Kirkwood Wellness & Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician-ordered prescription medications were received timely from the pharmacy and administered as ordered, for six residents (Residents #66, #10, #52, #93, #131, and #108). The sample was 21. The census was 91. Review of the facility's Ordering Medication policy, undated, showed:-Procedure:--Medication orders are faxed to the pharmacy and written on a medication order form provide by the pharmacy. The entry includes:---Date ordered;---Indication of new or refill order;---New orders should include: name of medication, strength of medication, dosage, time or frequency, route of medication, quantity or duration, and diagnosis or indication of use;---Reorder medication three days in advance to ensure an adequate supply is on hand; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound dressing changes were completed as ordered and as needed for two residents (Residents #12 and #123) and facility staff failed to ensure compression stockings were applied as ordered for one resident (Resident #12). The sample was 21. The census was 91. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (skin damage caused by prolonged pressure usually occurring over boney areas) when staff failed to report a new skin issue to the Wound Nurse in a timely manner, and when staff failed to implement pressure-reducing interventions timely upon identification of a new skin integrity issue for one resident (Resident #505). The census was 66. The sample was 33. Review of the Wound Management policy, dated 7/1/25, showed:-Policy: To promote healing of wounds in accordance with standards of practice;-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders pertaining to the nutritional requirements for one resident, which included no monthly weight since September 2025 and not administering a nutritional supplement as ordered. The resident had a 5.49% weight loss in four months (Resident #27). The sample was 21. The census was 91. Review of the facility's Weight Variance policy, dated July 2025, showed:-All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian (RD). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services to assist a resident (Resident #507) lacking decision-making capacity in obtaining a legal representative, despite hospital documentation identifying the need for guardianship. The facility failed to ensure admission agreements and Do Not Resuscitate (DNR, no life saving measures) code status was signed upon admission and in the medical record for two residents (Resident #507 and Resident #505). The facility failed to ensure care plan meetings were conducted quarterly and updated with the goals, medical needs, and daily living support of one resident (Resident #94). The sample size was 33. The census was 66. Review of the facility's undated Social Services Director job description, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update records of residents' personal possessions per facility policy for two sampled residents (Residents #44 and #12). The facility failed to ensure one resident received an admission packet (Resident #124). In addition, the facility failed to ensure that residents were provided an accurate admission agreement that reflected financial terms related to refundable deposits following a change in management (Resident #129). The sample size was 21. The census was 91. Review of the facility's Grievance and Missing Property policy, dated, 7/1/25, showed:-Policy: Residents and their representatives have to right to report missing items or property;-Procedure: Grievances may be presented to any staff member and the staff member may resolve the issue immediately; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure payments were issued or issued in a timely manner, to the facility's food supplier, staffing agency, dietician, and other necessary vendors utilized to provide services for the needs of residents, placing residents at risk for interruption of services and inadequate care. This deficient practice had the potential to affect all residents. The census was 91. Review of the facility's Facility Assessment, undated, showed:-Purpose: The facility assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends) and emergency operations. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not include a monthly average number of residents who required assistance with activities of daily living. The census was 91. Review of the facility's Facility Assessment, updated 12/18/25, showed:-People involved in completing: Administrator A, Director of Nursing (DON) C, and Director of Maintenance;-Date reviewed with Quality Assurance Performance Improvement (QAPI) committee: 12/18/25;-Number of licensed beds: 117;-Average daily census: 100;-Average weekday admissions by shift: 3-4;-Average weekend admissions by shift: 0-1;-Average weekday discharges by shift: 3-4;-Average weekend discharges by shift: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The sample was 21. The facility census was 91. Review of the facility's QAPI policy, dated 7/1/25, showed:-Policy: The QAPI plan will describe how the facility will ensure care and services delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress towards improvement is achieved and sustained. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) for six residents (Residents #13, #12, #63, #4, #108, and #7). The facility failed to use appropriate infection control practices during perineal care (cleaning of the genitals and rectal area) for four residents (Residents #13, #63, #4, and #11). The facility failed to disinfect a Hoyer lift (mechanical lift) in between use on two residents (Residents #7 and #91). [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The census was 91. Review of the facility's Antibiotic Stewardship policy, dated, 7/1/25, showed:-Intention: It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use;-Policy: The Medical Director, Director of Nursing (DON), Infection Prevention Control (IPC) Nurse, and Consultant Pharmacist serve as leaders of antibiotic stewardship program and receive support from the Administrator and governing officials at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer the COVID-19 vaccine for five out of five residents reviewed (Resident # 12, #13, #8, #9, and #6). The census was 91. Review of the facility's COVID Vaccine policy, dated, 7/1/25, showed:-Policy: The facility will offer the COVID vaccine to assist in mitigating the spreads of COVID-19;-Procedure: COVID-19 vaccinations shall be offered to all residents unless such immunization is medically contraindicated; Residents shall be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including the information of the benefits and risks with the Centers for Disease Control and Prevention (CDC) or Food and Drug administration (FDA); Residents shall be offered the opportunity to ask questions about the risk and benefits of the vaccination; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year and all ten were sampled. Three out of 10 CNAs did not have any documented training hours, and seven out of 10 CNAs did not have the required training hours. The facility failed to ensure all CNAs were in-serviced on dementia care and abuse and neglect. In addition, there were no CNAs that received education after September 2025. The census was 91. Review of the Facility Assessment, updated and reviewed on 12/18/25, showed Staff Training/Education and Competencies:-Abuse, neglect and exploitation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner when staff wore earbuds while providing care for one resident (Residents #11) and one resident reported that staff frequently have earphones in (Resident #44). In addition, the facility failed to ensure all residents were served meals on reusable dishware and utensils instead of Styrofoam. The sample was 21. The facility census was 91. Review of the facility's Resident Rights policy, reviewed 7/1/25, showed the facility shall treat residents with kindness, respect, dignity, and ensure residents rights are being followed. The resident/resident representative will be informed of their rights upon admission. Review of the facility's employee handbook, undated, showed non-negotiable expectations: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable food requests of offering fresh fruit for one resident (Resident #13), and five of five residents representing the resident council who said they wanted fresh fruit. Fresh fruit was listed on the facility menu as an option for breakfast. The facility census was 91. Review of the facility's Resident Rights policy, reviewed 7/1/25, showed:-Policy: The facility shall treat residents with kindness, respect, dignity, and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission;-Resident rights included the right to:--Exercise rights;--Planning/implementing care;--Make decision/choices;--Self-determination. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances raised by resident council members were acted upon in a timely manner and failed to give a rationale as to why the grievances were not acted upon. This deficient practice had the potential to affect all residents in the facility. The sample was 21. The census was 91. Review of the facility's Grievance policy, dated 7/1/25, showed:-Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at this facility, without fear of discrimination or reprisal;-Procedure: Grievances may be presented to any staff member; the staff member may resolve the issue immediately. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the federal survey results for all residents and visitors to view. The sample was 21. The census was 91. Observation of the front desk area on 1/23/26 at 10:30 A.M., showed no sign indicating the location of the facility's survey results. No survey results documentation was visible. During a group interview on 1/26/26 at 11:30 A.M., five out of five residents, whom the facility identified as alert and oriented, said they did not know where the survey results were located. During an interview on 1/29/26 at 2:07 P.M., Director of Nursing (DON) C said he/she expected the facility's survey results to be readily available to residents and family members. During an interview on 1/29/26 at 11:54 A.M., Administrator B said he/she updated the survey result binder this week and it was located at the front desk. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable homelike environment for three residents (Residents #78, #91 and #93). The facility also failed to keep the 200 hall shower room clean and odor free. The sample was 21. The census was 91. Review of the facility's Cleaning Resident's Rooms policy, undated, showed: -Policy: -Resident rooms at the facility are maintained and cleaned on a daily and weekly schedule; -Procedure: -Daily cleaning: -Clean the bathroom; -Dust the furniture, windowsill television and pictures; -Clean chairs, tables, and handrails with disinfection spray; -Clean door know, light switches and telephone with disinfecting spray; -Sweep and mop floors. Review of the facility's Bathroom and Shower Cleaning policy, undated, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances and prompt the facility to resolve grievances for one resident (Resident #44). In addition, five out of five residents who represent the resident council said the facility failed to properly follow up on grievances. The failure has the potential to affect all residents with grievances. The sample was 21. The census was 91. Review of the facility's Grievance and Missing Property policy, dated 7/1/25, showed:-Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at the facility, without fear of discrimination or reprisal; All residents, resident representatives, and families also have the right to report missing items or property.