Kirksville Manor Care Center

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff failed to ensure food items were sealed, labeled, dated, and stored in sanitary conditions. Staff did not practice proper hand hygiene when handling residents' drinks. The ice machine did not contain an air gap at the drain or backflow prevention device to prevent potential backflow from the drain back into the ice machine. The facility census was 56.1. Review of the facility policy, Food Receiving and Storage, dated 2001, showed the following: -Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity control, free of insects rodents and kept clean; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures to ensure resident trust accounts were not allowed to go into a negative balance for one resident (Resident #53) and failed to deposit residents' personal funds in excess of $50.00 into an interest-bearing account for two residents (Residents #15 and #2). The facility reported holding funds for nine residents. The facility census was 56. Review of the facility's undated policy, Accounting and Records of Resident Funds, showed the following:-The business office maintains a record of all financial transactions involving the resident's personal funds on deposit with the facility;-Individual accounting ledgers are maintained in accordance with generally accepted accounting principles; -The policy did not address negative balance in the resident trust fund account. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system to ensure residents' money was managed in accordance with proper accounting principles when the facility did not reconcile the residents' petty cash each month. The facility also failed to reconcile the resident trust fund bank account monthly to ensure accurate accounting of funds. The facility census was 59. Review of the undated facility policy, Accounting and Records of Resident Funds, showed the following:-The business office maintains a record of all financial transactions involving the residents' personal funds on deposit with the facility;-Individual accounting ledgers are maintained in accordance with generally accepted accounting principles. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain walls, flooring, resident sleeping rooms, resident restrooms, and shower and toilet rooms to be clean and good repair. The facility census was 56. Observations on 03/16/26 from 10:18 A.M. to 4:23 P.M. and on 03/17/26 from 10:13 A.M. to 3:24 P.M., during the Life Safety Code tour of the facility, showed the following: -In occupied resident room [ROOM NUMBER], ten wooden slats were missing from the closet door; -In occupied resident room [ROOM NUMBER], eight wooden slats were missing from the closet door. The edge of the room door was chipped and a 2-inch piece of plastic was missing from the door covering; -In the bathroom to occupied resident room [ROOM NUMBER], the floor was discolored yellow, and there was brown and black residue around the toilet which had areas of missing caulk; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update care plans to reflect current care needs for six residents (Residents #1, #34, #22, #45, #6, and #42), in a review of 18 sampled residents. The facility census was 56. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed the following:-The RAI and Care Planning as required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool;-It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #26) in a review of 18 sampled and three additional residents (Resident #32, #12 and #8), received the prescribed insulin (a hormone used to treat diabetes by controlling blood sugar levels) dosage when staff failed to prime the insulin pen prior to administration per the manufacturer's guidelines. The facility census was 56. Review of the facility's policy, Insulin Pen, revised 08/15/25, showed the following:-Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge; -Procedure: -Attach pen needle: -Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current infection control standards for seven residents (Residents #3, #1, #6, #26, #42, #4 and #45), in a review of 18 sampled and three additional residents (Residents #8, #12, and #32). [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to notify the physician for one resident (Resident #4), in a review of 18 sampled residents, when the resident had a change in condition and abnormal lab results. The facility census was 56. Review of the facility's policy for lab and diagnostic test results, last revised November 2018, showed the following:-When test results are reported to the facility, a nurse will first review the results.-A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition.-The reason for getting a test often affects the urgency of acting upon the result;-Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of bed hold policy and written notice of transfer to the resident and/or the resident's representative when three residents (Residents #2, #4, and #56), in a review of 18 sampled residents, were transferred to the hospital. The facility census was 56. Review of the facility's Bed Hold Policy, last revised October 2022, showed the following:-All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents (Residents #45 and #34), in a review of 18 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 56. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen and ensure all areas of the kitchen were clean. The census was 48. Review of the facility's Sanitation policy, revised November 2022, showed the following:-All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects;-All utensils, counters, shelves and equipment are kept clean;-Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration;-Kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1) from physical and verbal abuse. Certified Nurse Assistant (CNA) A slapped the resident with an open hand and referred to the resident as a pedophile in the presence of the resident. The facility census was 48. On 06/30/25, the administrator was notified of the past noncompliance which occurred on 6/13/25. On 6/21/25, the administrator became aware of the staff to resident abuse allegation involving Certified Nurse Assistant (CNA) A and Resident #1. Upon discovery, the facility suspended CNA A, conducted an investigation, and notified the appropriate parties. All facility staff were educated on the facility abuse policy related to physical and verbal abuse and on the expectations for monitoring for abuse and reporting abuse. The deficiency was corrected on 6/21/25. [...]

