Lansdowne Village

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus and recipes were followed to ensure they maintain nutritional value. Staff served the wrong meal for breakfast for one of three breakfast meal observations. Staff failed to follow the recipe for two of three puree diets to ensure proper nutritional value and texture. In addition, staff failed to follow meal tickets to ensure preferences were reasonably accommodated for one resident (Resident #24). This had the potential to affect all residents at the facility. The census was 121.1. Review of the facility's menu for the date of 9/30/25, showed cereal of choice, breakfast sandwiches, bacon, and hashbrowns. Observation of the breakfast hall tray meal service on 9/30/25 from 8:30 A.M. thorough 10:00 A.M., showed no breakfast sandwiches observed to be provided. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance. In addition, the facility failed to ensure food was palatable for one of two sample trays tested. Residents interviewed reported concerns with the palatability and flavor of food (Residents #4, #61, #75, #118, and #6). The sample was 24. The census was 121.1. During an interview on 9/26/25 at 10:11 A.M., 10 residents who represent the resident council, said the food is terrible. Sometimes it is so bad you cannot eat it. The fried eggs are hard. The oatmeal is bad. They put dislikes on their meal tickets but are still served those items. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food safety and facility policy on three of three days of observation. The facility failed to ensure the hot water in the hand washing sink was functional and failed to ensure staff washed their hands after touching their face mask, personal phone and other potentially unclean surfaces. Staff failed to clean food debris from the floors, dish washing 3-vat sink, equipment, and food preparation surfaces. Staff stored dried goods with no lids or the lids opened. In addition, drinks and other liquids were spilled in the dry storage room and not cleaned for all three days of observation. This had the potential to affect all residents who ate from the facility kitchen. The census was 121.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program in the facility kitchen. Staff failed to ensure food debris was cleaned up daily resulting in roaches being present in the kitchen. The census was 121. Review of the facility's Pest Control policy, dated 8/2/21, showed:-The facility maintains an effective pest control program to remain free of pests and rodents. Pest control strategies are developed emphasizing kitchens, cafeterias, laundries, central supply areas, loading docks, construction, activities, and other regions prone to pest infestations;-All food stored in the dietary area is kept in a designated area in securely covered containers and stored off of the floor and away from the walls. Review of 5 months of pest control visit documents, showed:-Technician visit on 5/9/25: Target issue- ants. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/and or responsible parties were notified in a timely manner when resident accounts were within $200.00 of the Medicaid limit or when the resident's account was over the Medicaid limit ($6068.80) (Residents #19, #6 and #35). The facility also failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two of three sampled residents who expired and had money in their accounts (Residents #131 and #129). The sample size was 24. The census was 121. Review of the facility's undated Business Office-Resident Trust Fund Policy and Procedure, showed:-Policy Statement: Residents of a skilled Nursing Center are to have their funds managed and personal spending money available to them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required tube feeding for nutrition received the feedings as ordered and received the care to prevent complications. One resident did not receive tube feeding as ordered when the pump, which was set at the correct rate, did not deliver the feeding at the correct rate. In addition, as a result of the slow infusion of formula, staff did not change the tube feeding bottle as frequently as they otherwise would have. The tube feeding hung for over 24 hours, on two different days of the five days of observation, putting the resident at risk for receiving spoiled formula (Resident #44). In addition, one resident with a history of pneumonia was provided personal care with their head lowered as the tube feeding infused, increasing the risk for aspiration pneumonia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve residents a nourishing snack at bedtime when the time between meals was more than 14 hours. This had the potential to affect all residents (including Residents #61, #24, #36 and #4), who ate from the facility kitchen. The sample was 24. The census was 121. Review of the facility's Meals and Snacks policy, dated 3/31/21, showed:-Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. Nutritional services shall be responsible for all food preparation including snacks and shall deliver meals to the residents or the nursing units. Snacks shall be delivered to the nursing units by nutritional services personnel. