Ignite Medical Resort St. Marys LLC

Inspectors wrote3. Review of Resident #62's POS dated 11/27/23 showed the following physician's orders: -Skin checks weekly. Every day shift, every Friday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's care plan dated 11/28/23 showed: -The resident was at risk for alteration in skin integrity. -The resident would remain free of new skin impairment through the review date of 8/2/2024. -The resident would receive skin/wound treatments as ordered. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was at risk for developing pressure ulcers. -The resident did not have one or more unhealed pressure ulcer(s) at stage I or higher. -The resident did not have any other ulcers, wounds, or skin problems. Review of the resident's POS dated 6/11/24 showed the following physician's orders: -Wound Care: Right Ankle: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floor under the deep fat fryer and the six burner stove free from a buildup of food debris; failed to maintain the floor under the shelves in the dry good storage room free from dried food debris; failed to maintain the utensil rack free from dust; failed to maintain the sprinkler heads over the back side of the kitchen free from a dust buildup; failed to maintain the temperature of milk in a serving container the dining room at or close to 41°F (degrees Fahrenheit) and failed to maintain the area around the door of the North entrance to the kitchen free from a buildup of dust. This practice potentially affected all residents who ate food from the kitchen. The facility census was 84 residents. 1. Observation on 8/19/24 from 9:49 A.M. to 10:13 A.M., during the initial kitchen review showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain commode risers (assistive devices to improve the accessibility of toilets to older people or those with disabilities. They can aid in transfer from wheelchairs and may help prevent falls) in resident rooms A110, A105, A102, B104, C106, C104, C102, E107, E108, G104, D107 free from areas that were not easily cleanable; failed to maintain the fan in resident rooms B105, free from a buildup of dust; failed to maintain the ceiling vent in in resident room A101; failed to ensure the floor was maintained clean in resident rooms A105 and C109; failed to ensure the countertop in the A Hall shower room was in good repair; failed to ensure the grab bar was firmly attached to the wall in the restroom of B105; and failed to ensure the shower chair in D105 was in good repair. [...]

Inspectors wroteBased on observation, interview and record review, the facility's physician failed to visit one sampled resident (Resident #8) at least once every 30 days for the first 90 days after admission and the facility failed to ensure the physician visited the resident every 60 days for five sampled residents (Resident's #25, #38, #41, #62, and #15) out of 18 sampled residents. The facility census was 84 residents. Review of the facility Physician's Visits Frequency, Timeliness and Alternates policy and procedure updated 5/2024, showed: -The Physician or Nurse Practitioner must make actual face to face contact with the resident and at the same physical location, not via a telehealth arrangement. -Residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for Gradual Dose Reduction (GDR) for psychotropic (relating to or denoting drugs that affect a person's mental state) medication in a timely manner for two sampled residents (Resident #25 and #62), failed to follow up on a physicians response to the pharmacist's Medication Regimen Review (MRR), failed to follow a physician dose recommendation, and failed to ensure appropriate indication for antipsychotic medication dose increases for one sampled resident (Resident #50) out of 18 residents. The facility census was 84 residents. Review of the facility's Pharmacy Services policy and procedure updated 5/2024, showed: -Medication Regimen Review-Reviews will be conducted in accordance with all state and federal requirements. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain hot foods on room trays for C and E Hall, at or close to a temperature of 120 °F (degrees Fahrenheit) at the time of service; failed to maintain the temperature of milk in glasses on room trays at or close to a temperature of 41 °F at the time of service; and failed to evaluate the room tray delivery procedure. This practice potentially affected at least 12 residents who resided on those halls who received room trays towards the end of the room tray delivery time for those halls. The facility census was 84 residents. Review of the Facility's policy entitled Food Temperatures, the Correct Use of the thermometer, dated 2021, showed: -To ensure food safety, food temperatures are taken and recorded. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the audible portion of the call system was operational at the Nurse's area on C Hall (a unit with residents who had some level of dementia),. This practice affected 14 residents who resided on C Hall. The facility census was 84 residents. Review of the description page of the Nurse Call system for the Touchscreen Nurse Console showed: -The Touchscreen Nurse Console is used on the nurse call system as the primary interface among users of the system. -Consoles are typically located in areas where staff congregate and need to communicate with patients, residents and fellow staff members. -The Console displays incoming calls, including calling station, room number, the bed ( A or B), call priority, elapsed time of the call, and other relevant patient information. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the covers of cleanouts (an access point which provides access to the sewer or other plumbing line so that blockages could be removed) in a tight fitting manner so the covers would not be a hazard to facility residents or staff located on C Hall and at the area between D Hall and the Rehabilitation Unit Nurse's station. This practice potentially affected 14 residents on C Hall and 19 residents who resided on D Hall and E Hall who would pass through that area. The facility census was 84 residents. 1. Observation on 8/22/24 at 11:01 A.M., showed the cleanout cover on C Hall moved around when the cover was stepped on and the blue tape which once held it to the floor, was broken. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignity and privacy while completing Activities of Daily Living (ADL-A collective term for all basic skills you need in regular daily life) and performing perineal care (care to the area between the anus and the exterior genitalia) for one sampled resident (Resident #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's Dignity policy and procedure updated in July 2024, showed: -The facility will promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident ' s dignity and respect. -All staff will provide dignity to each resident by maintaining the resident ' s privacy of body. -All staff will refrain from any practice which could be considered demeaning to an elder. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician order for self administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for two sampled residents (Resident #343 and #345) out 18 sampled residents. Facility's resident census of 84 residents. The facility did not provided a policy for Resident Self-administration of medication at time of exit. 1. Review of Resident #343's admission Face Sheet showed the resident admitted to the facility on [DATE], had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the skin issues that were identified in the initial skin assessment were acted upon timely for one sampled resident (Resident #47); failed to obtain treatment orders timely for one sampled resident (Resident #47); and failed to ensure documentation of the weekly skin assessments were completed for one sampled resident (Resident #47) who was admitted with skin issues and was at risk for developing pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body) and failed to complete and document weekly skin assessment orders and failed to follow up on a change in condition in skin for one sampled resident (Resident #62) out of 18 sampled residents. The facility census was 84 residents. [...]

