Jefferson Health Care

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's environment was free from accident hazards, when one resident (Resident #1) was not secured appropriately with a lap belt in the facility van during transport on 9/8/25 and the resident was ejected from his/her wheelchair. The resident's face hit the console/cup holder in front of him/her, resulting in his/her lip bleeding and swelling and facial bruising. The resident was admitted to the hospital for observation. Facility staff did not call 911 or notify any facility staff at that time. The facility census was 64 residents. The Administrator was notified on 9/18/25 of the past noncompliance immediate jeopardy which began on 9/9/25. The facility immediately completed education for staff on the appropriate transportation policies and procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess the resident's level of acuity including how many residents were dependent on transfers, bathing, feeding assistance, and level of care needs for the resident population to determine staffing needs. The facility census was 64 residents. 1. Review of the facility's Facility Assessment, revised date 8/2/24, showed: -The facility did not have documentation showing the base staffing levels were meeting the resident's acuity or care needs. -There was no documentation that showed the number of residents that were dependent on transfers. -There was no documentation that showed the number of residents that needed bathing assistance. -There was no documentation that showed the number of residents that needed feeding assistance. During an interview on 4/4/25 at 10:50 A.M. the Administrator and Director of Nursing (DON) said: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive Quality Assurance (QA) measures that addressed the staffing needs for the residents based on the Payroll Base Journals (PBJ) reports that triggered a low staffing alert for the second and fourth quarters in the year 2024. This failure had the potential to affect all residents who currently lived in the facility. The facility census was 64 residents. Review of the QAPI Program policy, revised 2019, showed: -The quality improvement committee involves members at all levels of the facility to provide oversight for the quality assurance program. -The functions of the quality improvement committee: --Determine quality improvement programs. -Areas that may be appropriate to monitor and evaluate include: --Clinical outcomes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affected the lungs, that was characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for three sampled residents (Residents #63, #57, and #33) out of five residents sampled for TB screening; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed maintain the dignity of three sampled residents, (Resident #35, #272, and #12), out of 16 sampled residents. The facility census was 64 residents. Review of the facility's Dignity policy revised 2/2021 showed: -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continuous throughout the resident's facility stay. -Individual needs and preferences of the resident are identified through the assessment process. -Residents my exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to preclude any commingling (the mixing or blending of funds that should be kept separate) of resident funds with facility funds for five supplemental residents (Resident #172, #36, #173, #174, and #175) and one sampled resident (Resident #66). The facility census was 64 residents. Review of the facility policy Resident Trust Fund Management dated as revised [DATE] showed it did not address the improper practice of commingling resident funds with facility funds. 1. Review of an email dated [DATE] showed a refund of $56 was requested for Resident #172 in an email to the corporate business office dated [DATE]. Review of a form dated [DATE] that was attached to the printed email dated [DATE] showed a refund of $56 was due to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete discharge assessments timely when two supplemental residents who automatically triggered in the survey system (Residents #68 and #65) were discharged from the facility and failed to complete a death in facility assessment timely for one supplemental resident who automatically triggered in the survey system (Resident #4). The facility census was 64 residents. Review of the facility policy Resident Assessments dated as revised [DATE] showed: -Discharge assessments (return anticipated and return not anticipated) were required. -The Resident Assessment Instrument (RAI) User's Manual provides detailed information on timing and submission of assessments. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.19.1 dated [DATE] showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean working environment while performing feeding tube care; failed to follow standards of practice when checking placement of a feeding tube for three sampled residents (Resident #33, #17 and #2) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's undated policy, Verify Feeding Tube Placement Policy, showed: -Observe the external portion of the tube for movement of the ink mark with new tubes. -Prepare equipment at bedside, perform hand hygiene, apply gloves. -Verify tube placement via aspiration of gastric contents. -Place feeding tube on hold. Attach the syringe to the end of the feeding tube, draw back on the syringe slowly. Observe appearance of aspirate (stomach content). Slowly readminister aspirate content. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen tubing was stored in a sanitary condition for one sampled resident (Resident #32), and failed to ensure Continuous Positive Airway Pressure (CPAP - a machine that uses air pressure to keep breathing airways open while asleep) masks were stored in a sanitary condition for one sampled resident, (Resident #32) and one supplemental resident (Resident #276) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's undated policy, Oxygen Administration Policy, showed: -Cannulas and masks should be changed weekly. -Oxygen cannulas, oxygen masks, CPAP masks, should be stored in a plastic bag when not in use. 1. Review of Resident #32's care plan dated 2/3/25 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staff on the weekends to provide care and services for one sampled resident (Resident #35) and two supplemental resident's (Resident #12 and #272) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Staffing, Sufficient, and Competent Nursing, dated 09/2020 showed: Sufficient Staffing: -Licensed nurses and certified nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including: --Assuring resident safety. --Attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident. --Assessing, evaluating, planning and implementing resident care plans. --Responding to resident needs. -A licensed nurse is designated as a charge nurse on each shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA's) had competencies to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three sampled employees (CNA L, CNA M, and CNA N). The facility census was 64 residents. Review of the facility policy showed: -There was no policy on file for Certified nursing assistant competencies. 