Lewis & Clark Gardens

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nursing (DON) worked in the facility completing the duties of the DON and did not work as a charge nurse when the facility had an average daily occupancy of over 60 residents. The facility census was 86. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and homelike environment free from the presence of persistent urine and fecal odors with the carpet maintained in good repair. The facility census was 86. Review of the facility policy, Housekeeping Department, Seven Steps of Cleaning a Resident Room, undated showed no dust, no spots, no smudges, no smells equaled clean. 1. Observations on 03/20/26 from 9:30 A.M. to 4:30 P.M. [...]

Inspectors wroteBased on interview, and record review, the facility failed to consistently complete an investigation following falls to identify the root cause for the falls and failed to consistently evaluate the effectiveness of interventions and identify/revise interventions to prevent falls for two residents (Resident #5 and #1), in a review of 10 sampled residents. Staff failed to immediately report Resident #1's fall to the nurse per facility policy prior to assisting the resident off the floor following a fall. The facility census was 86. Review of the undated facility policy, Event Investigation, showed the following:-Purpose: to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse immediately and no later than two hours to the state survey agency after an allegation was made of physical abuse towards one resident (Resident #1) in a review of seven sampled residents. The facility census was 85. Review of the undated facility policy for Abuse and Neglect showed the following:-It is the policy of this facility that each resident will be free from Abuse. [...]

Inspectors wroteBased on interview and record review the facility failed to conduct a timely and thorough investigation of an allegation of abuse involving one resident (Resident #1), in a review of seven sampled residents. Resident #1 made an allegation of verbal and physical abuse on 1/9/26, involving a staff identified by the resident as Certified Nurse Aide (CNA) A. The facility census was 85. Review of the undated facility policy for Abuse and Neglect showed the following:-It is the policy of this facility that each resident will be free from Abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with a palatable meal served at appetizing temperatures and texture and that conserved nutritive value and flavor. The facility census was 89. Review of the facility policy, Food Temperatures, dated April 2015, showed the following:-The Dietary Manager or designee is responsible for seeing that all food is the proper cooking temperature(s) as indicated on the standardized recipe before meal service begins;-The temperature of hot foods and beverage should be maintained no less than 135 degrees Fahrenheit (F) during the duration of the meal service;-Hot food and beverage should be at least 120 degrees F when served to the resident;-Temperature of potentially hazardous cold foods should be maintained at no more than 41 degrees F. Prepare cold items a day in advance when possible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing for four residents (Residents #1, #2, #3, and #4), who relied on staff to assist with their activities of daily living (ADLs), in a review of five sampled residents, during the time the residents were temporarily relocated to the COVID isolation unit. The facility census was 85. Review of the facility's ADL policy, dated March 2015, showed no documentation related to how often a resident should be offered and/or assisted with bathing. 1. Review of Resident #1's undated face sheet showed he/she received hospice services. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 07/10/25, showed the following:-His/Her cognition was intact;-He/She required substantial/maximum assistance with bathing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of seven sampled residents, was free from abuse and neglect when Certified Nurse Aide (CNA) A while sweeping the resident's room, refused to assist the resident with his/her request to retrieve paper from the floor and grabbed the resident's left hand/arm pushing the resident back causing the resident to fall onto the foot board of the bed. The resident fell onto the bed then slid off the bed onto the floor. CNA A stood watching the resident with no attempt to prevent the fall or assist the resident. The resident then scooted on the floor towards the door of the room, while CNA A continued to sweep the floor telling the resident to stay in the room, with no attempt to call for assistance or a nurse to assess the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping services to maintain a clean, sanitary and orderly environment for one resident, (Resident #1) out of seven sampled residents. The facility census was 69. The facility did not provide a policy for housekeeping services or clean and comfortable homelike environment. