the potential for alterations in psychosocial well-being with an intervention to encourage the resident to spend time awake up and out of bed engaged in activity as tolerated and desired. -The resident had potential for poor activity involvement related to report of little interest or pleasure in doing things with the following interventions: --Enlarged monthly calendar provided in room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care for three sampled residents (Resident #90, #94 and #367) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube is passed into a resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Administration of Medications via PEG Tube dated March 2023 showed: -Check placement of the tube by gently drawing back on the position of the syringe. -Medication should be administered separately with flushing of approximately 30 cc of water before and after each medication. -Verify that the medication cup were clear of any remnants of crushed pills or liquid medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen was documented on the Resident's Physician's Order Sheet (POS) that included the amount and duration oxygen should be administered, when tubing and supplies should be changed for one sampled resident (Resident #366); failed to ensure a physician's order for a Continuous positive airway pressure (CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or mouth during spontaneous breathing) device including the settings for the device, when tubing and mask should be cleaned for one sampled Resident (Resident #366); and failed to store oxygen supplies to prevent contamination when not in use for six sampled residents (Resident #23, #96, #366, #316, #317, and #318) out of 33 sampled residents. The facility census was 122 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs during the breakfast meal on 1/29/24. This practice potentially affected 7 residents who had pureed diets. The facility census was 122 residents. 1. Review of the undated recipe for pureed scrambled eggs showed: -10 one ounce (oz.) serving of scrambled eggs. - 5 oz. of milk. Observation on 1/29/24 from 8:13 A.M. through 8:16 A.M., showed the following: - The Production Manager (PM) took 7 portions of eggs from the flat pan of scrambled eggs and placed those portions in the food processor. - The PM did not have a recipe book open during that time. - The PM did not add milk to the pureed eggs. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the hot foods of the breakfast meal on room trays for at least seven residents on the F Hall and at least six residents on the C Hall was served to residents at or close to a temperature of 120ºF (degrees Fahrenheit) including interviews with four residents sampled residents (Resident #23, #68, #317, and #65) out of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #23's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 1/9/24, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines the resident's attention, orientation and ability to register and recall new information. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pureed (cooked food, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) versions of items such as sausage and French Toast on the breakfast menu was available for 7 residents with pureed diets. The facility census was 122 residents. 1. Review of the breakfast portion of the Week 2 At-a-Glance menu, dated 1/29/24, showed the following items for breakfast on 1/29/24: -Choice of hot or cold cereal. -Egg of choice. -Sausage or bacon. -Waffles (French Toast was substituted for waffles on that day). -Syrup. -Margarine. -2% milk. -Coffee. -Condiments. Observation on 1/29/24 from 7:06 A.M. through 7:40 A.M., during the breakfast meal preparation showed: [...]

Inspectors wroteBased on interview and record review, the facility failed inquire about or address the negative balance of one resident (Resident #37) who had a negative balance since from 1/27/23 through 1/23/24 on the facility statement document. The facility census was 122 residents. 1. Review of Resident #37's deposit receipt dated 1/15/23, showed the resident received a check for $237.54 from a pension organization. Review of the resident's statement document dated 1/25/23, showed the resident withdrew $40.00 for personal needs. Review of the resident's statement document dated 1/27/23 showed the check was returned for insufficient funds which created a $48.00 negative balance in the resident's account. Review of the resident's statement document dated 3/14/23, showed a deposit of $20.00 by the resident which caused the negative balance to decline to $28.00. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) for one sampled resident (Resident #1000) who was discharged from Medicare part A services out of three residents sampled for reviewing Medicare Beneficiary Notices and out of 33 sampled residents. The facility census was 122 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold form to the resident upon or during one sampled resident's (Resident #115) unplanned hospitalization out of four closed records and 33 sampled residents. The facility census was 122 residents. Review of the facility's undated Bed Hold policy and procedure showed: -Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. -Under certain conditions, we can reserve your existing bed for you at your request so when you return to the facility, you will have the same bed and room. -The Nursing Home Care Act requires a nursing facility to hold a bed for a maximum of 10 days when you are hospitalized . The facility must hold a bed for up to 10 days during a hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to appropriately discharge on e sampled resident (Resident #115), that was a closed record, by failing to provide the resident a 30 day discharge notice and inform him/her of his/her rights to appeal; and to discharge to a placement that was comparable to the skilled services the resident was receiving at the facility out of four closed records and 33 sampled residents. The facility census was 122 residents. Review of the facility undated admission Contract, Section D, showed the facility may transfer or discharge the resident in compliance with facility standards: -If necessary for the resident's welfare and the resident's needs cannot be met in the facility. -If appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) prior to admission for two sampled residents (Residents #76 and #91) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy, dated May 2023, titled PASRR Policy showed: -Staff were to review all potential admissions Level 1 PASRR to determine if the individual would need further screening. -Staff were to review the Level 1 screening and not admit any individual with a mental or intellectual disability until the Level 2 screening process had been completed. Review of the facility's policy, dated May 2023, titled Behavior Health Services showed: [...]