Inspectors wrote2. Review of Resident #74's After Visit Summary (discharge orders) from the resident's hospital stay, dated 7/19/24, showed an instruction to facility staff to attempt a voiding trial to remove the urinary catheter in one week (7/26/24) and, if unsuccessful, consult with a urologist. Review of the resident's Care Plan, dated 7/20/24, showed he/she had a urinary catheter in place. Review of the resident's admission MDS dated [DATE], showed: -Diagnoses of high blood pressure, renal failure (inability of the kidneys to adequately filter blood), benign prostatic hyperplasia (BPH, an enlarged prostate). -The resident had an indwelling urinary catheter. -The resident was not evaluated for urinary continence. -The resident was cognitively intact. -The resident required moderate assistance from staff for toileting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen equipment was stored using the proper infection control practices when not in use for one sampled resident (Resident #37) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's policy titled Oxygen Handling and Transport dated January 2024 showed oxygen concentrators, cylinders, and equipment would be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines. 1. Review of Resident #37's face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #8) who had a diagnoses of Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) received trauma based interventions or developed a care plan that showed interventions for the staff to provide care to protect the resident and prevent trauma from recurring out of 18 sampled residents. The facility census was 84 residents. Review of the facility's policy titled Trauma Informed Care dated May 2024 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services for one sampled resident (Resident #62) who had major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and was frequently accompanied by a loss of interest in things that were once pleasurable) out of 18 sampled residents. The facility census was 84 residents. A policy was requested related to social services and no policy was received. 1. Review of Resident #62's admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Care Plan dated of 11/28/23 showed: -The resident had the potential for altercations in psychosocial well-being. -The staff needed to allow the resident time to answer questions, verbalize feelings, perceptions and fears. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician documented a rationale for why he/she disagreed with the pharmacist's recommendation in a timely manner for two sampled residents (Resident #25 and #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's Pharmacy Services policy and procedure updated 5/2024, showed: -Medication Regimen Review-Reviews will be conducted in accordance with all state and federal requirements. Pharmacist medication reviews to the physician and nursing will be completed in a timely manner, but not later than five days from receiving. -The policy did not address the physician's response to recommendations. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) sausage was made to a consistency without graininess. This practice potentially affected six residents who consume pureed diets. The facility census was 84 residents. 1. Observation on 8/22/24 at 7:50 A.M., during a taste test showed the texture of the pureed sausage, was grainy (having the existence of small particles). Observation on 8/22/24 at 7:51 A.M., showed Dietary [NAME] (DC) A tasted the pureed sausage and he/she noticed the sausage was grainy also. During an interview on 8/22/24 at 7:51 A.M., DC A said the pureed sausage needed to be smoother. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Visitor's Food Policy, by storing foods in the visitor's food refrigerator which were labeled with names of residents the food was for and the dates the foods were received. This practice potentially affected between 3-5 residents. The facility census was 84 residents. Review of the Resident/Visitor food Policy dated 10/19, showed: -Policy -This facility supports and encourages residents to always maintain autonomy of living. The residents may have personal refrigerators to store food brought to the facility by or for the resident or the resident's family. -The facility requires that all food items be stored in a manner using proper sanitation, temperature, light, moisture ventilation and security. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the cover of the outdoor dumpster was in good repair to be close fitting and failed to prevent the accumulation of trash on the ground around the outdoor dumpster. The facility census was 84 residents. 1. Observation on 8/22/24 at 10:29 A.M., showed: -The dumpster lid with a 15 inch (in.) long crack. -A significant amount of debris and trash on the ground behind and at the side of the dumpster's. During an interview on 8/22/24 at 10:34 A.M., the Environmental Services (EVS) Director said: -He/she would have to notify the dumpster company for a new dumpster container. -He/she did not know there was a crack in the lid of the dumpster. -Sometimes when employees place trash in the dumpster. they may miss at times and the trash ended up on the ground around the dumpster.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident signatures were obtained for goods and services for two sampled residents for funds (Resident #21 and #17); to disperse resident funds to the funeral home upon death for one sampled resident (Resident #268); and to submit resident money back to the State of Missouri timely for one sampled resident for funds (Resident #269). The facility census was 76 residents. A policy was requested and not received from the facility. 1. Record review of Resident #21's Resident Fund Statement dated 4/1/22 through 6/30/22 showed: -On 5/12/22 the resident received a haircut for $10.00. -On 6/24/22 the resident received a haircut for $10.00. Record review of the resident's Withdrawal Receipt dated 5/12/22 showed: -The resident received a haircut for $10.00. [...]