-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete all required background checks for newly hired employees prior to hiring for 10 out of 10 employees sampled. The facility failed to check the Nurse Aide (NA) Registry (checks for Federal Indicators (FI) given to individuals found guilty of abuse, neglect, and misappropriation of resident property) for seven out of 10 employees and failed to check either a criminal background check or the Family Care Safety Registry (FCSR, checks both the criminal background check (CBC) and employee disqualification list) for eight out of 10 employees. The census was 91. Review of the facility's Employee Background Checks policy, undated, showed:-The facility is committed to maintaining high quality care and service while protecting its residents from abuse, neglect, and exploitation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care that met professional standards of quality when staff failed to obtain weights as ordered for one resident (Resident #13) and failed to administer Vitamin D as ordered for one resident (Resident #78). The sample was 21. The census was 91. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 10/17/25, showed:-admission date 8/29/25;-Diagnoses included heart disease, kidney disease, and high blood pressure. Review of the resident's medical record, showed:-An order, dated 10/21/25, for monthly weights;-An order, dated 12/17/25, weekly weights;-No weights documented August 2025 through January 2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate activities of daily living (ADL) care to meet their needs, including showers, nail care, and assisting residents out of bed for four residents (Residents #93, Resident #12, Resident #17, and Resident #13). The sample was 21. The census was 91. Review of the facility's ADL policy, dated 7/21/25, showed the nursing staff will assist in bathing the residents to promote cleanliness and dignity. The Charge Nurse will be made aware of residents who refuse bathing. Review of the facility's Oral Hygiene policy, revised 7/1/25, showed the facility will provide oral hygiene to residents as directed by the care plan. Oral care will include cleansing the oral cavity and removing food and debris. This may reduce odors and infection and provide comfort. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent the risk of accidental hazards by failing to ensure staff used appropriate techniques during two transfers using a Hoyer lift (mechanical lift) (Residents #7 and #91) and during one assisted transfer without a gait belt (Resident #111). In addition, the facility failed to safely store a topical antiseptic solution by leaving it open in the room of a cognitively impaired resident (Resident #7). The sample was 21. The census was 91. Review of the facility's Total Lift Transfer policy, dated, 7/1/25 showed:-Policy:-The facility will utilize a total lift device on residents who are unable to assist with transfers;-Responsibility: Nursing employees, Nursing administration, Director of Nursing (DON);-Definitions: -Full body lift: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient nurse staffing on a 24-hour basis to care for resident's basic needs for three sampled residents (Residents #93, #12, and #17). The facility also failed to ensure sufficient therapy staff to provide speech therapy and restorative therapy. In addition, the facility failed to ensure new staff and/or agency staff were properly oriented. This practice had the potential to affect all residents. The sample was 21. The census was 91. Review of the facility's Facility Assessment, updated 12/18/25, showed:-People involved in completing: Administrator A, Director of Nursing (DON) C, and Director of Maintenance;-Date reviewed with Quality Assurance Performance Improvement (QAPI) committee: 12/18/25;-Number of licensed beds: 117;-Average daily census: 100;-Average weekday admissions by shift: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, four errors occurred, resulting in a 13.33% medication error rate (Residents #33, #34, #78, and #79). The census was 91. Review of the facility's Medication Administration Procedure Policy, undated, showed:-Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis;-Procedure:-Review the resident's medication administration record (MAR);-Read each order entirely;-Remove medication from drawer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete, accurate, and readily accessible to staff and leadership following the transition from electronic medical record (EMR) Program A to EMR Program B. The facility failed to ensure records from the prior system were fully integrated into the current system. The facility failed to ensure Administration had direct access to historical clinical information. This breakdown in record management created barriers to timely access to critical resident information and placed residents at risk for gaps in care, treatment decisions, and continuity of services. The sample was 33. The census was 66. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments), provided to residents upon admission, allowed the resident or his/her representative to revoke the facility's arbitration agreement within 30 days of signature. This had the potential to affect all residents admitted to the facility who signed the arbitration agreement. The facility identified 11 residents admitted in the past 30 days. The census was 91. Review of the facility's admission Agreement, showed:-Arbitration Agreement: [...]