Inspectors wroteBased on observation, interview or record review, the facility failed to ensure the resident's care plan was updated to show the resident's current capability/capacity for participation in activities or limitations to participating in activities for two sampled residents (Resident #6 and #366) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Care Plans dated April 2023 showed: -The comprehensive care plan was developed within seven days of CAA completion. -The baseline care plan required the following: --Initial goals based on admission orders (services planned to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being including but not limited to: Activities of Daily Living (ADLs), nutrition, fall risk, skin integrity, and pain management) --Dietary orders. --Therapy services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to have active physician order for use, monitoring/care and maintenance of a Peripherally Inserted Central Catheters (PICC) or Central Line Catheter (CVS) (is a long, thin, hollow, flexible tube that goes into a vein in your arm or chest and ends at the right side of your heart/right atrium. The PICC line is one type of catheter used to access the large veins in your chest, used to give intravenous (IV) therapy), and to document the flushing of the PICC line and dressing changes for one sampled resident (Resident #90) out of 33 sampled resident. Facility resident census of 122 residents. Review of the facility Policy for Physician Order revised on 5/2023 showed the facility will ensure all medication are administered as ordered by health professional in accordance with all state and federal guidelines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe transfer with a full body mechanical lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) for one sampled resident (Resident #69) and to ensure a comprehensive fall investigation and initial detail fall nursing note or incident note was completed for one sampled resident (Resident #49) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's Mechanical Lift Transfer policy revised 3/2023 showed: -At least two staff are required to transfer a resident with a mechanical lift. Review of the facility's Investigation policy revised 3/2023 showed: -Investigation will be completed by the Director of Nursing (DON) or designee. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's physician's orders for a catheter (a tube placed in the body to drain and collect urine from the bladder) were complete to include the catheter size and indication for the catheter, failed to assess and document the resident's ability to provide self-care of his/her catheter, failed to ensure the catheter bag was kept below his/her bladder, and failed to ensure the resident's care plan showed the resident performed self-care of his/her catheter for one sampled resident (Resident #12) out of 33 sampled residents. The facility census was 122 residents. Review of the facility Catheter policy and procedure revised 4/2023, showed: -The purpose of catheter care was to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary mental and behavioral health treatment and services, consistent with professional standards of practice, to promote mental health wellness by not providing mental health counseling and therapy services for one sampled resident (Resident #91), who had a mental health diagnosis. The facility census was 122 residents. Review of the facility's policy, dated May 2023, titled Behavior Health Services showed: -Staff were screen all residents prior to admission using the Preadmission Screening and Resident Review (PASARR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis). -Staff were to provide mental health and behavioral health services in accordance with state and federal laws. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the pharmacy failed to provide the correct anti-psychotic medication (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disorganized thinking) as ordered by the physician for one sampled resident (Resident #91), out of 33 sampled residents. The facility census was 122 residents. A written request for policies related to pharmacy services was requested and not received at time of exit. 1. Review of Resident #91's medical record showed he/she was admitted to the facility with an allergy to Seroquel (a brand name anti-psychotic medication, generic name of Quetiapine). Review of the resident's undated Order Summary Report showed the physician ordered Seroquel Extended Release 200 milligrams (mg) with a note that indicated name brand only on 12/19/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who admitted to the facility with infected pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure) received the ordered antibiotics (a drug used to treat infections caused by bacteria and other microorganisms) for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. Review of Medlineplus.gov's article, dated 5/15/18, titled Ampicillin and Sulbactam (antibiotics) Injection showed: -Missed doses could cause the infection to not be fully treated and could allow the bacteria to become resistant to this medication. Review of Medlineplus.gov's article, dated 6/15/22, titled Vancomycin (an antibiotic) Injection showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one sampled resident (Resident #65) with his/her stated food preferences as documented on his/her meal ticket out of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #65's breakfast meal ticket showed the resident wanted wheat farina (a form of milled wheat popular in the United States which was often cooked as a hot breakfast cereal), grits, raisin bran, fruit loops, and rice krispies with breakfast. -The resident wanted cottage cheese and fruit for a snack. Observation on 1/29/24 at 7:08 A.M., during the breakfast meal preparation showed the Production Manager (PM) cooked a large pot of oatmeal cereal. Further observation showed there were no other cereals cooked at that time. [...]