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnosis of Huntington's disease (a hereditary neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain. It affects movement, cognition, and behavior, and there is currently no cure). Review of the resident's annual Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff dated 5/28/25 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse when one Resident (Resident #2) of seven sampled residents, reported to staff another staff had threatened to hit him/her with a closed fist and the resident was fearful of retaliation. The facility census was 66. Review of the undated facility policy for Abuse Prohibition showed: -All staff are to report to the Administrator and/or Designees any alleged (all allegations) violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one resident (Resident #1), of seven sampled residents, to address care of a resident with diagnosis of Huntington's disease (a hereditary neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain. It leads to a decline in cognitive function, mood disturbances, and uncontrolled movements). The facility census was 69. Review of the facility policy for Care Planning Guidelines dated 10/1/2015 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), was free from verbal abuse when Certified Medication Technician (CMT) B yelled and cussed at the resident and told the resident to shut up and when the resident refused cares. Resident #1 said he/she was shocked CMT B treated him/her in that manner and was scared of CMT B. The facility census was 73. The administrator was notified of the past noncompliance on 5/13/25, which occurred on 5/3/25. On 5/5/25 the administrator became aware of a staff to resident abuse allegation involving Resident #1. Upon discovery, the facility suspended the staff member, conducted an investigation, and notified appropriate parties and the police. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1) out of a sample of eight residents, received adequate supervision to prevent accidents. The facility failed to respond to a door alarm timely after the resident, who was assessed by the facility to be at risk for elopement, exited the facility through an alarmed exit door without staff knowledge. The door alarm volume was not loud enough for staff to hear until they were halfway down the resident's hall. The facility also failed to complete 15 minute checks for the resident who required 15 minute checks for aggressive behavior. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of sampled residents, remained free from misappropriation of property when Certified Nurse Aide (CNA) A took the resident's government issued debit card without the resident's knowledge and permission and used the card to withdraw cash from several ATM's totaling $864.00, used the card to pay Boost Mobile (a cell phone company) $65.00, Spectrum for $140.86, Ameren for $100.00, and for doordash food totaling $140.23. The facility census was 76 On 4/11/25 at 3:00 P.M., the administrator was notified of the past noncompliance which occurred on 4/3/25. On 4/3/25, the administrator became aware of the violation of misappropriation of the resident's government issued debit card and monies taken from the account by CNA A. [...]

Inspectors wroteRefer to CDGZ12. Based on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for wound care for two residents (Resident #2 and Resident #1), in a review of ten sampled residents. The facility census was 85. Review of the undated facility policy titled, Physician Orders, showed the following: -Physician's orders must be signed by the physician and dated when such order was signed; -Physician orders must be reviewed and renewed; -The policy did not address following physicians orders. Review of the undated facility policy titled, Wound Care and Treatment, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -There must be a specific order for the treatment. 1. [...]

Inspectors wroteRefer to CDGZ12. Based on interview and record review, the facility failed to implement an ongoing activities program designed to meet individual interests for two residents (Resident #2 and #5), in a review of 10 sampled residents and four additional residents (Resident #15, #18, #19 and #20). The facility also failed to provide activities in the evenings and on the weekends. The facility census was 85. Review of the facility policy, Role of the Activity Director, dated March 2012, showed the following: -The Activity Director provides a key role in enhancing the quality of a resident's daily life; -The Activity Director plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility. 1. Review of the facility's activity calendar, dated September 2024, showed the following: -No activities scheduled after 3:00 P. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was clean and maintained in a manner to ensure the safe storage, preparation, and distribution of food. Staff failed to wash hands and utilize gloves appropriately during meal preparation and service, failed to properly wash dishes in the three-compartment sink and ensure sanitizer solution was available for use, failed to properly clean food preparation surfaces with sanitizing solution, and failed to ensure the temperature in one freezer was at least 0 degrees Fahrenheit or below. The facility census was 82. 1. Review of the Registered Dietician's Kitchen Observation, dated 7/22/24, showed the following: -Open food items were not stored or properly sealed and labeled and dated; -Not all food was properly covered, labeled or dated; -The stove/oven was not clean. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for wound care for two residents (Resident #2 and Resident #1), in a review of ten sampled residents. The facility census was 85. Review of the undated facility policy titled, Physician Orders, showed the following: -Physician's orders must be signed by the physician and dated when such order was signed; -Physician orders must be reviewed and renewed; -The policy did not address following physicians orders. Review of the undated facility policy titled, Wound Care and Treatment, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -There must be a specific order for the treatment. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an ongoing activities program designed to meet individual interests for two residents (Resident #2 and #5), in a review of 10 sampled residents and four additional residents (Resident #15, #18, #19 and #20). The facility also failed to provide activities in the evenings and on the weekends. The facility census was 85. Review of the facility policy, Role of the Activity Director, dated March 2012, showed the following: -The Activity Director provides a key role in enhancing the quality of a resident's daily life; -The Activity Director plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility. 1. Review of the facility's activity calendar, dated September 2024, showed the following: -No activities scheduled after 3:00 P.M.; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure hazardous materials were kept secured and inaccessible to residents. The facility capacity was 142 and the census was 82. Observation on 8/5/24 from 11:28 A.M. to 6:58 P.M., during the life safety code tour of the facility, showed the following: -Six containers of chafing fuel were in an unlocked cabinet in the 200 hall dining and activity room; -A bottle of nail polish remover was in an unlocked lower cabinet in the ice cream/popcorn area located near the resident sitting area. The nail polish remover bottle label read '100% pure acetone, Warning: Keep away from children, Danger! Extremely flammable!; -A bottle of commercial surface disinfectant was in a lower unlocked cabinet in the 100/200 wing dining room. The label on the bottle read 'Keep out of reach of children'; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six residents (Residents #135, #136, #3, #22, #3, #43, and #42), in a review of 18 sampled residents, received respiratory therapy/care consistent with professional standards of practice and the residents' plan of care. The facility failed to administer Resident #135's oxygen per physician's orders, failed to obtain orders for his/her CPAP machine upon the resident's admission to the facility, and failed to label oxygen tubing per the resident's physician's orders. The facility failed to apply Resident #136's BiPAP as ordered, failed to label Resident #3's oxygen tubing and humidification, and failed to properly store nebulizer masks when not in use for Residents #22, #43 and #42. The facility census was 82. Review of the facility's undated policy, Oxygen Administration, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served food that was palatable and at an appetizing temperature. The facility census was 82. Review of the facility policy, Food Temperatures, dated April 2011, showed the following: -Hot foods should be at least 120 degrees F when served to the resident; -Place cold menu items in the steam table over an ice bath with the well of the steam table turned off. 1. During an interview on 08/06/24 at 10:23 A.M., Resident #135 said the food did not taste good. During interview on 8/6/24 at 10:35 A.M., Resident #72 said the food was often bland. During interview on 8/5/24 at 2:50 P.M., Resident #67 said the food was cold and had no seasoning. 2. Review of the spreadsheet menu on 8/5/24 showed the dinner meal included barbeque pork and pasta salad. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff offered nourishing evening snacks for residents who wished to have a snack for seven residents (Resident #3, #46, #43, #47, #54, #135 and #72), in a review of 18 sampled residents, and for two additional residents (Residents #13 and #67). The facility also failed to ensure all residents were provided equal opportunity to have a snack. The facility census was 82. Review of the facility's undated policy, Menus, showed a bedtime snack shall be offered to all residents per federal and state regulations. 1. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 10/9/23, showed the following: -Cognition was intact; -He/She considered it very important to have snacks between meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed appropriate hand hygiene and changed gloves during the provision of care for two additional residents (Residents #32 and #2), and four residents (Residents #23, #22, #43, and #47), in a review of 18 sampled residents. The facility failed to implement Enhanced Barrier Precautions for one resident (Resident #19), and failed to complete Tuberculin Skin Testing to rule out Tuberculosis (TB) for three employees, in a review of 10 sampled employees. The facility census was 82. Review of the facility policy, Hand Hygiene and Gloves, dated August 2009, showed the following: -Wash hands with soap and water when hands are visibly dirty or soiled with blood or other body fluids, or after using the restroom; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for five residents (Residents #23, #78, #3, #19, and #45), in a review of 18 sampled residents. The facility census was 82. Review of the facility's undated policy, Immunization, showed the following: -The resident's physician will be consulted and determine the level of risk and need for the vaccinations; -A physician order is required to administer any vaccination; -The resident/or responsible party have been educated/given a copy of The Center for Disease Control Vaccine Information Sheet on pneumococcal vaccines and have had the immunization consent. or refusal form filled out and signed by resident/ or responsible party. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for one resident (Resident #135), in a review of 18 sampled residents, when staff failed to recognize the resident's need for portable oxygen when out of in his/her room, failed to ensure the resident had means for locomotion after his/her requests for a wheelchair due to his/her shortness of breath, and failed to recognize the resident's use of a cardiac (heart) monitor for his/her pacemaker (surgically implanted device to control an irregular heart rhythm) and to contact the physician for orders to continue use of the monitoring device. The facility census was 82. During an interview on 08/08/24, the Director of Nursing said the facility did not have a policy for accommodation of needs. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare pureed food items according to the recipe to ensure the puree was a smooth consistency. The facility identified one resident on a pureed diet. The facility census was 82. Review of the facility policy, Types of Diets, dated April 2011, showed for a pureed diet, foods should be blended to a mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. Review of the Resident Orders, dated 8/6/24, showed one resident had a physician order to receive a pureed diet. 1. Observation on 8/5/24 at 12:04 P.M. showed the Dietary Manager prepared the pureed meal tray from the steam table. The pureed chicken was the consistency of ground chicken with visible chunks of chicken, and the pureed carrots contained visible chunks of carrots. 2. [...]

Inspectors wroteRefer to NITN12. Based on observation, interview, and record review, the facility failed to ensure facility staff provided two residents (Resident #1 and #5), of nine sampled residents who were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene. Staff failed to assist and provide nail care and grooming to include shaving. The facility census was 82.

Inspectors wroteRefer to NITN12. Based on observation, interview, and record review, the facility failed to apply hand splints (an external device that is used to support and protect injured bones, ligaments, tendons, and other tissues and to treat contractures (a shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) that can be caused by disease or trauma) for one resident (Resident #1) with hand contractures in a sample of nine residents. The facility also failed to apply palm protectors (used to prevent fingers from digging into the palm of your hand, to prevent skin damage and prevent further deformity) for Resident #1 as directed by Occupational Therapy. The facility census was 82.

Inspectors wroteBased on interview and record review, the facility failed to prevent sexual abuse between two residents (Resident #1 and Resident #2), who engaged in sexual intercourse and whose capacity to consent to sexual activity had not been determined, in a review of 13 sampled residents. Resident #1 was assessed as severely cognitively impaired and had diagnoses including Alzheimers Disease, dementia, herpes viral infection, and human immunodeficiency virus disease. Resident #2 had diagnoses including vascular dementia and depression. When Resident #2 talked to his/her responsible party after the incident, he/she told the responsible party he/she did not want the sexual activity to occur, he/she was scared, and did not want to be around Resident #1. The facility census was 85. The administrator was notified on 5/10/24 at 4:13 P.M. of an Immediate Jeopardy (IJ) which began on 5/2/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff provided two residents (Resident #1 and #5), of nine sampled residents who were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene. Staff failed to assist and provide nail care and grooming to include shaving. The facility census was 82. Review of the facility policy Bath (partial), undated showed the following: -The purpose was to maintain skin integrity, comfort, and cleanliness; -Wash face and ears, wash neck arms chest and abdomen, give special care to the folds of skin, hands, and feet. Wash thighs, legs, and feet; -Care of fingernails and toenails was part of the bath. Be certain nails are clean. Review of the facility policy Bath (shower), undated showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply hand splints (an external device that is used to support and protect injured bones, ligaments, tendons, and other tissues and to treat contractures (a shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) that can be caused by disease or trauma) for one resident (Resident #1) with hand contractures in a sample of nine residents. The facility also failed to apply palm protectors (used to prevent fingers from digging into the palm of your hand, to prevent skin damage and prevent further deformity) for Resident #1 as directed by Occupational Therapy. The facility census was 82. Review of the facility's Restorative Nursing Manual, dated 6/28/23, showed the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to act promptly upon the grievances and recommendations of the Resident Council concerning issues of resident care and quality of life in the facility, and failed to provide the Resident Council with rationale, responses, and actions taken regarding their concerns. The facility census was 79. Review of the facility policy for Resident Council dated 3/2012 showed: -Monthly Meetings will be held with minutes of the meetings documented. Recommendations for changes by the council will be given to the Administrator who will evaluate the recommendations. The resident council serves as a liaison between the employees, residents and others who interface with the facility; -Monthly meetings are held to assist with activity planning for the following month; -The Activities Director will act as the facility liaison for resident council; [...]