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to follow the facility's policy to use appropriate technique and hand hygiene during incontinence care (peri-care, cleansing the genitals and anal area) for 5 out of 5 residents observed (Residents #10, #59, #6, #117 and #69). The staff also failed to wear a gown when providing high contact care for residents on 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 required by the Centers for Medicare and Medicaid Services (CMS) for 5 out of 6 residents observed (Residents #6, #117, #69, #75 and #57). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity for one resident (Resident #61) when a Licensed Practical Nurse (LPN) spoke rudely to the resident. The sample was 24. The census was 121. Review of the facility's Resident Rights policy dated 4/26/23, showed:-The facility shall treat residents with kindness, respect and dignity and ensure resident rights are being followed. The resident/resident representative will be informed on their rights upon admission;-Resident rights included: Respect and dignity. Review of Resident #61's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/4/25, showed:-Cognitively intact;-Diagnoses include depression and psychotic disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to self-administer medications is protected if the interdisciplinary team has determined the practice is clinically appropriate for one resident (Resident #97) who had a desire to self-administer a medication and had an order to self-administer, with no assessment to ensure safe administration. The sample was 24. The census was 121. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, when the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) was incorrectly coded that the residents received insulin. (Residents #4 and #74). The sample was 24. The census was 121. 1. Review of Resident #4's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes;-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days: one. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with personal care received the care timely for three residents who were left wet/soiled for extended periods (Residents #10, #59 and #6). Moreover, the facility failed to ensure staff cleansed all areas of the skin for these residents during incontinence care. The sample size was 24. The census was 121. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately provide assistance to promote good nutrition. The facility identified 33 residents who received fortified foods. On one of one day of meal preparation observation, the facility failed to prepare and serve fortified food, super cereal. The facility failed to ensure one resident (Resident #11) with nutritional needs received fortified foods, health shakes and one on one meal assistance, as ordered. The sample size was 24. The census was 121. Review of the facility's Weight Variances policy, dated 3/31/21, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored appropriately. The facility identified ten medication/treatment carts and four medication rooms. Six of the ten carts and two of the four medication rooms were checked for medication storage. Issues were found in four medication carts and one medication room. Staff failed to date an opened Lispro insulin pen (fast-acting insulin used to manage blood sugar levels), to label two opened bottles of Nitroglycerin (used to treat and prevent chest pain in people with coronary artery disease) tablets, to store an opened Ensure (nutritional shakes used as meal supplement) carton with ice or refrigerate, and to make sure an opened topical cream had a cap or cover. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to schedule follow up appointments with the urologist (a doctor that specialized in the urinary system) for one resident (Resident #5) who has recurrent urinary tract infections and severe urethra erosion (damage to the urinary opening) from prolong use of an indwelling urinary catheter (flexible tubing that carries urine to outside of body into a urine catch bag). The sample size was 6. The census was 123. Review of the facility's Policy and Procedure for Physician Order, dated 9/28/2022, showed: -To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their licensed staff was competent in their knowledge of the facility policy for when to provide Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation to restore blood circulation and breathing) for one resident whose physician ordered him/her as a full code (CPR desired) when staff failed to have knowledge of when CPR would not be indicated in a full code resident, such as when there is evidence of clinical signs of irreversible death (Resident #3). This had the potential to affect 74 residents at the facility who have a full code status. The sample size was 6. The census was 120. Review of the facility's CPR policy, last reviewed [DATE], showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one resident after an aide left the resident unattended in the bathroom during toileting (Resident #33). The resident was found in the hallway across the room, laying on their back on the floor, with a gash to the forehead. The resident was sent to the emergency room and returned with bruising to the head, face, and neck areas. The census was 113. The Administrator was notified on 3/8/24 of the past non-compliance. The nursing staff immediately assessed the resident and treated for injuries. Staff called 911 and reported the unwitnessed fall to the resident's next of kin and physician. The facility immediately in-serviced staff on toileting residents. The subject matter included to never leave a resident unattended in the bathroom or shower. [...]