1. Review of CNA L's employee file on 4/3/25 showed: -He/She was hired as a CNA prior to 9/22/23. -No competencies in the file. 2. Review of CNA M's employee file on 4/3/25 showed: -He/She was hired as a CNA on 3/28/24. -No competencies in the file. 3. Review of CNA N's employee file on 4/3/25 showed: -He/She was hired as a CNA prior to 9/22/23. -No competencies in the file. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's prescribed medication were stored at the appropriate temperature, failed to ensure the medication room was clean, failed to ensure resident's prescribed medication had the date that it had been opened written on it, failed to ensure resident's medications were stored in a medication cart, and failed to ensure non medical objects were stored with the medications. The facility census was 64 residents. Review of the facility's policy, Medication Labeling and Storage, dated 2001 showed: -The facility stores all medications and biologicals in locked compartments under proper temperature controls. -The nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) for three residents (Resident #57, #2, and #33) and influenza (flu - an infection of the respiratory system: nose, throat and lungs) vaccines for one resident (Resident #33) out of five residents sampled for immunizations. The facility census was 64 residents. Review of the facility's Influenza Vaccine policy dated as Revised August 2016 showed: -Between October 1st and March 1st each year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated for the resident or they have already been immunized. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide COVID-19 (a highly contagious respiratory disease caused by a new coronavirus that emerged in December 2019) vaccines for five residents (Residents #2, #33, #54, #57, and #63) out of five residents sampled for immunizations. The facility census was 64 residents. Review of the facility's Coronavirus Disease (COVID-19) - Vaccination of Residents policy dated as revised May 2023 showed: -Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. -The resident (or resident representative) can accept or refuse a COVID-19 vaccine and to change his/her decision. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident timely that received Medicaid (program that helps with medical costs for some people with limited income and resources) benefits when the amount in the resident's account reached $200 less than the Supplemental Security Income (SSI) resource limit (the maximum value of assets an individual or couple can own and still be eligible for benefits) of $5,909.25 for one person and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reached the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI for one supplemental resident (Resident #36). The facility census was 64 residents. Review of the facility policy Resident Trust Fund Management dated as revised [DATE] showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of a discharge to one sampled resident (Resident #277) out of 16 sampled residents when he/she was discharged out of 16 sampled residents. The facility census was 54 residents. 1. Review of Resident#277's Post Fall Investigation Report dated 10/2/25 showed the resident was discharged to the hospital. Review of the resident's entry tracking form showed the resident returned to the facility on [DATE]. During an interview on 4/4/25 at 10:50 A.M., Licensed Practical Nurse (LPN) A said the nurse who sent the resident out to the hospital was responsible for providing the discharge notice. During an interview on 4/4/25 at 1:30 P.M., the Director of Nursing (DON) said: -The nurse who was discharging the resident should have given the resident the discharge notice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the smoking section of the care plan was up to date for one sampled resident (Resident #17) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy 'Care Plans, Comprehensive Person-Centered', dated revised 3/2022 showed: -The care plan was to be prepared by an Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative. -The Facility's IDT will develop a comprehensive care plan for each resident in accordance with Minimum Data Set (MDS -a federally mandated assessment tool to be completed by facility staff for care planning) guidelines within 7 days of admission and longer then 21 days. -The IDT team reviews and updates the care plan: --When there has been a significant change in the residents condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist two sampled residents with changing their briefs after going to the bathroom in a timely fashion for (Resident #35 and Resident #272) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Dignity, dated February 2021 showed: -Each resident should have been cared for in a manner that promoted and enhanced his/her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. -Staff were expected to promote dignity and assist residents by; -Promptly responding to a resident's request for toileting assistance. Review of the facility's policy, Staffing, Sufficient,and Competent Nursing, dated August 2022 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #35) had his/her brace applied to his/her contracted hand out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Physician Services, dated February 2021 showed: -Supervising the medical care of residents includes: -Prescribing therapy. 1. Review of Resident #35's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnoses: -Left side Hemiplegia (a muscle weakness on one side of the body). -Cerebral Infarction (Stroke -when the blood flow to the brain was disrupted, leading to brain damage). Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 12/23/24 showed: -He/She was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall prevention measures to reduce the hazards/risks as much as possible for one sampled resident, (Resident #16) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Falls and Fall Risk, Managing, dated December 2007 showed: -Based on previous evaluations and current data, the staff would have identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -The staff, with the input of the Attending Physician, would have identified appropriate interventions to reduce the risk of falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing communication, monitoring and collaboration with the dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) facility regarding dialysis care and services for one sampled resident (Resident #57) out of 16 sampled residents. The facility identified one resident as receiving dialysis. The facility census was 64 residents. Review of the facility's policy Care of a Resident with End-Stage Renal Disease (ESRD - when the kidneys are not able to function as well as necessary) dated as revised September 2010 showed residents with ESRD would be cared for according to currently recognized standards of care. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were safely administered to the correct resident by administering one supplemental resident's (Resident #20) medication to one sampled resident (Resident #35) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Administering Medications, dated April 2019 showed: -Only persons licensed by this state were to administer medications. -The individual administering the medication would have checked the label to verify the right resident, right medication before giving the medication. --NOTE: The policy did not direct staff to watch the resident take the medication, who to notify of a medication error and/or when to notify administration and physician of a medication error. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #3) was protected from verbal abuse when on 2/27/24 Certified Medication Technician (CMT) A was witnessed screaming in the resident's face telling him/her they were acting fucking stupid, and disrespectful when the resident refused to take his/her medications crushed in pudding and wanted his/her medications whole with water out of six sampled residents. The facility census was 52 residents. Review of the facility's undated Abuse and Neglect Policy showed: -The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical of chemical restraint not required to treat the resident's symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two nurses were counting narcotics at the beginning and end of their shifts; to ensure staff kept the medication carts locked when staff was not in attendance of it; to ensure the medication refrigerator was within the correct temperature range; to ensure there was a means to lock the medication safe if the electricity went off; to dispose of expired medications, and to date medications that had been opened. The facility census was 54 residents. Review of the facility's undated policy, Administering Medications, showed: -The expiration/beyond use date on the medication label must be checked prior to administering. -When opening a multi-dose container, the date opened should have been recorded on the container. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to maintain sanitary utensils and food preparation equipment; failed to safeguard against foreign material possibly getting into food and/or beverages; to change the deep fryer oil in a timely manner; failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; and to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly screen new employees for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for eight out of ten sampled new employees prior to hire. This practice had the potential to affect all residents, employees and visitors to the facility. The facility failed to ensure staff used proper infection control practices during wound care for two sampled residents (Resident #7 and #10) out of 14 sampled residents; to ensure visitors were wearing appropriate Personal Protective Equipment (PPE) while inside the building; to ensure staff were wearing appropriate PPE when entering residents room who had tested positive for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus); [...]

Inspectors wroteBased on interview and record review, the facility failed to deposit any residents' personal funds in excess of $100.00 ($50.00 if the resident's care is funded by Medicaid) in an interest bearing Resident Trust Fund (RTF) account (or accounts) and that credits all market comparable interest earned on resident's funds to that account, as required by Federal regulations and the State of Missouri statutes. This deficient practice had the potential to affect 19 residents who held an account in the facility's resident trust. The facility census was 54 residents with a licensed capacity for 118 residents at the time of the survey. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the code status was documented correctly throughout the medical record for four sampled residents (Residents #10, #44, #46 and #304) out of 14 sampled residents. The facility census was 54 residents. Review of the facility policy titled Advanced Directives dated September 2022 showed: -Do No Resuscitate (DNR a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating). -Prior to or upon admission of a resident, the social services director or designee inquired of the resident, his/her family members and/or his/her legal representative, about the existence of any written advance directives. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) for three out of ten sampled new staff prior to hire. This deficient practice had to potential to effect all residents, staff and visitors. The facility census was 54 residents. Review of the facility's Background Screening Investigations Policy, dated March 2019, showed: -The facility conducted employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents (direct access employees). -Direct Access Employee was defined as any individual who had access to a resident and had duties that involved one on one contact with a resident of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive Minimum Data Set's (MDS-a federally mandated assessment tool completed by facility staff for care planning) were completed and submitted timely for three sampled residents (Resident #41, #204, and #154 ) out of three sampled residents who triggered for late MDS assessments. The facility census was 54 residents. Review of the facility policy titled MDS Completion and Submission Timeframes dated July 2017 showed: -The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. -The assessment coordinator or designee was responsible for ensuring that resident assessments were submitted to Center for Medicare and Medicaid Services (CMS) system in accordance with current federal and state guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set's (MDS-a federally mandated assessment tool completed by facility staff for care planning) were completed and submitted timely for five sampled residents (Resident #12, #36, #21, #42, and #154) out of five sampled residents who triggered for late MDS assessments. The facility census was 54 