Life Care Center of Bridgeton

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a comfortable environment with hot water temperatures between 105 and 120 degrees Fahrenheit (F) in resident rooms and shower rooms on the north side of the facility, resulting in residents complaining the water temperature was too cold (Residents #11, #7, #8, #10, and #9). The census was 66. Review of the facility's Water Temperature policy, revised 01/21/25, showed:-Policy: The facility monitors all water temperatures on a weekly basis or more often if needed.-Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident;-Procedure: -Shower/Faucet Temperatures:-Temperatures will be taken weekly from one resident's room on each wing on a rotating basis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care needs were met for one resident when staff failed to check and change the resident's incontinence brief every two hours, leaving the resident in a urine-saturated brief for over seven hours (Resident #3). The sample was 12. The census was 66. Review of the facility's ADL care policy, revised 02/12/24, showed the resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/10/26, showed:-Ability to express ideas and wants: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed their abuse and neglect policy. Resident #4 informed Certified Nursing Assistant (CNA) K that CNA P was mean to him/her and twisted his/her right arm tightly. CNA K failed to notify his/her charge nurse of the accusation because he/she did not believe the resident. Due to CNA K's failure to report the resident's allegation, CNA P remained working until the Administrator was notified and suspended CNA P pending the facility's investigation. Ten residents were sampled. The census was 69. Review of the facility's Abuse and Neglect policy, issued on 1/3/22 and reviewed on 11/19/24, showed: -What: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and physician's orders by failing to notify the physician when one resident's blood sugar levels exceeded the physician's ordered parameters. In addition, the facility failed to obtain STAT (now/no delay) lab orders for the resident. The facility identified 22 residents with orders for routine blood sugar checks. Of the six that were sampled one, Resident #13, had blood sugar levels that exceeded the parameters to contact the physician. The census was 73. Review of the facility's Changes in Resident's Condition or Status, issued 11/26/25, and reviewed 9/5/24, showed:-Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status;-Notification of Changes: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #7 had fall mats in place and the resident's bed was kept in the lowest possible position when the resident was in bed and unattended by staff, and failed to include the fall mats and low bed as interventions on the resident's care plan. The facility also failed to ensure Resident #9's bed was kept in the lowest position when the resident was in bed and unattended by staff. Four residents were sampled. The census was 69. Review of the facility's Fall Management policy, issued on 6/4/20, and revised on 3/11/25, showed: -Policy: The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls; -Federal Regulations: [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. The census was 86. Review of the facility's certified dietary manager job description, undated, showed: -License and certification: Must have completed an approved Certified Dietary Manager course. Must maintain an active certification. During an interview on 2/28/25 at 9:53 A.M., the Dietary Director said she has her required qualifications but did not have a physical copy of the documentation. During an interview on 2/28/25 at 10:02 A.M., the Executive Director said he would expect the Dietary Director to have the required certifications. The Dietary Director did have the required certifications, but they have expired.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to treat residents with dignity when staff removed one resident's personal items without the resident's permission while he/she was out of his/her room receiving a shower (Resident #68). Furthermore, staff spoke to three residents in an unprofessional manner (Resident #68, Resident #29, and Resident #45). Staff also used their personal cell phone while assisting one resident during meal time (Resident #22). The sample was 18. The census was 86. Review of the facility's Dignity policy, reviewed, 9/26/24, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund (RTF) reconciliations. This facility identified 35 residents with funds handled by the facility. The census was 89. Review of the facility's Resident Trust Policy and Procedures, reviewed 6/15/22, showed: -In large part, these policies have been developed with the guidance of: -The Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, State Operations Manual, Appendix PP - Interpretive Guidelines for Long-Term Care Facilities; -State laws and regulations must also be followed when they are more stringent or more specific; -Each skilled nursing facility that is owned by the corporation shall: Manage a resident's personal funds via the Resident Fund Management Service (RFMS); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one resident with mobility impairments when staff failed to ensure the resident had access to a call light adapted to meet his/her needs (Resident #9). The sample was 18. The census was 86. Review of Resident #9's medical record, showed diagnoses included multiple sclerosis (MS, disease of the central nervous system), quadriplegia (paralysis of all four limbs), seizures, abnormal posture, generalized muscle weakness, contractures to left and right hands, cognitive communication deficit, anxiety, and depression. Review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/20/25, showed: -Severe cognitive impairment; -Clear speech; -Makes self understood: Usually understood; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's physician (Resident #26) was notified after the resident developed an elevated temperature on the evening shift of 2/24/25. The resident was sent to the hospital the next morning on 2/25/25, and admitted with a diagnosis of sepsis (a serious condition in which the body responds to infection) pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.). The sample size was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/18, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for Resident #29. The facility failed to ensure Resident #29's hair was clean, facial hair was shaved, body was clean and free from odors, and failed to provide foot care. The sample was 18. The census was 86. Review of the facility's ADL care policy, revised 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Review of the facility's foot care policy, dated 8/28/18, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain labs as ordered for one resident (Resident #14), and to document a thorough, ongoing assessment following the resident's