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 sampled residents, including one closed record (Residents #110, #51 and #112). The resident sample was 23. The census was 113. 1. Review of the facility's Comprehensive Person-Centered Care Plan Policy, revised 10/23/19, showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Procedure: The Comprehensive Person-Centered Care Plan shall be fully developed within 7 days after completion of the admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the floors in the main kitchen and walk in freezer were clean and free from trash and food debris and failed to ensure the air fryer was clean. The sample was 23. The census was 113. Review of the facility's nutritional services sanitation policy, dated 3/31/21, showed: -Policy: nutritional services shall ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with federal, state, and local regulations governing food sanitation and safety; -Procedure: personnel shall be responsible for daily, weekly, and monthly cleaning assignments as determined by the Dietary Manager and/or his/her designee. Cleaning assignments shall include equipment, cabinets, storage areas, walls, food service-related carts, and refrigeration units. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents who required staff assistance to maintain nail care were provided personal care and hygiene (Residents #112, #72 and #7). The facility also failed to maintain one resident's hair, which was matted and long (Resident #112). The sample was 23. The census was 113. Review of the facility's Nail Care policy, 7/21/22, showed: -Policy: The purpose of Nail Care is to clean the nail bed, trim nails, and prevent infection; -Nails may be cleaned during bathing; -Nursing Assistants do not trim nails on diabetic residents. -Nail Care includes daily cleaning and regular trimming; -Observe/Report changes in the skin color around the nail bed, blueness of the nails, signs of poor circulation, cracking of the skin, swelling, bleeding, etc.; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities, three errors occurred resulting in a 11.53% error rate (Residents #18, #15, and #221). The census was 113. 1. Review of the facility's Injectable Medication Administration policy, dated 8/2018, showed: -Purpose: To administer medications via subcutaneous (under the skin, as an injection), intradermal (between the layers of the skin, as an injection) and intramuscular (into the muscle, as an injection) routes in a safe, accurate, and effective manner; -Procedure: -Check order on the medication administration record (MAR) to see that an injection is currently ordered and due; -Remove air bubbles. Prime pen needle per manufactures guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free of significant medication errors related to the incorrect dosage administration of a controlled medication Ativan (lorazepam, a sedative used to treat anxiety) for one of 23 sampled residents (Resident #99). The census was 113. Review of Resident #99's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/29/23, showed: -admission date 12/22/23; -discharge date [DATE]; -Severe cognitive impairment; -Diagnoses include diabetes, dementia, end stage renal disease (ESRD) and acid reflux. Review of the a Subjective, Objective, Assessment, Plan (SOAP) note by the Nurse Practitioner (NP) Q, dated 1/17/24 at 1:40 P.M., showed: -Subjective: Resident is seen today for concerns of increase in weakness and lethargy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, medical records are maintained that are complete and accurately documented for one resident who obtained injuries and/or change in condition (Resident #33). Staff failed to accurately and completely document a the circumstances of a fight with another resident on 1/7/24, failed to document the circumstances surrounding a fall to include where the resident was found and how they were found on 2/2/24, and follow up observations and assessments regarding a change in condition on 2/7/24. The resident was transported to the hospital on all three dates. The sample was 23. The census was 113. Review of the facility's Accident and Incident documentation and investigation policy, revised 4/26/23, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate infection control practices during wound care for one resident (Resident #219) and blood glucose testing for two residents (Residents #18 and #73). The sample was 23. The census was 113. Review of the facility's Wound Management policy, reviewed 11/15/22, showed to promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of the facility's Standard Precautions policy, reviewed 10/25/22, showed: -Policy: The facility will use standard precautions which are the minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where health care is delivered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain management was provided to residents who require such services for one resident (Resident #5), who was placed on hospice and expressed pain. The facility failed to ensure the pain medication ordered by the hospice company was made available timely. This resulted in the resident expressing pain by yelling out with movement and care. In addition, staff completed wound care on the resident without waiting for pain medication to be administered. The census was 128. Review of the facility's Pain Management policy, dated 11/15/22, showed: -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; -Evaluate/prevent: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and homelike environment and provide housekeeping services necessary to maintain a sanitary interior for two residents (Residents #5 and #21). The census was 128. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence for bathing; -Diagnoses included cancer and dementia. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Physical help in part required for bathing activity; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene, for one of six sampled residents sampled (Resident #5). The facility failed to provide good grooming and personal care when the resident was observed with dirty and long finger nails and staff did not rinse soap and towel dry as directed during care. The census was 128. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence for bathing; -Diagnoses included cancer and dementia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control when staff provided wound care for a resident and failed to sanitize their hands after removing gloves and prior to touching clean surfaces. In addition, staff positioned the resident's bed so the indwelling urinary catheter bag rested directly on the floor for one resident (Resident #5). The census was 128. Review of the facility's Hand Hygiene policy, dated 4/28/22, showed: -The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections; -Hand hygiene should be performed following the clinical indications: Before/after providing care. Contact with blood, body fluids, or contaminated surfaces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a safe and effective medication system to ensure a newly admitted resident did not experience a significant medication error. The resident was admitted to the facility on [DATE] from the hospital with diagnoses of hypertension (high blood pressure), hypertensive urgency and a urinary tract infection (UTI), with a discharge order for 4 blood pressure medications and antibiotics. As of the morning of [DATE], the resident had not received the ordered medications. This resulted in the resident experiencing an elevated blood pressure of 152/92 (Resident #369). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when facility staff did not provide wound treatments as ordered. This affected three residents (Residents #101, #86, and #92) of 23 sampled residents. The census was 110. Review of the facility's Skin Management Guidelines, revised July 2017, showed: -Purpose: -To identify at-risk residents for potential breakdown or ulcerations; -To prevent breakdown of tissue or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Risk factors: -Cognitive impairment; -Exposure of skin to urinary or fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice by failing to adequately assess and treat pain for one of three residents investigated for pain concerns. The resident fell and suffered a broken hip, experienced severe pain and was not provided effective pain management (Resident #79). The facility also failed to provide ordered Tylenol for one hospice resident in pain (Resident #264). The sample was 23. The census was 110. Review of the facility's Pain Management Guidelines, revised September 2017, showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: --Recognize when a resident is experiencing pain; [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full time basis. This had the potential to affect all residents of the facility. The sample was 23. The census was 110. Review of the facility's license and certification records showed the facility was licensed for 145 beds and all 145 beds were certified for Medicaid and Medicare. Review of the Facility Assessment, updated 1/1/22, showed Social Worker Q was identified as staff completing Social Services. Review of the facility's key personnel list, received 3/14/22, showed Social Worker Q was identified in the role of the facility Social Worker. Review of Social Worker Q's employee record, showed a re-hire date of 10/22/20. He/she worked in Admissions. During an interview on 3/21/22 at 4:14 P.M., Social Worker Q said he/she worked in Social Services since 7/6/21. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to document in writing, their actions and rationale regarding residents' ongoing and/or new concerns expressed during resident group meetings regarding medications being received late or not at all, showers not received, missing property and contact information of local agencies. The facility census was 110. Review of the facility's Resident's [NAME] of Rights, undated, showed: -Residents Rights. The resident has a right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section; -The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their grievance policy and ensure residents were educated on the grievance process. The facility failed to provide prompt resolution of Resident #68's grievance regarding wound care and pain medication administration. The facility also failed to provide prompt resolution of grievances and ensure complaints of lost/stolen items were investigated for three residents (Residents #73, #43 and #7). The facility census was 110. Review of the facility's Grievance/Missing Property policy, dated 8/30/18, revised on 4/28/21, showed: -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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the state Nurse Aide (NA) Registry was checked for a Federal Indicator of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property, for nine out of ten reviewed employees. The census was 110. Review of the Facility's Abuse Prevention Policy, reviewed 4/28/21, showed: -Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Steps to prevent, detect, and report: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for 12 residents (Resident #313, #312, #314, #217, #215, #216, #214, #266, #367, #364, #368 and #101) of 23 sampled residents within 48 hours of admission to provide instructions needed for the provision of effective and person-centered care of the residents. The census was 110. Review of the facility's Comprehensive Person Centered Care Plan policy, dated 1/23/19, showed: -Definitions: --Interdisciplinary-All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; --Baseline Care Plan-Is developed within 48 hours of admission and updated with a change in resident condition as applicable until completion of the comprehensive care plan; -Procedure: --A Baseline Care Plan is to be developed within 48 hours. [...]