Inspectors wroteBased on observations and interview, the facility failed to maintain a comfortable environment and safe environment by failing to ensure the temperature was comfortable and to prevent a draft from the window in the room for two sampled residents (Residents #23 and #42) which caused the relative (Family Member E) of Resident #42 to bring in portable heaters to maintain a comfortable temperature in the room and to maintain one sampled resident's (Resident #317) toilet in good repair our of 33 sampled residents. The facility census was 122 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there were enough nursing staff available to provide resident cares for 121 residents in the facility. The facility sample was 13 residents. The facility census was 121 residents. 1. Review of the facility's Facility Assessment updated on 5/17/23 showed: -The facility was licensed for 162 beds and the average daily census was 110 residents. -The average census on the long term care unit was 75 residents and the average census on the rehabilitation unit was 30. -Of the residents in the facility who required 1-2 staff assistance or were totally dependent, 97 residents needed assistance with dressing and bathing, 89 residents needed assistance with transfers, 48 residents needed assistance with eating and 87 needed assistance with toileting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light display monitor was working properly on one hall, and to ensure call lights were answered timely for three sampled residents (Resident #5, #8 and #11) out of 13 sampled residents. The facility census was 121 residents. Review of the facility Daily Device Activity Report showed documentation that showed each time a call light was turned on. Documentation showed the date, time it was turned on, hall, bed and how long the call light was on before it was answered/turned off. Documentation from 8/29/23 to 8/31/23 showed: -On 8/29/23 on the day shift (6:00 A.M. to 6:00 P.M.) there were 12 call lights that were on longer than 20 minutes. The longest call light was on for 55 minutes. On the evening shift (6:00 P.M. to 6:00 A.M.) there were 5 call lights that were on longer than 20 minutes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to observe, monitor and assess one sampled resident (Resident #5) as he/she self-administered his/her medication, and to ensure an order for self-administration of medication was on the physician's order sheet out of 13 sampled residents. The facility census was 121 residents. 1. Review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, difficulty walking, kidney disease, heart failure, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), hypotension (low blood pressure) and anemia (low iron). [...]

Inspectors wroteBased on interview and record review, the facility staff failed to administer the correct form of insulin to one sampled resident (Resident #2) out of three sampled residents for insulin administration. The facility census was 121 residents. On 9/7/23 the Administrator was notified of the past noncompliance which occurred on 8/20/23. Chief Nursing Officer (CNO) provided immediate education to nursing staff on medication administration, including accessing the emergency medications, two person verification process added to all insulin orders and education on the five rights of medication administration. All education to nursing staff was done prior to the start of shift. The deficiency was corrected on 8/21/23. Review of the facility policy titled Insulin Administration Procedure, dated November, 2018 showed: -Insulin is only given with a physician or nurse practitioner order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the area under the automated dishwasher free of dishes and debris; to maintain the wall mounted fan free of a heavy dust buildup in the dishwashing area; to maintain two out of three cutting boards without numerous grooves, indentations and stains, which made the cutting boards not easy to clean; to remove food debris such as a discarded sausage patty, jelly packets from under the steam table towards the front of the kitchen; to label a container which contained a white powdery substance; to take and record a temperature of unpasteurized eggs, a potentially hazardous food (PHF-a term used by food safety organizations to classify foods that require time-temperature control to keep them safe for human consumption) before placing them in a pan to be sent to the C and D hall kitchenette; [...]