residents. Review of the facility policy titled MDS Completion and Submission Timeframes dated July 2017 showed: -The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. -The assessment coordinator or designee was responsible for ensuring that resident assessments were submitted to Center for Medicare and Medicaid Services (CMS) system in accordance with current federal and state guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set's (MDS- a federally mandated assessment tool completed by facility staff for care planning) were submitted timely for seven sampled residents (Resident #12, #36, #21, #42, #41, #204, and #154) out of seven sampled residents who triggered for late MDS assessments. The facility census was 54 residents. Review of the facility policy titled MDS Completion and Submission Timeframes dated July 2017 showed: -The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. -The assessment coordinator or designee was responsible for ensuring that resident assessments were submitted to Center for Medicare and Medicaid Services (CMS) system in accordance with current federal and state guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set's (MDS- a federally mandated assessment tool completed by facility staff for care planning) were signed by the Registered Nurse (RN) for seven sampled residents (Resident #12, #36, #21, #42, #41, #204, and #154) out of seven sampled residents who triggered for late MDS assessments. The facility census was 54 residents. Review of the facility policy titled MDS Assessment Coordinator dated November 2019 showed: -A Registered Nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). -A RN shall be designated the responsibility of conducting and coordinating each resident's assessment. -The resident assessment coordinator must date and sign each assessment to certify that the assessment had been completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders to complete lab tests for two sampled residents (Residents #4 and #40); to accurately document the administration of as needed pain medication for one sampled resident (Resident #46); to complete weekly wound assessments by not having a measurement or indicating if the wound was worsening or improving for one sampled resident (Resident #10) who had a stage IV pressure wound (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling); and to verify the placement of a feeding tube before administering medications for one sampled resident (Resident #10) out of 14 sampled residents. The facility census was 54 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to respond timely to a call light when the resident was requesting assistance for two sampled residents (Resident #46 and #27) and to provide two baths or showers weekly for three sampled residents (Resident #10, #15, and #27) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's undated call light policy showed: -The objective was to respond to a resident's requests and needs. -The procedure was to answer call lights promptly, between three to five minutes. Review of the facility's policy on bathing did not state how often a bath or shower was to have been offered. 1. Review of Resident #46's undated care plan with an admission date of 6/16/23 showed the resident was unable to dress and transfer from one surface to another independently. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted daily in a prominent place, readily accessible to residents and visitors of the daily resident census, and the number of nursing staff for each shift. This practice had the potential to affect all residents and visitors who were inquiring about the facility staffing hours. The facility census was 54 residents. Requested the facility staffing policy on 9/20/23, 9/21/23, and 9/22/23 and did not receive it by the time of exit on 9/22/23 at 5:00 P.M. Review of the Code of Federal Regulations (CFR-the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the Federal Government) section 483.35 paragraph (g) (1)-(4) Nurse Staffing Information showed the following: -Data requirements (g) (1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set's (MDS-a federally mandated assessment tool completed by facility staff for care planning) were coded correctly and were accurate for one sampled resident(Resident #38) out of two sampled residents who triggered for inaccurate MDS assessments. The facility census was 54 residents. Review of the facility policy titled MDS Assessment Coordinator dated November 2019 showed: -Each individual who completed a portion of the assessment must certify the accuracy of that portion of the assessment by: --Dating and signing the assessment. --Identifying each section completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan that included dialysis for one sampled resident (Resident #44) out of 14 sampled residents. The facility census was 54 residents. The facility did not have a policy regarding baseline care plans. 1. Review of Resident #44's face sheet with the admission date of 6/30/23 showed the resident was dependent upon renal dialysis. Review of the resident's undated initial care plan showed: -The resident admitted to the facility on [DATE]. -No information regarding the resident receiving dialysis. Review of the resident's Physician's Order Sheet dated September 2023 showed the resident had dialysis on Mondays, Wednesdays and Fridays. During an interview on 9/22/23 at 11:06 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to care plan the resident's dental status for one sampled resident (Resident #46) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy titled, Care plans - comprehensive person-centered dated March 2022 showed: -A comprehensive, person-centered care plan designed to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. -The care plan interventions were derived from a thorough analysis of the comprehensive assessment. 1. Review of Resident #46's undated care plan with the admission date of 6/16/23 showed it included nothing about the resident's teeth or any dental needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a new physician order for wound treatment for one sampled resident (Resident #7) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Administering Medications policy revised on April 2019 showed: -Medications were administered in accordance with prescriber orders. -Pharmacy Services Regulations: --The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them. Review of the facility's Physician Services policy revised February 2021 showed: -Orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), Nurse Practitioner (NP), or clinical nurse specialist (CNS). -Supervising the medical care of residents includes (but is not limited to): --Providing consultation or treatment. [...]