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 ten of 23 sampled residents (Residents #43, #96, #42, #10, #364, #368, #101, #213, #104, and #90). The census was 110. Review of the facility's Comprehensive Person Centered Care Plan Policy, dated 1/23/19 and reviewed on 1/24/19, showed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team (IDT) will provide care. -Responsibility: Interdisciplinary Team Members; -Definitions: -Interdisciplinary-All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided according to accepted standards of clinical practice by failing to document treatments for one resident admitted with a burn (Resident #65). The facility failed to administer medications per physician's orders for ten of 23 sampled residents (Residents #32, #25, #65, #22, #68, #79, #86, #92 ,#104, and #500). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services related to communication, including speech and language service, by failing to provide language assistive devices for three of three sampled residents (Residents #212, #59, and #62) who communicated in a different language. The facility also failed to update the residents' person centered care plans with information regarding how the resident communicated with staff. The census was 110. Review of the facility's Resident Census and Conditions of Residents form, dated 3/14/22, showed the following resident characteristics: -Do not communicate in the dominant language of the facility: 4 residents; -Use non-oral communication devices: 4. 1. Review of Resident #212's admission MDS, dated [DATE], showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the transportation driver transported residents in a safe manner for two residents (Resident #89 and #500). The facility failed to ensure fall incidents were reported, investigated, interventions implemented, and post-fall monitoring completed for two of three residents sampled for falls (Resident #90 and #89). The facility also failed to ensure medications were stored safely and in accordance with facility policy and procedure. The sample was 23. The census was 110. Review of the facility's Fall Management policy, revised 7/14/17, showed: -Fall event: When a fall occurs, assess resident for injury prior to moving resident; -The Licensed Nurse will complete: Risk report in electronic medical record; -24 hour report; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff with the appropriate competencies and skill sets assisted residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure nursing staff are able to demonstrate competency in skills and techniques necessary to care for residents, by failing to provide wound treatments, failed to verify and administer medications per physician's orders, post fall assessments, assess and identify a resident's need for mental health services. In addition, the facility failed to ensure all staff were adequately trained and informed of facility policies and expectations per acceptable nursing standards. The census was 110. Review of the Facility Assessment, updated 1/1/22, showed: -Education/In-services: Communication: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident by not ensuring initial and quarterly social service assessments were completed for four (Residents #212, #110, #23 and #43) of 23 sampled residents. The facility also failed to ensure policies and procedures were in place for two of two residents reviewed for appropriateness for the secured unit (Residents #59 and #62). The census was 110. Review of the Facility Assessment, updated 1/1/22, showed: -Services provided based on resident need: Mental health and behavior; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility failed to ensure two of two medication carts contained insulin vials and insulin pens (pre-measured) that were labeled with an open date, stock medications/supplements did not exceed their expiration date, failed to follow their policy regarding labeling with expiration dates, failed to label one injectable multi-use medication vial and one multi use tube of medication with a resident's name, failed to ensure refrigerated medications did not exceed their expiration date, and failed to ensure refrigerator temperatures were monitored and recorded for two of two medication refrigerators. The sample was 23. The census was 110. Review of the medication storage policy, dated 11/2018, showed: -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a process was in place for STAT (immediate) laboratory testing for influenza to be obtained and results received in a timely manner for five residents (Residents #111, #7, #76, #27, and #45). The facility used specimen collection swabs that were not compatible with their current lab, resulting in delayed testing and diagnosis. The sample was 23. The census was 110. Review of the facility's Laboratory Test policy, reviewed 4/28/21, showed: -Policy: Laboratory tests may be completed on residents upon admission or re-admission if not already performed at the discharging facility. Lab tests are completed as ordered by the physician or physician extender such as Nurse Practitioner, Physician Assistant, and Clinical Nurse Specialist. Physician Orders supersede any guidelines listed in this policy; [...]