Inspectors wroteBased on interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), which included the following: a risk assessment to identify where waterborne pathogens could grow and spread, diagrams of which hot water heaters provide hot water to which sections of the facility, testing protocols with acceptable ranges for control measures when control measures in water from the water company were not maintained, how will facility account for changes in water quality such as water main breaks and construction and specific actions that would be taken in response to a legionella positive water sample. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its call light system was maintained in compliance with the stipulations outlined in their state approved exceptions letter dated 10/13/21. This practice potentially affected all residents. The facility census was 103 residents. Record review of the exception letter regarding call lights showed: -The facility had an approved exception for complying with state regulation 19 CSR 30-85.012 (124) Facilities shall provide an electrically-powered nurses' call system with indicator lights at the corridor entrance of each bedroom. Audible signals and indicating panels shall be located in each nurses' station and utility room. Facilities shall provide signal buttons at the head of each resident bed, in each toilet room and in each bathroom. -The following stipulations were spelled out in the exception letter: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's bed fit him/her properly for one sampled resident (Resident #194); failed to ensure resident needs were met by facility staff not answering call lights in a timely manner for five sampled residents (Residents #62, #194, #80, #26, and #88) and three supplemental residents (Residents #4, #68 and #12); and to ensure call lights were within reach for one sampled resident (Resident #17) and two supplemental residents (Residents #302, and #303) out of 21 sampled residents. The facility census was 103 residents. Record review of the facility's call light policy dated November 2018 showed: -The call light system was provided as a tool for residents to communicate with staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain authorization forms for three sampled residents (Resident's #30, #43 and #63) out of five sampled residents selected for the resident trust fund review portion of the survey. The facility census was 103 residents. 1. Record review on 6/24/22, of authorization forms for the five residents selected, showed: - The absence of authorization forms for Resident's #30 and #43. - Resident #63 did not sign the authorization forms. During an interview on 6/24/22 at 11:43 A.M., the Business Office Manager (BOM) said Resident #30 had been at facility since 5/31/19 and has had a guardian since 5/28/19. During an interview on 6/24/22 at 11:45 A.M., the BOM said Resident #43 had been at facility since 11/20/20, and has had a guardian since 6/27/19. During an interview on 6/24/22 at 11:49 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to reconcile (to account for) the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis and to ensure there were resident signature approved withdrawals which accurately reflected the amount of money in the petty cash in the account at the beginning of June 2022. This practice potentially affected 48 residents who had resident trust accounts. The facility census was 103 residents. 1. Record review of the monthly accounts for the months of June 2021 through May 2022 showed the absence of documentation of the ending balances for petty cash for the months of June 2021 through May 2022. During an interview on 6/24/22 at 11:04 A.M., the Business Office Manager (BOM) said: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one party (the surety or bond company) guarantees the performance or obligations of a second party (the principal (the nursing home) to a third party (the oblige--the residents who are a part of the resident trust)) that was one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 48 residents who allowed the facility to manage their resident funds. The facility census was 103 residents. 1. Record review of the instructions for determining what a surety bond amount should be, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the floor in the restroom of Resident #193's room free of a sticky substance; to maintain a shower chair in resident room H9 without a crack; to maintain commode risers (a device which fit over a commode seat which adds some height to the seat, making it easier for a person to sit or stand without bending) in resident rooms H12 and F4 without rust; to maintain shower chairs in resident rooms G4 and G6, without rust; to maintain the trash container in resident room D12 without a black/brown substance which had a white substance on the black/brown substance and to maintain the floors of resident rooms C12, B9, B12, B5, A11, A7, A10, without food crumbs and debris. This practice potentially affected at least 20 residents who resided in or used those rooms. The facility census was 103 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they completed a check of the Employee Disqualification List (EDL) and/or Criminal Background Check (CBC) prior to hire for four out of 10 staff sampled. The facility census was 103 residents. Record review of the facility's background checks and pre-hire process policy dated November 2020 showed background checks should be completed prior to hire. 1. Record review of the facility's list of employees hired since their last annual survey showed employee A was hired on 2/8/22. Record review of employee A's employee files showed the EDL was requested for employee A on 2/25/22 (27 days after date of hire). 