Inspectors wroteBased on interview and record review, the facility to ensure resident trust funds were held in the resident trust fund account and/or failed to prevent commingling of resident money in the facility operating account for seven sampled residents (Resident #269, #267, #271, #272, #273, #274, #275) who were sampled for funds. The facility census was 76 residents. A policy was requested but not received from the facility. 1. Record review of Resident #269's financial information showed: -Personal Funds Account Balance Report (a report sent to the State of Missouri to show the amount of personal funds the resident had at time of death) showed the resident passed away on 9/4/21. The form was not submitted to the State of Missouri until 4/18/22. -The resident had $3789.77 which had been held in the facility operating account and not in the resident's trust fund account. [...]

Inspectors wroteBased on record review and interview the facility failed to check results of the Employee Disqualification List (EDL) as part of the employees' complete background check for two sampled newly hired employees (Employee A and Employee F) and to check their current employees against each quarterly EDL update to assure no employees were added to the EDL since their initial or previous EDL check. The facility had 151 employees. The facility census was 76 residents. Record review of the facility's Applicant Reference and Background Checks and Licensure and Certification Verification policy, undated, showed: -All selected applicants must have references checked, licensure and/or certification verified and have background check screenings before an employment offer can be made. -A conditional offer of employment will be made to an applicant pending a complete background check. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's orders for enteral feeding (also known as tube feeding, is a way of delivering nutrition directly to your stomach or small intestine) for one sampled resident (Resident #56) out of 19 sampled residents. The facility census was 76 residents. Record review of the facility's Tube Feeding policy dated 11/19 showed: -Continuous tube feeding are based on a 22-hour consumption period or other time frame based on individual resident needs per Registered Dietician (RD) assessment and to be delivered over a 24 hour period. -There are no set hours for the tube feeding to be off. -An order was required by the physician or nurse practitioner for the type of formula and the rate. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary anti-anxiety Pro Re Nata (PRN-as needed) medications (medications which affect psychic function, behavior, or experience) were limited to 14 days for one sampled resident (Resident #2) out of 17 sampled residents. The facility census was 76 residents. Record review of the facility's Psychotropic Medications (medications which affect psychic function, behavior, or experience) policy dated 12/2019 showed: -The resident's need for the medication needed to be monitored as well as when the resident had received the optimal benefits from the medication and when the medication can be lowered or discontinued. -The physician must certify the medication was necessary to treat a specific condition or behavior. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the lid of the dumpsters were closed for three days during the survey. The facility census was 76 residents. 1. Observations on 10/18/22, 10/19/22 and 10/21/22, at 8:15 A.M., 7:22 A.M. and 5:03 A.M. respectfully, showed: -The facility had two large trash containers/dumpers with two top lids attached on each dumpster. -The two trash dumpsters were enclosed by a fenced area with its sides measuring approximately eight feet tall with a large gate enclosing the dumpsters. -On 10/18/22, two lids on one of the containers were open lids. -On 10/19/22, one lid was open on each of the dumpsters. -On 10/21/22, one lid was open on one of the containers. During an interview on 10/21/22 at 7:06 A.M., the Dietary Manager said each person that uses the dumpster is responsible for closing the lids after they discard trash.