Inspectors wroteBased on observation and interview, the facility failed to keep carpet in good repair and odor free and failed to ensure resident equipment was clean and in good repair for one resident (Resident #2) of five sampled residents. The facility census was 79. Review of the undated facility policy for Housekeeping showed resident rooms cleaning procedure should be used for all resident rooms to maintain cleanliness and to promote infection control. The facility did not have a policy to address carpet cleaning or removal of stains, urine, feces or odors from the carpet. 1. Observation of the facility on 12/27/23 at 9:45 A.M. showed the following: -Upon entry through the front door, the lobby, hallways and sitting area were carpeted. There was a strong odor of urine noted; -The 100 hall and resident rooms were carpeted; [...]

Inspectors wroteBased on interview and record review, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances. The facility failed to develop a grievance policy and procedure that included all required components for three residents (Resident #2, #4 and #5) out of five sampled residents. The facility census was 79. Review of the undated facility policy for Grievance Protocol showed: -The purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; -The Social Service Director is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two residents (Residents #4 and #5), in a review of five sampled residents, when staff failed to ensure residents' preferences for bathing were honored. The census was 79. The facility did not provide a policy for resident preferences for bathing. 1. Review of Resident #4's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 9/27/23 showed: -Able to understand others and able to make self understood; -Alert and oriented and able to make appropriate decisions; -Ability to make decisions about daily activities and choices very important -Dependent upon two staff members for Activities of Daily Living (ADL's); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for two residents (Resident #2 and #3), of five sampled residents when failed to obtain and administer medications and supplements for weight loss as ordered by the physician. Review of the undated facility policy for admission Nurse's Note showed the following: -Ensure information is documented for the resident upon admission; -Upon admission of a resident the nurse will document the time the physician was notified of admission and verification of admission orders, and the time medication was ordered from the pharmacy. Review of the facility policy for Medication Orders, Standing Orders dated 7/2021 showed: -Policy: Certain, common, self-limited conditions are often amenable to treatment with nonprescription medications, using good nursing judgement. [...]