Inspectors wroteBased on interview and record review, the facility failed to offer eligible residents for pneumococcal pneumonia (pneumonia caused by bacteria) and influenza (flu) vaccine for five out of five residents sampled for immunizations (Resident #12, #13, #8, #9, and #6). The census was 91. Review of the facility's Pneumococcal Vaccine policy, dated, 7/1/25, showed:-Policy: The opportunity to receive the pneumococcal vaccine will be extended to all residents; The facility will provide pertinent information regarding the risks and benefits of receiving the vaccine;-Procedure: Residents will be offered the pneumococcal vaccine upon admission and administration of additional doses will be completed in accordance of Center for Disease Control and Prevention (CDC) guidelines; Obtain a consent; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach for two residents (Resident #95 and Resident #11) and failing to repair a shower in the 200 hall shower room timely, requiring one resident to go to another shower room that was located further from his/her room (Resident #44). The sample was 21. The census was 91. Review of the facility's Call Lights: Accessibility and Timely Response policy, dated 7/1/25, showed:-The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain records and accounting for resident trust prior to September 2025. Issues were found for eight of eight residents investigated for resident trust funds (Residents #64, #65, #52, #7, #82, #92, #94, and #100). The facility failed to ensure residents had signed authorization for management of personal funds, failed to prevent resident accounts from balance negatives prior to cash withdrawals and/or debits for three residents, and failed to apply applicable interest to resident accounts. The census was 91. Based on interview and record review, the facility failed to maintain records and accounting for resident trust prior to September 2025. Issues were found for eight of eight residents investigated for resident trust funds (Residents #64, #65, #52, #7, #82, #92, #94, and #100). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a process to ensure refundable resident deposits were identified and returned upon discharge. This deficiency had the potential to affect recently discharged residents, which included one resident (Resident #129). The resident sample was 21. The census was 91. Review of the facility's admission agreement under the previous management company, revised on 3/22/23, showed:-To reserve a room, I agree to pay in advance: -A $6,000 interest free security deposit, which is refunded within 45 days after discharge, less balances from Medicare, insurance and hospice companies. The deposit is viewed as an asset by Medicaid and must be applied toward monthly charges to quality for Medicaid. The monthly charge for room and board starts the first day a bed is held in reserve. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 21 sampled residents had a signed advanced directive or received information about their right to formulate an advanced directive. The facility also failed to ensure code status sheets were located in the facility-designated binders on the hall (Residents #17, #52, #63, and #93). The sample was 21. The census was 91. Review of the facility's Advanced Directives policy, dated 7/1/25, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to privacy during personal care and medical treatments when staff failed to close the door to one resident's room while performing dressing changes to their nephrostomy tubes (tube that is put into the kidney to drain urine directly from the kidney), leaving the resident exposed to the hallway during care (Resident #108). The sample was 21. The census was 91. Review of the facility's Catheter Care policy, last reviewed on 7/1/25, showed:-Policy: The facility will maintain consistent and adequate hygiene standards for residents with an catheters to maintain function and prevention of infection and complications.-Responsibility: Nursing staff, licensed nurses, nursing administration, and Director Nurses (DON);-Procedures included:--Provide privacy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of alleged abuse was reported to the facility Administrator and to the Department of Health and Senior Services (DHSS) for one of 21 sampled residents (Resident #65). The census was 91. Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: Facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;-Procedure: The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were investigated in a timely manner for two of 21 sampled residents (Residents #17 and #65). The census was 91. Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: Facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;-Procedure: The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home or must be paged and informed of such incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had safe discharge plans with arrangements for services/outside resources to assist in transitioning back home, or documented discharge summaries for 2 of 2 residents reviewed for discharges (Residents #124 and #1). The sample 21. The census was 91. Review of the facility's Discharge Planning Policy, dated 7/2025, showed:-An interdisciplinary summary is completed on a resident upon discharge to assure the continuum care needs of the residents are met;-Responsibility Licensed Nurse, Social Services, Therapist, Registered Dietitian/Certified Food Service, Director, and Activities Director;-Guidelines:-A physician's order must be obtained;-Upon notification or impending discharge, the interdisciplinary team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #123) had baseline care plan completed within the first 48-hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility identified 11 newly admitted residents in the past 30 days. Of those 11, two were sampled and issues were found with one. The census was 91. Review of the facility's Comprehensive person-centered care plan policy, dated 7/1/25, showed:-Each resident will have a person-centered plan of care to identify problems, needs, strength, preferences and goals that will identify how the interdisciplinary team will provide care. -A baseline Care Plan is developed within 48 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had a comprehensive care plan completed within 7 days of completion of the resident assessment and no further out than 21 days after admission, that would address individual care for four sampled residents (Residents #1, #4, #63, and #93). The sample was 21. The census was 91. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received urinary catheter (a thin, flexible tube inserted into the body to drain urine from the bladder) care when staff failed to ensure catheter bags were positioned appropriately and failed to obtain physician orders for catheter use and care for two residents (Resident #500 and #518). The sample was 33. The census was 66. Review of the facility's Catheter Care policy, reviewed 7/1/25, showed:-Policy: Maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ostomy (medical device used to collect bodily waste) care was provided by staff and physician orders were obtained for ostomy care for one resident who had an ileostomy (surgical procedure that creates an opening (stoma) in the abdominal wall, bringing the end of the small intestine to the surface to divert waste in an external pouch) (Resident #93). The sample was 21. The census was 91. Review of the facility's Pouch Changes - Ileostomy policy, dated 7/1/25, showed:-Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) received appropriate gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) care to avoid potential complications from the tube feeding. Facility staff failed to ensure the resident's head of bed was elevated to prevent aspiration (choking). Facility staff failed to label the tube feeding bag to ensure the tube feeding formula was not in use for an excessive amount of time to prevent spoiled formula. The facility also failed to include the resident's tube feeding care on the care plan. The sample was 21. The census was 91. Review of the facility's Tube Feeding policy, dated 7/1/25, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and document informed consent for the use of side rails, to document attempted alternative approaches prior to side rail use, and to assess for the use of side rails for three residents (Residents #63, #52, and #78). The sample was 21. The census was 91. Review of the facility's Bed Rail policy, dated 7/1/25, showed:-Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication carts were free from personal items and to ensure medications were stored securely and at proper temperatures, resulting in multiple medications being discarded. In addition, the facility failed to ensure medications were appropriately labeled with open dates and/or resident names. Four medication carts were observed, and problems were found with each. The census was 91. Review of the facility's Refrigerator Temperature Monitoring Policy, dated [DATE], showed:-Purpose: To ensure the safe storage of medications, vaccines, biologicals, and other temperatures-sensitive items in compliance with Missouri Department of Health and Senior Services (DHSS), Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS) and applicable regulatory standards;-Scope: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a urinalysis as ordered in a timely manner for one resident (Resident #63). The sample was 21. The census was 91. Review of the facility's Intake and Outtake Measurement policy, dated 7/1/25, showed:-Policy: Obtain an accurate record of the resident's fluid Intake and output and information will be recorded as clinically indicated;-Procedure: Charge nurse will notify physician of any abnormality or significant imbalance between intake and output. Review of the facility's laboratory test policy, dated 7/1/25, showed:-Policy: Laboratory tests are completed as ordered by the physician;-Procedure: Licensed nurse will complete lab requisitions for routine laboratory test needing to be done on the day they are due. This will be done using the information on the lab scheduling/tracking form. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide therapy services as ordered for one resident (Resident #15) who received outside physical therapy (PT) due to inconsistent therapy provided by the facility. The facility also failed to update the resident's medical record to reflect outside therapy services. The facility also failed to offer speech therapy (ST) between 9/1/25 through 1/22/26. In addition, the facility failed to have an active restorative program in accordance with resident needs, placing residents at risk for avoidable decline. The sample was 21. The census was 91. Review of the facility's Therapy Services Policy and Procedures, reviewed 7/1/25, showed:-Policy: It is the policy of the facility to provide therapy services that promote optimal resident function, independence, safety, and quality of life. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for three residents with side rails (Residents #63, #52, and #78). The sample was 21. The census was 91. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed:-It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pain received pain medications as ordered by the physician. This affected one of three sampled residents (Resident #2). The census was 112. Review of the facility's Pain Management policy, dated 7/1/25, showed the following:-Policy: The facility will use a systematic approach to Pain Management; recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmacological/non-pharmacological interventions to assist in pain management;-Responsibility: Nursing personnel, nursing administration, and Director of Nursing (DON);-Procedure: -Evaluate/Prevent: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity when Certified Nursing Assistant (CNA) B was rough and mean to a resident during peri-care (Resident #1) and told a resident he/she did not take his/her religion seriously because he/she refused to go to church service (Resident #2). CNA B had a history of complaints from residents about being rough, bossy and intimidating. The census was 91. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of three sampled residents in certified beds (Residents #2, #3 and #4) who were at increased risk of bleeding due to receiving anticoagulant treatment. The census was 82 with 33 in certified beds. Review of the facility's Care Plan policy, dated 2/20/25, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residents medical, nursing, mental and psychosocial needs; and all services that are identified in their comprehensive assessment and meet professional standards of quality. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to discard outdated food and label, date, and cover food. Also, facility staff performed improper infection control practices while he/she prepared puree dishes and poured the food into plates. In addition, the facility also failed to ensure kitchen equipment was clean and in working condition. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 81 with 38 residents in certified beds. 1. Observations on 5/2/24 at 9:17 A.M., 5/3/24 at 7:15 A.M., 5/4/24 at 3:04 P.M., showed the following: -Storage room: -A large can of potato salad, with a best buy date of 12/23 and 12/23/19 written on the outside of the can; -A large can of Campbells soup, with an expiration date of 3/26/23 and 12/30 written on the outside of the can; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to reconcile the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis. The facility also failed to maintain enough funds in the resident trust to cover all residents with a resident trust for three months. The facility held funds for five residents. The census was 81 with 38 residents in certified beds. Review of the facility's Resident Rights policy, dated 1/10/24, showed: -Manage you money: You have the right to manage your own money or to choose someone you trust to do this for you; -In addition, if you deposit your money with the nursing home or ask them to hold or account for your money, you must sign a written statement saying you want them to do this; [...]