Inspectors wroteRefer to Event ID M9W912 Based on interview and record review, the facility failed to provide care and treatment following a fall with injury for one resident (Resident #9) with a personal history of a stroke and who was on Xarelto (anticoagulant or blood thinning medication) of nine sampled residents. The resident complained of right sided rib pain at the time of the fall and continued to complain of pain 9 out of 10 (on a scale from 0 to 10 with ten being the worst pain) to the right side. Approximately 2-1/2 hours after the resident was found, the resident's family member arrived at the facility to check on the resident and requested the resident be re-evaluated by staff due to the resident's severe pain, along with shortness of breath. Approximately 10-3/4 hours after the resident was found, the resident continued to complain of pain of 7 out of 10. [...]

Inspectors wroteRefer to Event ID M9W912 Based on interview and record, review the facility failed to develop a care plan with interventions to prevent falls for one resident (Resident #9) of nine sampled residents, who was at risk for falls and was admitted to the facility after having falls at home. The resident sustained a fall while at the facility on 10/21/22. Staff failed to complete a thorough post fall assessment or notify the Director of Nursing (DON), as directed by facility policy, at the time of the fall. The facility failed to communicate the resident's fall to the oncoming shift at shift change. The facility failed to communicate pertinent information regarding the fall to the on-call physician, who was not familiar with the resident which delayed evaluation and treatment. [...]

Inspectors wroteRefer to Event ID M9W912 Based on observation and interview, the facility failed to maintain resident dignity and self determination for four residents (Resident #1, #8, #2, and #7) when staff failed to provide grooming assistance to include basic haircuts. The facility census was 51.

Inspectors wroteRefer to Event ID M9W912 Based on observation, interview, and record review, the facility failed to provide three residents (Resident #7, #8 and #2 ), of nine sampled residents, with assistance with activities of daily living (ADL) when staff failed to check for incontinence. The facility failed to ensure Resident #7's hair was groomed and pulled back out of the resident's face during meals and throughout the day. The facility also failed to ensure Resident #2 received routine showers. The facility census was 51.

Inspectors wroteRefer to Event ID M9W912 Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five sampled residents (Resident #7, #8, #2, #6, and #1). The facility failed to have adequate staffing to check and provide incontinence care to residents in a timely manner, to provide routine showers to ensure good personal hygiene, to answer call lights in a timely manner and to assist residents out of bed for meals, and ensure all residents were served meals. The facility census was 51.

Inspectors wroteBased on interview and record review, the facility failed to provide care and treatment following a fall with injury for one resident (Resident #9) with a personal history of a stroke and who was on Xarelto (anticoagulant or blood thinning medication) of nine sampled residents. The resident complained of right sided rib pain at the time of the fall and continued to complain of pain 9 out of 10 (on a scale from 0 to 10 with ten being the worst pain) to the right side. Approximately 2-1/2 hours after the resident was found, the resident's family member arrived at the facility to check on the resident and requested the resident be re-evaluated by staff due to the resident's severe pain, along with shortness of breath. Approximately 10-3/4 hours after the resident was found, the resident continued to complain of pain of 7 out of 10. [...]