change in condition, and to appropriately communicate the resident's change in condition to the next shift. In addition, the facility failed to ensure staff provided feeding assistance in accordance with physician orders for one resident identified as dependent on assistance for eating (Resident #9). The sample was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/28, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure staff obtained a treatment order, and provided daily monitoring for one resident (Resident #26) with a history of dermatitis (skin inflammation, typically characterized by itchiness, redness and rash) on his/her coccyx (tailbone)/sacrum (area located above the coccyx) that was observed to have an open area on the morning of 2/24/25. It was not identified by staff and the physician was not notified until the morning of 2/25/25. In addition, the facility failed to ensure licensed nurses who signed bath sheets showing an open area and/or a circle around the coccyx/sacrum of an anatomical figure on the bath sheet documented an assessment of the findings on the bath sheets. The sample size was 18. The census was 86. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by addressing the residents' behaviors related to his/her anxiety for one resident (Resident #68). The sample was 18. The census was 86. Review of the facility's Behavioral Health Services Policy, reviewed 9/6/24, showed: -Policy: The facility will provide behavior heal care and services that create an environment that promotes emotional and psychosocial will-being, meets each resident's needs, and includes individualized approaches to care; -Procedure: Complete the nursing assessment and social services assessment upon admission/readmission. Quarterly, and as needed with change in condition; -Through this assessment the facility should identify residents who: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to discard expired medications from the medication carts, failed to ensure all medication bottles had a date of expiration, failed to ensure eye drops/ointments were dated when opened, and failed to ensure insulin pens were stored in the refrigerator and not in the medication cart. The facility identified four medication carts, two were sampled, and problems were identified in both. The census was 86. Review of the facility Medication Storage and Administration Quick Reference Guide, dated 8/2022, showed: -Insulin Vials and Pens: Store unopened insulin in the refrigerator; -Ophthalmic Solutions Storage Parameters: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow the manufacturer instructions, or facility policy. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff performed appropriate hand hygiene during meal service and failed to serve food in accordance with professional food safety standards, which affected three residents (Resident #22, #24, and #27). The sample was 18. The Census was 86. Review of the facility's hand hygiene policy, dated 6/13/23, showed: -Policy: The facility has adopted the Centers for Disease Control and Prevention (CDC) core infection prevention and control practices for safe healthcare delivery in all settings for indications for hand hygiene; -Procedure: Hand hygiene should be performed before and after contact with resident, after contact with objects or surfaces in the resident's environment. 1. Review of Resident #22's medical record showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for three residents (Residents #26, #29 and #45) with wounds requiring treatments, gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), or tracheostomies (a surgically inserted tube inserted into the windpipe to assist with breathing). The sample was 16. The census was 86. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a kitchen exit door was locked and armed after one resident (Resident #1) eloped from the facility through the kitchen door during the early morning hours, and was out of the facility for approximately 30 minutes. The resident was found on the facility's premises, approximately 30 feet from the exit door. The facility census was 74. The facility was notified of past non-compliance on 12/31/24. Facility staff immediately searched for the resident, reported the incident, and began their investigation. The investigation consisted of written statements and interviews. The investigation showed the kitchen door was not locked and armed. Staff were in-serviced on elopement policy, and abuse and neglect. A second alarm was added to the kitchen door. The deficiency was corrected on 12/27/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of one resident of four sampled residents, for unrestricted visitation, when the facility prevented the resident's relative from visiting the resident due to an allegation of the relative being unruly and having erratic behavior. The facility also failed to provide alternate methods of visits via a private setting, room, or by video teleconferencing platform (Resident #1). The census was 77. Review of the facility's policy Locking Entrance and Perimeter Doors: After-Hours visitors policy, revised 07/21/23, showed: -The resident has a right to receive visitors of his or her choosing at the time of his or her choosing; -The facility must provide immediate access to a resident by immediate family and other relatives of the resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policy and procedures to prevent abuse and neglect neglect of residents and prevent misappropriation of resident property when the facility continued to employ staff member, Certified Nurse Aide (CNA) A who was listed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified home) indicating he/she was ineligible to work in a certified long-term care facility. CNA A was hired on 12/17/14, put on the EDL list on 8/13/20 with a disqualification length of six years, and terminated from the facility on 1/12/24. The census was 74. The administrator was notified on 2/20/24, of the past non-compliance. Upon discovering CNA A was on the EDL on 1/12/24, the facility took him/her off the schedule. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the scales were in proper working condition for two of two scales in the facility.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to maintain a clean and home-like environment for residents in the facility's common areas and in resident rooms. Specifically, six of six residents (R)8, R25, R29, R46, R59, and R68) that receive enteral feeding had residue buildup on the feeding pump and feeding tube pole; debris under R1's bed; R1, R10 and R49's over bed tables had peeling veneer around the edges; R4 and R12's footboard on their beds were loose; R8's specialty mattress had yellow and brown stains and torn covering; R12's drawer in the resident's nightstand was off the track; R59's room had dried beige residue on the floor next to the resident's tube feeding pole and six residents (R8, R25, R29, R46, R59, and R68) receiving enteral feeding had dried beige; [...]