Inspectors wroteBased on observation, interview,, and record review, the facility failed to provide necessary services to provide oral hygiene, access to fluids and assistance with dining for one resident (Resident #2) in a review of five residents who was unable to carry out his/her own activities of daily living (ADLs). The facility census was 79. Review of the undated facility policy for Oral Hygiene showed the following: -The purpose is to clean he mouth, teeth and dentures; -Offer oral hygiene before breakfast, after each meal and at bedtime; -Equipment included toothbrush, toothpaste, water, emesis basin, towel, tissue and denture cup if necessary. Review of the undated facility policy for Hydration showed the following: -Each resident is supplied with sufficient fluid intake to maintain proper hydration; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for pressure ulcer prevention or care plan interventions to prevent the development of pressure ulcers, when staff failed to document skin assessments and wound assessments for one resident (Resident #2), developed a Stage II pressure ulcer, of five sampled residents. The facility census was 79. Review of the undated facility policy for Wound Care and Treatment showed: -Purpose: It is the purpose of this facility to prevent and treat all wounds; -There must be a specific order for the treatment; -The care plan should reflect the current status of the wound and appropriate goals and approaches -Prevention Strategies included on-going skin assessment with weekly documentation of status. 1. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to honor an advance directive for one resident (Resident #174) of 13 residents reviewed for code status. Resident #174 had a Durable Power of Attorney (DPOA) advance directive indicating the resident's wish for do not resuscitate (DNR) if the resident was found unresponsive. On [DATE], the facility called 911 and initiated cardiopulmonary resuscitation (CPR), despite Resident #174's advance directive. Subsequently, Resident #174 received CPR for 17 minutes against the resident's wishes. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide notification that a resident no longer qualified for Medicare Part A skilled benefits for one resident (Resident #244) of 3 residents reviewed who should have received notification. Specifically, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for Resident #244 when the resident was discharged from therapy services.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for one resident (Resident #8) of 3 residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, it was determined the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASARR) was completed for one resident (Resident #47) of 3 residents reviewed for PASARR.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide assistance with bathing for one resident (Resident #19) of 3 residents reviewed for bathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served the correct portion sizes and prepared food items according to the dietary spreadsheet menu for residents on physician-ordered regular, mechanical soft, and pureed diets. The facility census was 101. 1. Review of the facility's Order Report by Category, dated 6/12/19, showed 76 residents on a regular diet, 13 residents on a mechanical soft diet, and six residents on a pureed diet. 2. Review of the diet spreadsheet for lunch on 6/12/19 (Spring/Summer 2019, Week 2, Day 11) showed residents on a regular diet were to receive 6-ounces (2/3 cup) of ham and beans and 4-ounces (1/2 cup) of seasoned cabbage. Observation on 6/12/19 at 10:49 A.M. showed Dietary Staff W placed all pans of food on the steam table for the lunch service. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing staff washed their hands and changed soiled gloves when indicated by professional practices during personal care for five Residents (Resident #154, #7, #96, #76 and #15) of 21 sampled residents and for two additional residents (Resident #46 and #87). Staff failed to properly handle dirty linen and trash when staff allowed collection bags to remain on the floor throughout their shift, failed to properly store the cap of a feeding tube in a way that prevented the risk of contamination, failed to administer medications with appropriate infection control technique and failed to complete and document TB (serious infection, usually of the lungs caused by bacterium Mycobacterium tuberculosis) testing in the required time after admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity for two residents (Resident #7 and #96) of 21 sampled residents and one additional resident (Residents #46) when staff left them exposed for an extended amount of time during personal cares. The facility census was 101. 1. Review of the booklet, Resident Rights For Long-Term Care in Missouri provided to residents and families by the facility upon admission, showed residents should be treated with consideration and respect and with full recognition of dignity and individuality. 2. Review of the Nurse Assistant in a Long-Term Care Facility Student Reference, under Resident Rights (State of Missouri) revised 2001, showed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had reasonable access to their personal funds on an ongoing basis. The facility managed funds for 55 residents. The facility census was 101. 1. Review of the Facility/Business Office Manager Resident Trust Workflow and Facility Policy showed no documentation of times for facility banking hours. 2. Record review of the facility undated admission agreement, section titled Protection of Resident Funds, showed the following: -The facility would maintain resident personal funds that do not exceed $50.00 in a non-interest bearing account or petty cash fund; -These funds were kept in the facility; -Residents could withdraw or deposit these funds by contacting the office manager during normal business hours. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good personal hygiene and prevent body odors for four residents (Resident #7, #15, #16, and #96), in a review of 21 sampled residents. Staff failed to provide complete incontinence care, oral care and grooming to include shaving. The facility census was 101. 1. Review of the facility policy, Oral Hygiene, dated March 2015, showed the following guideline in part: -Purpose was to cleanse the mouth, teeth and denture; -Offer oral hygiene before breakfast, after each meal and at bedtime. 