Inspectors wroteBased on record review and interview, facility staff did not conduct and document a thorough facility-wide assessment to determine what resources are necessary to care for residents during both day-to-day operations and emergencies. The facility failed to identify the needs of residents who do not communicate in the dominant language of the facility. The facility also failed to accurately document the number of residents with behavioral health needs. The facility census was 110. Review of the facility's Resident Census and Conditions of Residents form, dated 3/14/22, showed the following resident characteristics: -Documented signs and symptoms of depression: 41 residents; -Dementia: 26 residents; -Documented psychiatric diagnosis: 25 residents; -Medications: Any psychoactive medication: 74 residents; -Anti-psychotic medications: 30; -Anti-anxiety medications: 13; [...]

Inspectors wroteBased on interview and record review, the facility failed to vaccinate eligible residents with the Influenza vaccine as indicated by the current Centers for Disease Control (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for five out of five residents reviewed for Influenza vaccination (Residents #27, #86, #98, #104 and #23). In addition, three residents developed flu-like symptoms (Residents #27, #111, and #45) with one residents testing positive for Influenza A (Resident #27). The sample was 23 residents. The census was 110. Review of the facility's Influenza Vaccine policy, dated March 2017, showed: -Policy statement: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to close a privacy curtain or door, leaving one resident (Resident #79) in his/her gown, and one resident (Resident #86) in his/her gown with no brief, and exposed to those in the hall. The facility failed to maintain resident privacy by hanging signs regarding care for specific residents at the nurse's station, visible to all who entered the unit. The facility failed to approach and provide care to one resident (Resident #101) in a respectful and dignified manner when a nurse aide failed provide care in a calm, caring, and patient manner. The census was 110. Review of the facility's Resident [NAME] of Rights, revised November 2016, showed: -Residents Rights: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents refunds of their personal funds from the operating account in a timely manner for six residents (Resident #12, #14, #34, #35, #37 and #38). The facility census was 110. 1. Record review of the facility's maintained Accounts Receivable Report for the period 03/01/21 through 03/21/22, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #12 $2,039.00 #14 $2,170.36 #34 $ 948.00 #35 $4,511.47 #37 $3,090.00 #38 $2,476.50 Total $15,235.33 During an interview on 03/21/22 at 12:09 P.M., the Business Office Manager said the refunds should have been completed but had not been done.

Inspectors wroteBased on record review and interview, the facility failed to reconcile the resident trust account monthly, in accordance with generally accepted accounting principles. The facility census was 110. 1. Record review of the facility maintained Resident Trust Account for the period 03/01/21 through 03/21/22, showed the facility could not provide zero-balanced reconciliations for April 2021 through October 2021. During an interview on 03/21/22 at 5:40 P.M., the Regional Business Office Manager said the resident trust reconciliations should show a zero balance for a reconciliation. During an interview on 03/30/22 at 3:50 P.M., the Business Office Manager said they are researching why the account was not reconciling to a zero-balance.

Inspectors wroteBased on record review and interview, the facility failed to provide a final accounting of resident trust fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate from four residents (Resident #10, #22, #24, and #26) out of a sample of six. The facility census was 110. 1. Record review of the facility Discharge List for the period [DATE] through [DATE], showed Resident #10 expired on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility imposed a charge for a service for which payment was made under Medicaid for four residents (Resident #5, #8, #19, and #23) out of a sample of 4. The facility census was 110. Record review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed the following: 13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services include, but are not limited to, the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete admission comprehensive assessments within 14 calendar days after admission to the facility and annual comprehensive assessments not less than once every 12 months (366 days) to assess functional capacity using the resident assessment instrument (RAI) for three out of 23 sampled residents (Residents #212, #368 and #364). The census was 110. Review of the facility's MDS 3.0 policy, revised 10/7/21, showed: Policy: The Minimum Data Set (MDS) is a standard comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to CMS (Centers for Medicare and Medicaid Services) in compliance with the guidelines provided in the MDS 3.0 RAI User's Manual; -Responsibility: MDS Coordinator and Interdisciplinary Team (IDT) members; [...]