Inspectors wroteBased on interview, record review and policy review, the facility failed to serve food that was palatable. This failure affected five residents (R20, R42, R54, R48 and R39) who consume the fish from the kitchen.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff were wearing hair restraints in accordance with facility policy while serving food to the residents during one of four meal observations.

Inspectors wroteBased on observation, interview, manufacturer's guidelines review and policy review, the facility failed to disinfect the glucometer between residents' uses as directed by the glucometer's manufacturer's instructions and facility policy for two residents (Resident (R) 44 and R52) of eight residents who received blood glucose monitoring. The facility's practice of inadequate cleaning of the glucometer between residents use places residents with blood glucose monitoring at risk for blood borne illnesses. Additionally, the facility staff failed to don a face mask or goggles when entering a COVID positive resident's (R130) room; failed to perform hand hygiene when passing trays between 11 resident rooms; failed to maintain a clean environment for one of one laundry room; four of four pill crushers were soiled with residue buildup; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents' transfer and discharge information was communicated to the Regional State Ombudsman for one resident (R)129 of five residents sampled for hospitalization.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure two (Residents (R) 18 and R29) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR) (an assessment performed to determine underlying mental health issues) had a Level I PASARR completed as required to determine if the residents require additional assessment and PASARR level II completion

Inspectors wroteBased on interviews, record review and document review, the facility failed to provide Activities of Daily Living (ADLs) to residents unable to carry out the necessary service for two (Resident (R) 20 and R24) of two residents reviewed for personal hygiene. Specifically, the facility staff failed to provide showers and/or bed baths to R20 and R24 twice per week.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure that one resident (R)8 of two residents with an indwelling urinary catheter was secured to the resident's thigh to prevent trauma to the resident urethra and failed to position for the urinary drainage bag to allow for adequate drainage and prevent contamination. The failure has the potential to contribute to reoccurrence of urinary tract infections for this resident.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure resident's medical record reflected the resident's accurate weight for one (Resident (R) 20) of five residents reviewed for nutrition.

Inspectors wroteBased on observations, interviews and record review, the facility failed to post the required contact information for the ombudsman. This information was not posted in the facility affecting all residents in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the survey results were readily accessible. This information affected all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, staff failed to follow facility policies and professional nursing standards for one resident with a gastrostomy feeding tube (g-tube, a tube inserted through the abdomen that brings nutrition directly to the stomach), a diagnosis of dysphagia (difficulty swallowing), and was noted to have a change in condition. Staff failed to document the resident's change in condition and their assessments of the resident and failed to notify the resident's physician of the change in condition. The resident was later found unresponsive, with no signs of life and required cardiopulmonary resuscitation (CPR/initiated when a resident is found with no signs of life), and Emergency Medical Services (EMS) who transported the resident to a hospital where he/she was pronounced dead. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to ensure residents remained free from pressure ulcers and to assess the resident's skin accurately to show the current status of the resident's pressure ulcers, ensure there were treatment orders and interventions implemented for one resident (Resident #276) and also failed to follow the resident's care plan and physician's orders to prevent further breakdown for two sampled residents (Residents #25 and #379) out of 9 reviewed residents. The census was 82. The administrator was notified on 6/30/21 at 2:30 P.M., of the past non-compliance which occurred through 6/19/20. On 6/16/20, the Director of Nursing (DON) was alerted to deficiencies related to the facility wide wound care program and protocols for care. The facility in-serviced the staff on 6/19/20. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have the right to make choices about aspects of their life in the facility that are significant to the resident. During the COVID-19 pandemic, the facility stopped allowing smoking at the facility, failed to permit the current residents admitted prior to the rule change and failed to provide in writing to newly admitted residents the new rule that smoking was no longer allowed at the facility. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Resident #227 and #36). The facility failed to allow residents who voiced a desire to eat in the dining room the right to eat in the dining (Resident #10 and #13). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to correct identified quality of life deficiencies related to activities provided. In addition, the facility failed to develop policies specific to the facility to address feedback, data collection systems and monitoring, including adverse event monitoring; to address how the facility will use a systematic approach to determine underlying causes of problems, how the facility will develop corrective actions, or how the facility will monitor the effectiveness of its performance improvement activities. This had the potential to affect all residents in the facility. The census was 82. Review of the facility's Quality Assurance and Performance Improvement Program Framework, dated 12/20/19, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly, upon the grievances and recommendations of the resident council, demonstrate their response and rationale for such response concerning issues of quality of life. The resident council reported concerns with activities during the three most recent meetings and the facility failed to document a follow-up with the concerns, act upon the recommendations and/or document a rationale as to why the facility could not act upon the concerns. The census was 82. Review of the resident's bill of rights, provided to residents upon admission to the facility, showed: -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were aware of available hours to receive their money during the week or to have money available to residents on the weekends. The census was 82. Review of the facility's Resident Trust Policy and Procedures, showed: -Cash on hand shall be held in a cash box clearly marked Personal Needs in a secure location; -Personal needs cash on hand is operations funds made available to advance cash to residents requesting withdrawals from their respective accounts; -The policy did not have times as to when residents' money was available. Review of the Authorization and Agreement to Handle Resident Funds form signed by the resident, did not show when their money was available to them or how to obtain funds on the weekends. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform a yearly review of code status for full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate (DNR), no life prolonging methods are performed) and obtain a signed code status form upon admission to the facility (Residents #13, #71, #61 and #227). In addition, the facility failed to ensure two witnesses signed a code status form for a resident who could not sign their name (Resident #324). The sample was 20. The census was 82. 1. Review of Resident #13's medical record, showed: -An admission face sheet, showed an admission date of 10/13/12; -A signed code status form, dated 9/22/17, for full code; -A physician's order sheet (POS), dated June 2021, showed an order dated 10/8/18, for full code status; -No updated code status form found since 9/22/17. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents could retain personal property safely from loss or theft, when they failed to complete an inventory sheet for 6 of 20 sampled residents (Residents #426, #378, #376, #373, #425 and #276). The census was 82. Review of the facility's admission packet, provided on 6/7/21, showed: -Section 12 Resident Funds, Valuables and Possessions: -You or your representative agree to inform the facility of all valuable property upon admission, and at any time new items are added to your possession. Upon admission, a detailed inventory of your possessions will be done; -The facility will attempt to reasonably safeguard your non-monetary personal property and belongings left in the facility, to the extent required by law. [...]

Inspectors wroteBased on interview and record review, the facility failed to disclose and provide to a resident or potential resident prior to time of admission, notice of service limitations of the facility. The facility is a smoking facility and the admission packet provided to residents identify the smoking area and smoking times. During the COVID-19 pandemic, the facility stopped allowing smoking at the facility, failed to grandfather in the current residents admitted prior to the rule change and failed to provide in writing to newly admitted residents the new rule that smoking was no longer allowed in the facility. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Residents #227 and #36). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure notification to the resident and the resident's representative in writing of a discharge, including the reason for the discharge, the effective date of the discharge, the location to which the resident is discharged and a statement of the resident's appeal rights. The facility also failed to follow their transfer or discharge policy for 9 of 20 sampled residents (Residents #25, #57, #227, #223, #23, #61, #71, #276, and #67). The census was 82. Review of the facility's policy for Transfers and Discharges, dated 5/16/19, showed before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move, in writing. 1. Review of Resident #25's medical record, showed: -discharged to the hospital 3/16/21; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and family or legal representative of the bed hold policy at the time of transfer to the hospital for various medical reasons for eight of 20 sampled residents (Residents #35, #23, #71, #57, #227, #67, #276 and #25) The census was 82. Review of the facility's Bed Hold/Reservation of Room Policy, dated 5/2/19, included the following: -The facility's bed hold policy will be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain vitals and neurological checks for a resident who had fallen (Resident #425), ensure physician's orders were obtained/followed for tube feedings and oxygen, and ensure braces, splints, or palm guards were applied as ordered, for five of 20 sampled residents (Residents #67, #23, #54 and #22). The census was 80. 