2. Review of the facility policy, Enteral Nutritional Therapy, dated March 2015, showed during cares, staff was to check the resident's mouth and give oral hygiene if necessary. 3. Review of the facility policy, Care of Nails, dated March 2015, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care, treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for three residents (Resident #93, #15 and #76 ) with an indwelling urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) of 21 sampled residents The facility identified seven residents with indwelling catheters. The facility census was 101. 1. Review of the facility's Catheter Care policy from the Nursing Guidelines Manual, dated March 2015, showed the following: -The purpose is to prevent infection and reduce irritation; -For the female, use a clean washcloth with warm water and soap to cleanse the labia; -Use one area of the wash cloth for each downward, cleansing stroke;; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs in locked compartments when staff left the medication carts unlocked, failed to consistently reconcile controlled drugs listed as Schedule II (high potential for abuse potential), narcotics, failed to destroy expired narcotic medications, failed to ensure physician written prescriptions were obtained prior to removal of narcotic medications from the 300 Hall medication room narcotic cabinet, and failed to properly label narcotic medications removed (from the 300 Hall medication room narcotic cabinet) by one Licensed Practical Nurse (LPN) and administered by another Certified Medication Technician (CMT). The facility census was 101. 1. Review of the facility policy Narcotic Count dated [DATE] showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that is served at an appetizing temperature. The facility census was 101. 1. Review of the facility policy, Food Temperatures, dated April 2011, showed the following: -Hot food should be at least 120 degrees Fahrenheit (F) when served to the resident; -The Dietary Services Manager or designee is responsible for seeing that all food is the proper temperature before trays are assembled. 2. During interview on 6/11/19 at 3:24 P.M., Resident #63 said the following: -The facility meals were terrible; -The food temperatures were always cold, even on foods that were supposed to be hot. During group interview on 6/13/19 at 10:00 A.M., Residents #5, #12, #82, and #89 said the food was usually cold. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/or responsible parties when two residents (Residents #91 and #93), in a review of 21 sampled residents, had a change in their condition. The facility census was 101. 1. Review of the facility's Condition Change Policy, dated March 2015, showed the following: -Purpose; To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; -Guidelines: After all resident falls, injuries or change in physical or mental function; notify the resident's responsible party and notify the resident's physician of the change in condition, need for treatment orders and/or medication changes. 2. Review of Resident #93's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 5/8/19 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an incident of staff to resident abuse for one resident (Resident #37) of 21 sampled residents, when the facility failed to follow their policy and interview other residents with similar care needs with specific questions related to the allegations and failed to interview staff, other than the staff involved with the allegation, who worked with the accused staff member. The facility census was 101. 1. Review of the undated, facility Abuse Prohibition Protocol Manual showed the following: -Facility investigative documentation would include: -Residents' statements; -Resident's roommate statements (if applicable); -Interviews obtained from three to four residents who received care from the alleged staff; -Interviews obtained from three to four different department staff, (if applicable); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) a federally mandated assessment instrument required to be completed by facility staff) for two residents (Residents #43 and #15) in a review of 21 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 101. 1. During interview on 6/14/19 at 4:30 P.M. the MDS Coordinator said he/she followed the Resident Assessment Instrument (RAI) 3.0 manual while completing residents' MDS. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and update a plan of care consistent with resident's specific conditions, needs, and risks for two residents (Residents #15 and #93), in a review of 21 sampled residents. The facility census was 101. 1. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) Users Manual, Version 3.0, Chapter 4, dated October 2011, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A well-developed and executed assessment and care plan looks at each resident as a whole human being with unique characteristics and strengths; -The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for one sampled Resident (Resident #90) by failing to ensure the resident recieved ordered narcotic medications and that staff who prepared the medications administered the medications and one additonal resident (Resident #87), when staff failed to administer eye drop medication in the prescribed amount and with the proper technique. The facility census was 101. 1. Review of the facility policy Installation of Eye Medication dated March 2015 showed the following: -The purpose was to introduce medication into the eye for treatment or for examination purposes; -Wipe away any secretions present; -Tilt resident's head backward, draw down lower lid. Have resident look up; -To prevent dropper tip from touching eye or lids, nurse should support hand on resident's forehead or bridge of nose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper technique during transfer for one resident (Resident #96) in a review of 21 sampled residents. During a transfer form the bed to wheelchair, staff lifted the resident under the arms and by pulling up on the back of the resident's pants and not with a mechanical lift as directed on the resident's care plan. The facility census was 101. 1. During interview on 6/25/19 at 4:00 P.M. the Administrator said the facility did not have a policy for transfers. 2. Review of the Nurse Assistant in Long Term Care Facility, student reference, 2001 revision, showed the following: -The nurse assistant should never transfer or ambulate residents by grasping their upper arms or under their arms; [...]