Inspectors wroteBased on interview and record review, the facility failed to assess residents using the quarterly review Minimum Data Set assessment timely for two of 23 sampled residents (Residents #7 and #6). The census was 110. Review of the facility's MDS 3.0 policy, revised 10/7/21, showed: Policy: The Minimum Data Set (MDS) is a standard comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to CMS (Centers for Medicare and Medicaid Services) in compliance with the guidelines provided in the MDS 3.0 RAI User's Manual; -Responsibility: MDS Coordinator and Interdisciplinary Team (IDT) members; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation. This affected two out of three closed records reviewed for discharge planning (Residents #218 and #314). The census was 110. Review of the facility's Discharge Plan/Summary- Voluntary policy, last reviewed 10/7/21, showed: -Policy: An interdisciplinary summary is completed on a resident upon discharge to assure the continuum of care needs of the resident are met; -Responsibility: A licensed nurse, social services, therapist, registered dietician/certified food service director, activities director; -Guidelines: -A physician order must be obtained; -Upon notification of 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 showers were received as scheduled/desired and to ensure residents were well groomed, clean, and free of odors for four (Residents #368, #313, #32, and #25) of 23 sampled residents. The census was 110. 1. Review of Resident #368's medical record showed: -An admission date of 2/22/22; -Diagnoses included diabetes, left leg above-the-knee amputation, muscle wasting and atrophy. Review of the resident's initial care plan, dated 3/15/22, showed: -Focus: At risk for skin breakdown; -Goal: Will have intact skin, free of redness, blisters, discoloration through review date; -Interventions: Pressure reducing mattress to bed, report changes in skin integrity to nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed maintain a system to obtain resident preferences related to initiation of Cardiopulmonary Resuscitation (CPR-basic life support provided prior to the arrival of emergency medical services for residents who experience cardiac arrest-cessation of respiration and/or pulse) upon admission for three residents (Residents #25, #23 and #212). The facility failed to ensure facility staff had access to current code status documentation, to follow up on changes to code status and documentation when requested by the resident (Resident #68, 98, and #73) so that staff knew immediately what action to take or not take if an emergency arises. Additionally, the facility failed to ensure the transportation driver maintained active cardiopulmonary (CPR) certification. The sample size was 23. The census was 110. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a restorative program for assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to provide recommended restorative services for two sampled residents (Resident #32 and #110) out of 23 sampled residents. The census was 110. Review of the Resident Screening and Assessment for Establishment of a Restorative Nursing Program, dated 1/1/14, showed: -Purpose: To provide guidance on a process for screening and assessing residents for further evaluation and development of a restorative nursing program and serve as a baseline of function; -Procedure: -Upon identification of a potential functional decline, the referring nurse shall complete the restorative assessment form; [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor weights and ensure nutritional services were provide to each resident, consistent with the resident's comprehensive assessment for two residents (Residents #16 and #400). Facility staff failed to ensure weights were obtained and documented as ordered. The sample was 23. The census was 110. Review of the Weight and Hydration Management Overview, dated February 2016, included: -Overview: -The resident's nutritional status will be monitored on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as body weight, protein levels, unless the clinical condition demonstrates this is not possible. The measurement of weight is a guide in determining the nutritional status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided proper respiratory care when the staff failed to follow physician orders for oxygen therapy (supplemental oxygen) and date oxygen tubing and oxygen humidifiers (device used to humidify supplemental oxygen) for three sampled residents (Residents #23, #79 and #28). The census was 110. Review of the Oxygen Administration and Storage policy and procedure, dated 1/1/14, showed: -Purpose: to ensure staff follow safety guidelines and regulations for storage and use of oxygen; -General guidelines: -Concentrator (medical device that provide extra oxygen) filters: Filters should be removed and cleaned by rinsing with clear, cool water weekly to maximize flow rate of clean air; -Tubing: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for one closed record review (Resident #42). The sample size size 23. The census was 110. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/22, showed: -Cognitively intact; -No set up/physical assist for dressing, eating, bed mobility, and personal hygiene; -One staff person assistance for transfers and toileting; -Lower extremity impairment, one side; -Walker/Wheelchair for mobility; -Diagnoses included kidney failure, diabetes, and depression. Review of the resident's current electronic physician's order sheet, showed: -An order, dated 1/15/22, up on dialysis days by 6: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate person-centered care and met the highest practicable psychosocial well-being when the facility failed to provide assessment and mental health services for two sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, 2 errors occurred resulting in an 8.0% error rate (Residents #7 and #101). The census was 110. Review of the facility's Physician Orders policy and procedure, revised 7/1/17, showed: -Purpose: To provide guidance to ensure physicians' orders are transcribed and implemented in accordance with professional standards; -Policy: -All orders shall be provided by licensed practitioners (physician, nurse practitioner (NP), or physician assistant (PA)) authorized to prescribe such orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record. The required components of a complete order: [...]