Inspectors wroteBased on interview and record, review the facility failed to develop a care plan with interventions to prevent falls for one resident (Resident #9) of nine sampled residents, who was at risk for falls and was admitted to the facility after having falls at home. The resident sustained a fall while at the facility on 10/21/22. Staff failed to complete a thorough post fall assessment or notify the Director of Nursing (DON), as directed by facility policy, at the time of the fall. The facility failed to communicate the resident's fall to the oncoming shift at shift change. The facility failed to communicate pertinent information regarding the fall to the on-call physician, who was not familiar with the resident which delayed evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat four residents (Resident #2 #1 #12 and #18) with dignity and respect, in a review of 18 sampled residents. Staff did not speak respectfully to residents and did not promptly respond to an incontinent resident when he/she required staff assistance. The facility census was 49. Review of the facility's policy titled Dignity, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -Staff speak respectfully to residents at all times; -Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by promptly responding to a resident's request for toileting assistance; -Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide four residents (Resident #2, #3, #16, and #8), of 18 sampled residents, with assistance with activities of daily living (ADL). Staff did not ensure Resident #2 had glasses to see when eating, left his/her hair wet after bathing, and did reposition or check for incontinence. Staff failed to check Residents #3, #16, and #8 for incontinence and reposition the residents timely. The facility census was 49. Review of the facility's Activities of Daily Living (ADL), Supporting policy, dated March 2018, showed the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -a. Hygiene (oral care); -b. Mobility (transfer); - c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five sampled residents (Resident #7, #8, #2, #6, and #1). The facility failed to have adequate staffing to check and provide incontinence care to residents in a timely manner, to provide routine showers to ensure good personal hygiene, to answer call lights in a timely manner and to assist residents out of bed for meals, and ensure all residents were served meals. The facility census was 51. Review of the facility policy titled, Staffing, dated October 2017, showed the following: -Our facility provides sufficient numbers of staff with skill and competency necessary to provide care and services for all residents in accordance with the resident's care plan and the facility assessment; [...]

Inspectors wroteBased on interview and record review, the facility failed to review and update the facility wide assessment to determine what resources were necessary to care for residents competently during their day to day operations and emergencies as required. The facility census was 51. Review of the facility policy titled, Facility Assessment, dated October 2018, showed the following: -A facility assessment is conducted annually to determine and update capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure proper signage on the entrance of the building, notifying visitors of Coronavirus Disease 2019 (COVID-19) outbreak in the building and failed to post transmission based precaution signage outside of one COVID-19 positive room for (Resident #5) in nine sampled residents. The facility census was 51. Review of the facility policy titled, COVID-19 Prevention, Response and Reporting, dated 5/29/24, showed the following: -It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections; -The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illness present in the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #53), in a sample of three residents, who presented with diagnoses of major depressive disorder, anxiety and dementia related psychosis, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. The facility failed to report the resident's statements related to direct self harm and suicidal ideation to the resident's physician to further evaluate the resident and ensure the resident's safety. The facility also failed to provide any psychiatric services to the resident after his/her admission from an acute psychiatric hospital unit for geriatric patients. [...]

Inspectors wroteBased on observations, interviews, and facility document and policy review, the facility failed to follow the prepared menu for residents who received a regular, controlled carbohydrate, renal, or pureed diet from the facility kitchen. Specifically, the facility failed to serve the correct portion size for meat, dessert, pureed entree, pureed vegetables, and pureed beans during the evening meal on 02/13/2024. This deficiency had the potential to affect all residents who received meals from the facility. The facility census was 56.

Inspectors wroteBased on record review, interviews, and facility document and policy review, the facility failed to provide written beneficiary notices at least two days before the end of covered services for 3 (Resident #44, #55, and #264) of 3 residents reviewed for beneficiary notifications. The Administrator identified 17 residents who were discharged from Medicare Part A services with benefit day remaining in the last six months. The facility census was 56.

Inspectors wroteBased on interviews, and facility document and policy review, the facility failed to make efforts to resolve grievances for 2 (Resident #28 and Resident #45) of 2 residents reviewed for grievances and failed to ensure information on how to file a grievance was available to residents and staff. The facility census was 56.