Inspectors wroteBased on interview and record review, the facility nursing staff failed to report one sampled resident's (Resident #42) fall to the Director of Nursing (DON) and the Administrator timely out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Accidents and Incidents-Investigating and Reporting policy revised July 2017 showed: -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The following data, as applicable, shall be included on the Report of Incident/Accident form: --The date and time the accident or incident took place. --The nature of the injury/illness (e.g., bruise, fall, nausea, etc.). --The circumstances surrounding the accident or incident. --Where the accident or incident took place. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete accuchecks (a blood sugar reading obtained by a small sample of blood from the finger) and insulin (lowers the level of glucose (a type of sugar) in the blood) administration for one sampled resident (Resident #4) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy titled Obtaining a Fingerstick Glucose (a simple sugar found in the blood which is an important energy source) Level dated October 2011 showed: -The purpose of the fingerstick procedure was to obtain a blood sample to determine the resident's blood glucose level. -The person performing the procedure should record the information in the resident's medical record: --Date and time the procedure was performed. --Blood sugar results. --Signature and title of person recoding the data. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to schedule an appointment with an oral surgeon for one sampled resident (Resident #46) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Dental Services policy dated December 2016 showed: -Routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and emergency dental services were provided to residents through: --A contract agreement with a licensed dentist who came to the facility monthly. --A referral to the resident's personal dentist. --A referral to a community dentist. -A referral to other health care organizations that provided dental services. -Social Services representatives assisted residents with setting appointments and transportation arrangements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #34) received Restorative therapy out of 14 sampled residents. The facility census was 54 residents. The facility policy was requested and was not provided by the time of exit. 1. Review of Resident #34's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Benign neoplasm of meninges (tumor in the covering of the brain and spinal cord). -Generalized osteoarthritis (when the flexible tissue at the end of a bone wears down). -Hemiplegia (paralysis on one side of the body). -Contracture of muscle (stiffening of muscles due to disease or lack of use). Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 5/24/23 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide nurse aides competency skills training and techniques necessary for resident care. This practice had the potential to effect all residents. The facility census was 48 residents. Record review of the facility's Staff Development Program Policy, dated May 2019 showed: -Staff development was defined as initial orientation, followed by regularly scheduled in-service training programs. -The primary objective was to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. -Training methods and teaching materials were appropriate to the level of education and expected roles of those attending. -Required training topics include: --Effective communication with residents and family (direct care staff). --Resident rights and responsibilities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff and support personnel with the appropriate competencies and skills sets to safely and effectively carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required and professional standards for food service safety. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 48 residents with a licensed capacity for 118 residents at the time of the survey. 1. Record review of the facility's dietary documentation for the month of October, 2022 showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the walk-in freezer floor clean; to maintain sanitary utensils and food preparation equipment; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; and to ensure the proper labeling of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 48 residents with a licensed capacity for 118 residents at the time of the survey. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy and did not request a Criminal Background Check (CBC) prior to hire for seven sampled staff and failed to follow facility policy and did not check the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (FI-a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for seven sampled staff; failed to date when the NA registry was checked for two sampled staff; and failed to ensure they completed a check of the Employee Disqualification List (EDL-a listing of individuals who have been determined to have abused or neglected a resident, patient, client, or consumer; misappropriated funds or property belonging to a resident, patient, client, or consumer; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included the resident's vision needs, goals, outcomes and preferences for one sampled resident (Resident #44), to develop a comprehensive care plan for high risk medications and dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) for one supplemental resident (Resident #21), to develop a comprehensive care plan for depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life) and insomnia (difficulty falling asleep or staying asleep) for one sampled resident (Resident #26) and to develop a comprehensive care plan for insomnia and the use of a high risk medication for one sampled resident (Resident #38) out of 12 sampled [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Medication carts were locked when not in direct eyesight; to maintain resident privacy as a result of having the Medication Administration Record (MAR) open and visible; to ensure medications refrigerator temperatures were within the acceptable range; and to ensure the medication refrigerator temperature logs were completed monthly. The facility census was 48 residents. Record review of the facility's policy , Storage of Medications, dated November 2020 showed: the facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals used in the facility were to be stored in locked compartments under proper temperature, light, and humidity controls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the code status was the same on the Physician's Order Sheet (POS) and face sheet for two sampled residents (Resident #13 and Resident #207) out of 12 sampled residents. The facility census was 48 residents. Record review of the facility's policy, Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care) dated [DATE] showed: -Upon admission, the resident would be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) (form CMS-10123) was dated and signed by the resident or their representative for one sampled resident (Resident #28) and to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (Centers for Medicare and Medicaid Services form (CMS)-10055) was provided to the resident or their representative for one sampled resident (Resident #36) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 48 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) for one supplemental resident (Resident #1) out of 3 supplemental residents identified for MDS decrepancies. This practice of not updating the MDS had the potential to affect all residents. The facility census was 48 residents. Record review of the facility's MDS Completion and Submission Time frames dated July 2017 showed: -The facility will conduct and submit resident assessments in accordance with current federal and state submission time frames. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a death in facility tracking form for one supplemental resident (Resident #4) and to complete a discharge assessment for one supplemental resident (Resident #2) out of three supplemental residents sampled for assessments. The facility census was 48 residents. Record review of the facility's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Completion and Submission Time frames policy dated [DATE] showed: -The facility will conduct and submit resident assessments in accordance with current federal and state submission time frames. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program based on the residents' preferences for three sampled residents (Residents #51, #36 and #48) out of 12 sampled residents. The facility census was 48 residents. Record review of the facility's Activity Programs policy dated June 2018 showed: -Activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. -Encourage both independence and community interaction. -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. -The program was ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation for all visits, from all disciplines of Hospice (end of life care) services was available for one sampled resident (Resident #13) out of 12 sampled residents. The facility census was 48 residents. Record review of the facility policy, Hospice Program, dated July 2017 showed: -Hospice providers who contract with the facility; -Must have a written agreement with the facility outlining in detail the responsibilities of the facility and the hospice agency. -Are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. -Communication with the hospice provider and document such communication to ensure that the needs of the resident were addressed and met 24 hour per day. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete weekly skin assessments, to document the findings of weekly skin assessments and to document a description of a wound on the resident's right palm for one sampled resident (Resident #48) out of 12 sampled residents. The facility identified four residents with pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear). The facility census was 48 residents. Record review of the facility's undated wound and skin care protocol showed the Director of Nursing (DON) was responsible for reviewing weekly wound reports and monitoring progress or decline of any wound and assuring compliance with current standards of wound care practice. Record review of the facility's skin and wound care protocol: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Aide's (NA) A became certified within four months of completing the nurse aide training. This had to potential to effect all residents. The facility census was 48 residents. Record review of the facility's NA qualifications and Training Requirements dated May 2019 showed: -Nurse Aides must undergo a state-approved training program. -The facility will not employ any individual as a Nurse Aide for more than four months full-time, temporary, per diem, or otherwise, unless: --That individual is competent to provide designated nursing care and nursing related services. --That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a medication error rate of less than five percent by not priming an insulin pen (a device that combines insulin medication (medication used to treat high blood sugars) and syringe in one unit) before administering insulin to a diabetic resident, by administering insulin more than one hour before a resident's meal was served, and by attempting to administer a resident's bedtime dose of medication at breakfast time. There were three errors out of thirty opportunities making the error rate 10%. The facility census was 48 residents. The facility did not have a insulin pen administration policy as requested. Record review of the manufacture's instructions, Novo Nordisk (Novolog Insulin- a fast acting medication used to lower your blood sugar) , dated 3/2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or offer pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for two sampled residents (Resident #38 and #26) out of five residents sampled for immunizations. This practice had the potential to effect all residents. The census was 48 residents. Record review of the facility's Pneumococcal Vaccine policy, dated March 2022, showed: -All residents were offered pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infections. -Prior to admission residents were assessed for eligibility to receive the pneumococcal vaccine series and when indicated were offered the vaccine series within 30 days of admission to the facility, unless medically contraindicated or the resident was already vaccinated. -Assessments were conducted within five days of being admitted to the facility. [...]