Inspectors wroteBased on interview and record review, the facility failed to timely provide or obtain the required services from an outside resource, for one resident with physician orders for rehabilitation services (Resident #25). The resident was admitted to the facility with orders for physical and occupational therapy evaluations, which were not completed timely. The sample was 23. The census was 110. Review of the Physician Orders policy and procedure, revised 7/1/17, showed: -Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; -Policy: -All orders shall be provided by licensed practitioners (physician, nurse practitioner (NP), or physician assistant (PA) authorized to prescribe such orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care. The facility also failed to asses a hospice resident's pain level per the physician's order (Resident #264). The census was 110. 1. Review of Resident #264's medical record showed: -An admission date of 1/14/22; -Discharge/death in facility on 1/17/22. Review of the resident's hospital discharge instructions, dated [DATE], showed he/she was admitted for cardiac arrest. Multiple goals of care discussions were had with family and the decision to artificially prolong life was not something the resident would want. He/she was transitioned to comfort care measures. He/she was discharged to a facility on hospice. Hospice care focuses on making you comfortable during the last months of your life. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide accessible, readily available information and contact information for the State Long-Term Care Ombudsman program and the State Survey Agency that could be read by residents in the facility without assistance. This had the potential to affect all residents of the facility. The census was 110. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives of residents. The sample was 23. The census was 110. Observation on 3/14/22 at 12:00 P.M., 3/15/22 at 10:09 A.M., 3/16/22 at 9:18 A.M., 3/17/22 at 9:37 A.M., 3/18/22 at 9:16 A.M., 3/21/22 at 10:00 A.M., 3/22/22 at 10:20 A.M. and 3/28/22 at 12:30 P.M., showed no survey binder readily available, nor a sign indicating where the binder was located. During an interview on 3/23/22 at 10:45 A.M., nine out of nine active members of the resident council said they were not aware of the location of the survey binder. During an interview on 3/28/22 at 12:54 P.M., the Corporate Nurse said the survey binder was located in the front lobby. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing in a prominent place readily accessible to residents and visitors on a daily basis. The census was 110. Observations from 3/14/22 through 3/18/22, 3/21/22 through 3/25/22, and 3/28/22, showed the facility did not post the nurse staff sheet in a prominent place readily visible and accessible to residents and visitors. During observation and interview on 3/28/21 at 12:54 P.M., the Corporate Nurse said the staffing coordinator was responsible for posting the hours. The nurse staff posting was located behind the double doors to the resident use TV room. The Corporate Nurse walked to the location of the staff posting. Behind the double doors stood a five tier bookcase. The staff posting was inside a frame, inside the fifth tier of the bookcase. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to fully implement their staff vaccination policy for COVID-19 by failing to ensure one contracted agency staff was fully vaccinated or had an approved exemption prior to working in the facility. The facility had a vaccination rate of 100% of facility employed staff fully vaccinated or with an exemption/delay, and no residents with COVID-19 infections within the last four weeks. The census was 110. 1. Review of the Covid vaccine policy, dated 1/14/22, showed: -Policy: to comply with Centers for Medicare and Medicaid Services (CMS) federal mandate that all facility employees are vaccinated against Covid-19, unless the staff had a religious or medical exemption; -Definitions: -Fully vaccinated: 2 weeks or more since completion of a primary vaccination series for Covid-19. [...]