2. Record review of the facility's list of employees hired since their last annual survey showed employee B was hired on 2/15/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going staff; to verify the correct count of narcotics; and to ensure the narcotic count sheet was not pre signed before the end of a shift and to administer the correct dose of Lidocaine Cream (an anesthetic [a substance that induces insensitivity to pain] causing loss of feeling in the skin and surrounding tissues to prevent and treat pain from some procedures) for one supplemental resident (Resident #4) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations (DRR) were reviewed and acted upon by the physician for five sampled residents (Resident #39, #49, #24, #62, and #80) out of 21 sampled residents. The facility census was 103 residents. Record review of the facility's Pharmacy Services policy dated April 2022 showed: -The Pharmacy Services guideline purpose was: --To maintain accurate and timely medication records. --To minimize medication-related adverse consequences or events. --The overall goal is to ensure the safe and effective use of medications. --The Interdisciplinary Clinical Team is the responsible party. -The facility will employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication refrigerator was within range of 36 degrees Fahrenheit (F) to 46 degrees F for one out of two sampled refrigerators which stored residents' prescribed medications and failed to ensure that two medication carts were locked during medication pass. The facility census was 103 residents. Record review of the facility's policy, Refrigeration Medication Storage, dated June 2022 showed: -The facility will assure that all refrigerators and freezers were clean, contents were properly stored, and the temperatures were monitored in accordance with all state and federal regulations. -An accurately calibrated thermometer would be kept in each refrigerator at all times. -Temperatures at which drugs were stored will be maintained between 36 degrees F to 46 degrees F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the area under the automated dishwasher and resident rooms B 12, A 12 and A 3, free of gnats (small flies). The facility also failed to maintain the floors of resident rooms B 8 and B 5 free of food crumbs as to not provide harborage for ants. This practice potentially affected at least eight residents. The facility census was 103 residents. 1. Observation during the initial kitchen observation on 6/22/22 showed: -At 9:17 A.M., gnats flew around in the kitchen around the automated dishwasher area. -At 9:25 A.M., gnats flew around the area next to the breaker box on the east side of the kitchen. 2. Observation with the Maintenance Director on 6/23/22, showed: -At 2:33 P.M., many gnats flew around a cup with a brown colored drink in it, in resident room B 12. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a physician's order to keep medications at the resident's bedside and to assess the resident's ability to self administer for one supplemental resident (Resident #4) and one sampled resident (Resident #297) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -If medication was ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication. -Remain with the resident to ensure that the resident swallows the medication. -Once the resident took the medication hit save on the Electronic Medication Administration record (eMar). -NOTE: This policy did not address resident's having medications at bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medications were administered as ordered for one supplemental resident (Resident #10) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's pain management policy dated November 2018 showed: -If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the elder's care providers. -Healthcare providers that have implemented a pain control mechanism, will reassess the resident to determine amount of pain control or relief achieved. -Pain control mechanisms may include administering medications for the control or relief of pain. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. The facility had two errors out of 25 opportunities making the facility error rate 8%. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. -Remove medication from (medication) drawer and read label three times. -If there is a discrepancy between the Medication Administration Record (MAR) and the label, check orders before administering medications. Record review of the facility's Pharmacy Services dated April 2022 showed: -Assure that the correct medication is administered in the correct dose, in the correct dosage form. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage pipe from the ice machine and the floor drain on the floor next to the ice machine and failed to place a grate over an 8 inch (in.) diameter drainage hole for the washing machines in the laundry area. This practice affected two non-resident use areas. The facility census was 103 residents. 1. Observations on 6/22/22 at 9:22 A.M. and on 6/27/22 at 1:31 P.M., showed: -The absence of an air gap between the ice machine drainage pipe. -The ice machine drainage pipe resting on top of a white padding over the drainage hole under the ice machine with a black substance around the drainage pipe. [...]