Inspectors wroteBased on observation and interview the facility failed to ensure a call light system or alternate system to contact staff for assistance was consistently accessible within the resident's reach for one resident (Resident #46) who was dependent on staff for several Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) while he/she was in his/her room. The facility census was 76 residents. Record review of the facility's ADL policy, dated 11/2020 showed the facility will provide all residents with care, treatment and services according to the resident's individualized care plan. 1. Record review of Resident #46's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide a clean environment when they did not keep resident bathrooms and the handrail on locked unit in clean condition. Lights on the locked unit were missing covers. The facility also failed provide a laundry service that was homelike. The facility census was 75. 1. Review of the facility's housekeeping checklist included: - Resident rooms to be completed daily; - The checklist included various rooms and the stairway on the locked unit but did not specify handrails in the hallway. Review of an undated work order which specified how to submit maintenance requests. Review of Resident Council Meeting Notes for November 2019 showed: - Residents indicated their rooms need thoroughly cleaned. Observations on 1/7/20 beginning at 10:51 A.M., showed the following bathroom floors contained dirt, dust, and debris: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents and their responsible person, including the reason for the transfer, in writing and in a language they understood. This effected three out of 19 sampled residents (Residents #4, #184 and #195). The facility census was 75. Review of the facility's policy for transfers or discharges, dated 11/20/19, showed: - When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 19 sampled residents (Resident #30, #49 and #52) dependent on staff assistance for activities of daily living (ADLs) received complete perineal care. The facility census was 75. 1. Review of the facility's procedure for Peri Care, dated December 2019, showed: - Wash the perineal area wiping front to back; - Separate the perineal fold and wash downward, front to back; - Continue to wash the perineum moving from inside outward to and including the thighs; - Do not reuse same disposable wipe to clean the inner perineal fold; - Wipe the rectal area thoroughly. 2. Review of Resident #30's care plan, start date 1/25/17, showed: - Resident will have daily care needs met; - Resident is dependent on staff for toilet use; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed infection control protocols to prevent the spread of infection related to hand hygiene during resident care when staff did not create a clean field during medication administration and when staff emptied a urinary catheter (a sterile tube inserted into the bladder to drain urine) drainage bag. This affected three out of 19 sampled residents (Residents #65, #194 and #195) and one additionally sampled resident (Resident #27). The facility census was 75. 1. Review of the facility's policy related to catheter care, dated December 2019, showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections. - Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. [...]

Inspectors wroteBased on observation and interviews, the facility failed to treat residents with dignity and respect during meal times when they did not assist one of 19 sampled residents (Resident #54) who had difficulty getting food to his/her mouth. The facility censes was 75. Review of the facility's policy for Quality of Care - Dignity, dated December 2019, showed: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; - Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Review of the facility's policy for Assistance with Meals, dated November 2019, showed: - It is the facility's policy that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 1. [...]

Inspectors wroteBased on record review and interviews the facility failed to distribute interest to each resident evenly with an account in the Resident Trust Fund (RTF). This effected one sampled resident (Resident #66). The facility was holding funds for 17 residents at the time of the survey. The facility census was 75. Review of the facility policy titled Resident Trust Fund, dated April, 2018, showed the following: - Resident funds must be paid in an interest bearing account that is separate from the community's operating accounts. - Interest earned on the funds shall be credited to trust fund participant accounts on at least a quarterly basis. 1. Review of Resident #66's RTF account showed the following: - The beginning balance on 1/1/19 was $0.00; - The resident deposited $60.00 in his/her account on 5/13/19 making the balance $60.00; [...]

Inspectors wroteBased on observation, record review and interviews, the facility staff failed to ensure they provided care and treatment in accordance with professional standards of practice when staff failed to follow manufacturers' guidelines when administering medicated eye drops and nasal spray. Staff failed to follow physician orders for a wound treatment. This affected two of 19 sampled residents (Resident #65 and #27). The facility census was 75. 1. Review of the manufacturer's guideline for Flonase (used to treat seasonal allergies) showed the patient should: - Shake the medication well; - Gently blow nose before administration; - Occlude the opposite nare while administering medication. Review of Resident #65's current physician's order sheet (POS), dated January 2020, showed: - The physician ordered Flonase 50 mcg/actuation nasal spray (used to treat allergies). [...]

Inspectors wroteBased on interview and closed record review, the facility failed to ensure staff completed a comprehensive discharge summary for two of 19 sampled residents (Resident #32 and #84) to include appropriate information about the residents' diagnoses, course of illness/treatment or therapy, a post-discharge plan of care to assist the resident to adjust to his/her new living environment when applicable. The facility census was 75. Review of the facility policy titled Transfer or Discharge, Preparing a Resident for, dated November, 2019, included the following: - Residents will be prepared in advance for discharge; - When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented; - A post-discharge plan is developed for each resident prior to his or her transfer or discharge. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to date oxygen tubing and maintain oxygen concentrator filters clean and free of dust. This affected three of 19 sampled residents (Resident #75, #80, and #134). The facility census was 75. Review of the facility policy titled Respirator Care- Prevention of Infection, dated November 2018, showed the purpose of this policy is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and associates. It listed the Infection Prevention Related to Oxygen Administration as: - Change the oxygen cannula and tubing every seven days, or per state regulations (whichever is more strict) or as needed; - Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 1. [...]