Inspectors wrote3. A review of Resident #27's admission Record revealed the facility readmitted the resident on 05/03/2022 with diagnoses that included dementia and psychotic disorder with delusions. A review of Resident #27's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. A review of Resident #27's comprehensive care plan revealed a Focus area, initiated on 09/19/2023, that indicated the resident required treatment for behavior management. Interventions dated 09/19/2023 directed staff to review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, and to monitor/record occurrence of for [sic] target behavior symptoms and document per facility protocol. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen tubing and nasal cannulas were stored in accordance with the facility's policy when not in use for 3 (Residents #24, #44, and #19) of 5 sampled residents reviewed for respiratory care. The facility census was 56.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to store refrigerated food items in accordance with professional standards for food service safety. Specifically, the facility failed to discard milk after the use-by date and failed to label prepared sandwiches and salad with a date they were prepared or a use-by-date. This deficiency had the potential to affect all residents who received meals from the facility's kitchen. The facility census was 56.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure dignity was provided during care for one (Resident #53) of five sampled residents reviewed for dignity when facility staff failed to cover the resident when direct care was not being provided. The facility census was 56.

Inspectors wroteBased on record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a comprehensive admission Minimum Data Set (MDS) in the required timeframe for 1 (Resident #165) of 21 sampled residents reviewed for MDS assessments. The facility census was 56.

Inspectors wroteBased on record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a quarterly Minimum Data Set (MDS) in the required timeframe for 1 (Resident #1) of 21 sampled residents reviewed for MDS assessments. The facility census was 56.

Inspectors wroteBased on interviews and record review, the facility failed to provide an accurate Minimum Data Set (MDS) to assess relevant care areas for 1 (Resident #40) of 21 sampled residents reviewed for MDS assessments. The facility census was 56.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure interventions were developed and implemented in an effort to prevent falls for 1 (Resident #53) of 2 sampled residents reviewed for accidents related to falls. Specifically, Resident #53, who was identified by the facility as a high fall risk, did not have interventions to prevent potential falls initiated until 02/07/2024, after the resident had sustained multiple witnessed and unwitnessed falls. The facility census was 56.