Inspectors wroteBased on observation and interview the facility failed to provide ileostomy (surgical opening in the abdominal wall also called a stoma) care to prevent excoriation of the peri-stomal skin (skin surrounding the stoma) for one resident (Resident #96), who had a history of peri-stomal skin excoriation, of four residents with ostomies. Staff failed to change the resident's leaking ostomy appliance (wafer and attached drainage pouch system used to collect feces) and failed to keep the skin surrounding the stoma clean and dry. The facility census was 101. 1. Review of the facility policy Colostomy and Ileostomy Care dated March 2015 showed the following partial guidelines: -Purpose was prevent infection, skin irritation and alleviate unpleasant odors and to obtain accurate bowel measurement output; -Be sure skin under bag was clean and dry. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were being fed by enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) means, received the appropriate treatment and services for the enteral feeding by failing to ensure the head of the bed was elevated during feeding and cares for one resident (Resident #7) in a sample of 21 residents. The facility census was 101. 1. Review of the facility policy titled Enteral Nutrition Therapy, dated March 2015, showed the resident should be placed in a Semi-Fowler's position (position where the back with the head and trunk are raised to between 15 to 45 degrees with 30 degrees being the most frequently used bed angle) unless contraindicated. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to manage pain for one resident (Resident #90), in a review of 21 sampled residents, by not ensuring physician ordered medications were available and administered when scheduled. The facility census was 101. 1. During interview on [DATE] at 4:00 P.M., the Administrator said the facility did not have a policy for pain management. 2. Review of Resident #90's care plan, dated [DATE], showed the following: -The resident was at risk for pain. Needs pain management related to amputation of lower extremity; -Goal: The resident will maintain adequate level of comfort as evidenced by his/her ability to participate with activities of daily living (ADLs), and no verbal or non-verbal signs of distress; -Administer and monitor effectiveness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a system to monitor residents who used psychopharmacological medications to ensure attempts were made for gradual dose reductions (GDR) in an effort to reduce or discontinue these medications for two residents (Resident #15, and #37) in a review of 21 sampled residents. The facility failed to identify and treat one resident (Resident #37) who exhibited symptoms of potential side effects associated with the use of antipsychotic medications including tongue thrusts, lip smacking and rhythmic movements. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a clean and comfortable environment by failing to ensure the ceiling vents throughout the facility were cleaned and free of dust and debris. The facility census was 101. 1. Observation on 06/12/19 between 8:00 A.M. and 5:05 P.M. during the life safety code tour of the inside of the facility showed the following: -In the soiled utility room by room [ROOM NUMBER], the ceiling vent was covered with a thick layer of dust; -In the spa room across from room [ROOM NUMBER], a 6 inch by 6 inch vent and 4 inch by 4 inch vent were covered with a thick layer of dust; -In the bathroom between room [ROOM NUMBER] and the beauty shop, a 4 inch by f4our inch ceiling vent was covered with a thick layer of dust; -In the beauty shop, a 4 inch by 4 inch ceiling vent was covered with a thick layer of dust; [...]