Inspectors wroteBased on interview and record review, the facility failed to check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry prior to hiring a new employee. In addition, the facility's policy failed to direct staff to check the NA registry on all employees prior to hire for three of five employees files reviewed. The census was 81 with 38 in certified beds. Review of the facility's undated Background Screening Investigation policy, showed: -Policy: Facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a tracking system to ensure 10 of 10 randomly selected Certified Nurse Aides (CNAs) received the required annual 12-hour resident care training, tracked and calculated by hire date. The census was 81 with 38 residents in certified beds. Review of the facility assessment, showed: -Staff training and competencies: Abuse, neglect, exploitation and reporting; -Resident rights; -Pressure ulcer prevention; -Medication administration; -Dementia care and abuse prevention; -Care for persons with cognitive impairment; -Care for persons with mental and psychosocial disorder as well as history of trauma/Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Implementing non-pharmacological interventions; -Falls; -Exercise and ambulation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control for three residents (Residents #9, #20, and #28). The facility failed to ensure the tubing for an indwelling urinary catheter (flexible tubing used to carry urine from the bladder into a drainage bag) did not drag on the floor. The facility identified two residents as having urinary catheters. Of those two, two were included in the sample and issues were identified with one (Resident #9). In addition, the facility failed to clean shared medical equipment between resident use, for two residents observed to be transferred with a mechanical lift (Residents #20 and #28). The census was 81 with 38 residents in certified beds. The sample was 12. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 28 opportunities observed, 2 errors occurred, resulting in a 7.14% error rate (Resident #19). The census was 81 with 38 residents in certified beds. Review of the facility's Administering Medications policy and procedure dated, 11/17/2023: -Policy statement: medications shall be administered in a safe and timely manner, and as prescribed; -Insulin pens containing multiple doses of insulin are for single resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident; -Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident; [...]

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to complete the Centers for Medicaid and Medicare Services (CMS) Form CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) four of four residents (Resident (R) R151, R149, R99, and R102) reviewed for advanced beneficiary notices. Failure to provide the form could result in the resident or their responsible party not being aware of the reason services were ending or of the options and cost to continue to receive services.

Inspectors wroteBased on observation, interview, record review and facility's policy, the facility failed to ensure, for one of one resident (Resident (R) 153), observed for blood glucose [sugar] via fingerstick that the resident had a physician's order for the task and, for one of one resident (R100) observed for intramuscular (IM) injection, the medication vial was not cleaned with an alcohol pad (prior to withdrawal of R100's medication into the syringe). The facility's deficient practice increased R153's risk of complications of adverse medication reaction and R100's risk of infection.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure one of one sampled resident (Resident (R) 12) reviewed for limited Range of Motion (ROM) was provided treatment/services to maintain/increase range of motion of his/her bilateral hands. The facility's deficient practice increased R12's risk of range of motion decline of his/her hands and contractures.

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to ensure an indwelling catheter was anchored to prevent excessive tension on the catheter and the catheter was not routinely (monthly) changed for one of one resident (Resident (R) 41) reviewed for catheter cares. The facility's deficient practice increased R41's risk of urethral tears, dislodgement of the catheter, and urinary tract infections.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure each resident's drug regimen was reviewed at least once a month by a licensed pharmacist for two of five residents (Resident (R) 2 and R7) reviewed for unnecessary medications. Additionally, the facility failed to ensure documented rationale for the physician's response was available for R7.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure behavior monitoring for psychotropic medications was in place to maintain the resident's highest practicable mental, physical, and psychosocial well-being for one resident of five residents (Resident (R) 7) reviewed for unnecessary medications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staffing information was complete and accurate and posted in a prominent place, in a readable format and readily available to residents and visitors. There were 46 residents residing at the facility.