Inspectors wroteBased on observation, record review, interviews, and facility document and policy review, the facility failed to ensure staff implemented proper hand hygiene practices while providing care to 1 (Resident #19) of 5 sampled residents reviewed for activities of daily living. Specifically, Certified Nursing Assistant (CNA) #21 did not wash her hands and change gloves after the provision of incontinence care prior to leaving the resident's room to retrieve supplies or prior to touching items in the resident's room, including the resident's oxygen nasal cannula and a mechanical lift. In addition, CNA #21 touched a soiled bed pad with her bare hands, and without washing her hands, went through the resident's dresser drawers. The facility census was 56.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and timely report changes in condition to the resident's physician for one resident (Resident #2), who was admitted to the facility following a fall, in a review of six sampled residents. The day following his/her admission, the resident developed blisters, edema, pain and bruising to his/her left knee. Staff did not consistently assess the resident's skin and his/her condition as the resident continued to have pain requiring a narcotic pain medication and received antibiotic therapy, and did not timely notify the physician of the changes in the resident's condition. The resident requested to see his/her physician (11 days after admission) and was admitted to the hospital with significant swelling from his/her knee to his/her toes, severe pain, and a wound on his/her knee. The facility census was 63. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice and as necessary to reduce the risk of falls, for one resident (Resident #20), in a review of three sampled residents. The facility also failed to safely secure the resident (Resident #20) in the facility van during a transport from the hospital where the resident was evaluated for injuries from a fall. The resident slid out of his/her wheelchair and onto the floor of the facility van. The facility staff did not report, evaluate, or modify interventions to prevent further falls during transportation in the facility van. The resident sustained multiple bruises over his/her face and arms in addition to skin tears with reported pain from his/her falls. The facility census was 63. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat four residents (Resident #3, #4, #5 and #6) in a review of six sampled residents, in a manner that promoted and/or enhanced the resident's quality of life by recognizing the resident's individuality, dignity and preferences. The facility failed to protect and promote Resident #4 and #6's wishes to wear pants or incontinence briefs while in bed. Resident #3 and #5 had cognitive impairment and were exposed to any passersby in the hall when their linens were pulled down exposing Resident #3's lower body and Resident #5's perineal area. The facility census was 58. Review of the facility policy titled Dignity, revised February 2021, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were discarded when expired; failed to ensure the ovens were free of a buildup of debris; failed to ensure staff did not touch food with contaminated gloved hands; and failed to air dry serving trays and plate covers prior to meal service. The facility's certified census was 68. 1. Observations on 02/24/20 between 9:52 A.M. and 1:30 P.M., showed the following: -In refrigerator #1 (closest to the service hall entrance from the kitchen), a 1/3 gallon of whole milk with an expiration date of 01/21/20 and one unopened quart container of liquid egg whites with an expiration date of 01/19/20; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three residents (Resident #56, #53, and #57) and one closed record resident (Resident #69), in a review six residents transferred to the hospital of 18 sampled residents, or their responsible party in writing of transfer to the hospital, including the reason for transfer or discharge, the effective date of transfer or discharge, the resident's appeal rights, contact information for the Ombudsman, and required advocacy groups. The facility also failed to notify the ombudsman of transfer/discharges to the hospital. The facility's certified census was 68. Review of the facility policy Transfer or Discharge Documentation, revised December 2016, showed the following: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan to address specific conditions, needs and risks to provide effective person centered care that met professional standards of quality of care within 48 hours of admission to the facility for four residents (Resident #43, #56, #57, and #64) in a sample of five newly admitted residents in a total sample of 18 residents. The facility failed to provide a copy of the baseline care plan to the resident or resident representative within 48 hours. The facility's certified census was 68. Review of the facility policy, Care Plans - Baseline, revised December 2016, showed the following: -Policy statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for seven residents (Resident #42, #43, #44, #51, #55, #56, and #64) in a sample of 18 residents in conjunction with the residents' comprehensive Minimum Data Set (MDS), a federally mandated assessment completed by facility staff. The facility's certified census was 68. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed the following: -Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; [...]

Inspectors wroteBased on observation, interview and record review the facility staff failed to follow physicians orders for one resident (Resident #56) for an abductor pillow (a device to be used to avoid dislocation of the resident's hip fracture that required surgery) in a sample of 18 residents. The facility also failed to follow physician orders for tube feeding administration for one resident (Resident #49) in review of 18 sampled residents. The facility's certified census was 68. The facility did not have a policy particular to following physician orders. 1. Review of Resident #56's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 2/14/20, showed the following: -admission date to the facility 9/21/19; -Diagnosis of Alzheimer's disease; -Severe cognitive impairment; -Inattention and disorganized thinking continuously; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, or follow the manufacturer's recommendations and specifications for installing and maintaining bed rails for 17 residents with side rails (Residents #7, #8, #33, #36, #42, #43, #44, #47, #49, #51, #52, #53, #55, #56, #57, #64, and #270), in a review of 18 sampled residents. The facility identified 40 residents in the facility had bed rails. The facility's certified census was 68. Review of the facility's policy Proper Use of Bed Rails, dated December 2007, showed the following: -To prevent resident injury and serve as an enabler for the resident; -The bed rails are considered a restraint when they are used to limit the resident's freedom of movement; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a registered nurse (RN) worked for a minimum of 35 hours as the director of nursing (DON). The facility's certified census was 68. Review of the facility's policy Director of Nursing Services, dated August 2006, showed the following: -The nursing services department is under the direct supervision of a RN. -The RN is licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing; -The Director of Nurses (DON) is employed full-time (40-hours per week). 1. Review of the facility's Payroll detail, dated 1/1/20-2/15/20, for the DON showed the following: -Week of 1/5/20-1/11/20: -32 hours as DON; -6.53 hours as a charge nurse; -Week of 1/12/30-1/18/20: -31.3 hours as DON; -21.72 hours as a charge nurse; -Week of 1/19/20-1/25/20: -32 hours as DON; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure four residents (Residents #31, #52, #56, and #57) in a review of 18 sampled residents, with orders for as needed (PRN) psychotropic medications were limited to 14 days except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility also failed to ensure residents had an appropriate diagnosis for use of antipsychotic medication and hypnotic medication for one resident (Resident #56). The facility's certified census was 68. 1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/19, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Resident #38, #57 and #270) in a review of 18 sampled residents, were free from significant medication errors. Staff failed to prime (remove the air) from the insulin pen (prefilled pen of insulin injected under the skin used to treat diabetes dose dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration), needle as instructed by the manufacturer prior to administration of the physician prescribed dose resulting in administration of less than the ordered dose of insulin. The facility's certified census was 68. 1. During an interview on 3/3/20, at 10:31 A.M., the director of nursing (DON) said the facility did not have a policy for insulin pen administration. 2. [...]

Inspectors wroteBased observation, interview and record review the facility failed to remove and destroy outdated medications for one resident (Resident #49) in a review of 18 sampled residents and one additional resident (Resident #65), properly label one insulin pen with a resident name and open date and failed to label seven over the counter medication bottles with open dates. The facility's certified census was 68. Review of the facility policy Administering Medications, revised December 2012, showed the following: -The expiration/beyond use date on the medication label must be checked prior to administering; -When opening a multi-dose container, the date opened shall be recorded on the container; -Insulin pens containing multiple doses of insulin are for single-resident use only; -Insulin pens will be clearly labeled with the resident's name or other identifying information. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for residents on a mechanical soft diet by not serving the correct amount of mechanical meat as directed by the spreadsheet menu. The facility identified six residents with diet orders for a mechanical soft diet. The facility's certified census was 68. Review of the diet spreadsheet, dated 02/24/20, showed residents on a mechanical soft diet were to receive a #8 scoop of ground deviled pork loin at the noon meal. Observation on 02/24/20 at 12:35 P.M. showed Dietary Aide F served the lunch meal. He/She did not fill the #8 scoop completely when serving the ground pork loin to all residents on a mechanical soft diet. The #8 scoop was approximately half full. During interview on 02/24/20 at 1:27 P.M., Dietary Aide F said he/she did not know why he/she did not serve a full scoop of the ground pork loin. [...]

Inspectors wroteBased on interview and record review facility failed to follow their antibiotic stewardship policy and consistently track infections and antibiotic use for four residents (Resident #51, #33, #49, and #55) in a review of 18 sampled residents. The facility's certified census was 68. Review of the facility's policy Antibiotic Stewardship, revised November 2016, showed the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program; -Purpose is to monitor the use of antibiotics for the residents; -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name; b. Dose; c. Frequency of administration; d. Duration of treatment (start/stop date, or number of days of therapy); e. Route of administration and; f. Indications for use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight residents (Residents #56, #42, #43, #44, #47, #8, #64, and #55), of 18 sampled residents. The facility's certified census was 68. Review of the facility's policy Bed Safety, dated December 2007, showed the following: -Facility shall provide a safe sleeping environment for the resident; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches; a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective call light accommodations for two residents (Resident #33 and Resident #51) in a sample of 18 residents. The facility's certified census was 68. Review of the facility's Answering the Call Light policy, revised October 2010, showed the following: -The purpose of this procedure is to respond to the resident's requests and needs; -General Guidelines: -Explain the call light to the new resident; -Demonstrate the use of the call light; -Ask the resident to return the demonstration so that you will be sure that the resident can operate the system; -Explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works; -Be sure that the call light is plugged in at all times; [...]