1. Review of the facility Fall Management Policy, dated 6/4/20, showed: -Purpose: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patient fall indicators; -Definition: Fall: refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had not caught him/herself, is considered a fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. The facility's activity director had worked at the facility for approximately four months and did not meet the requirements to be the activity director. The census was 82. Review of the activity director's resume and application for employment, showed: -Education: Bachelor of Science in Wellness with an emphasis in Kinesiology (body movement and positioning); -Work experience included experience as a Maître D (food service specialist) and home services provider (cleaning, cooking and shopping); -Volunteer experience in the Month of April, 2019 at a long term care facility in the activity program; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately monitor and provide assistance to promote good nutrition and to maintain acceptable parameters of nutritional status. Staff failed to ensure a timely nutrition assessment by the Registered Dietician (RD), failed to ensure response to the RD recommendation regarding resident weight loss, failed to notify the physician of significant weight loss, failed to implement interventions regarding nutrition per the care plan (Residents #54, #227 and #235). Furthermore, staff failed to provide meal assistance as needed, ensure the resident was positioned at a 90 degree angle when eating, and provide health shakes as ordered (Resident #324). The sample was 20 and the census was 82. 1. Review of Resident #54's care plan, initiated on 5/6/21 and in use during the survey, showed: -Focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper storage of medications in two of three medication carts observed. One medication cart contained an unidentified, pre-pulled pill in the top drawer and a tube of anti-fungal cream located inside of a box of lancets (small double-edged blades or needles used to make a puncture to obtain a blood specimen) in the bottom drawer. A second medication cart contained a box with various medications stored together, not labeled as stock or for a specific resident, a bottle of liquid Pro-source (a nutritional supplement) that lacked an opened-date, spilled over the side and into to the bottom of the medication cart and an unidentified pill on the bottom, right ledge of the cart. The facility had five medication carts. The census was 82. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain kitchen equipment, walls, ceiling tiles and floors in a clean and sanitary manner to prevent to the growth of bacteria and potential harborage of pests. Facility staff failed to ensure the meat slicer remained covered when not in use to prevent cross contamination and failed to ensure the inside perimeter of the mop bucket was clean. The census was 82. Observations on 6/7/21 at 8:28 A.M., 6/8/21 at 11:39 A.M., 6/9/21 at 8:05 A.M., 6/10/21 at 1:01 P.M., 6/11/21 at 10:16 A.M., 6/14/21 at 11:05 A.M., 6/15/21 at 1:57 P.M. and 6/16/21 at 7:03 A.M., showed the following: -The uncovered meat slicer positioned next to a food preparation sink; -The convection oven had a layer of grease and dust on top. The interior walls and the racks had a heavy carbon build up; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility failed to address the activity services required by the resident population considering the need for quarantine, the activity director staff competencies and the physical plant considerations such as the family dining room and courtyard utilized for meals and activities. In addition, the facility assessment failed to identify the smoking resident population and/or the location of the resident smoking area in the court yard. The facility identified one resident who smoked (Resident #13). [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent staff neglect from occurring when a staff member transferred one resident (Resident #10) using a sit to stand lift (mechanical lift) without assistance. The resident required a Hoyer lift (mechanical lift) with assistance of two staff members for all transfers. The resident fell and sustained a hematoma (a collection of blood outside of blood vessels) to the back of his/her head. The sample was 20. The census was 82. Review of the facility's Protection of Residents: Reducing the Threat of Abuse & Neglect Policy, dated Revised: 1/21/19; Reviewed 4/15/19, showed: - Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This includes but is not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of abuse to the Department of Health and Senior Services (DHSS) promptly, no later than 2 hours after the allegation was brought to the facility's attention, for two of 20 sampled residents (Residents #10 and #44). The census was 82. Review of the facility's Protection of Residents: Reducing the Threat of Abuse & Neglect Policy, revised: 1/21/19 and reviewed 4/15/19, showed: -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a preadmission screening for individuals with a mental disorder and individuals with intellectual disability by failing to ensure a resident had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screen is required) as required, for one of 20 sampled residents (Resident #67) The census was 82. Review of Resident #67's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/21, showed the following: -Date of admission on [DATE]; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation. This affected three of three reviewed closed records (Residents #276, #373 and #376). The census was 82. Review of the facility's Transfer and Discharge Policy, dated 5/6/19, showed: -Transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations; -The facility will provide equal care regardless of diagnosis, severity of condition, or payment source. Transfer and discharge policies are the same for residents regardless of payer source; -Documentation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary services to maintain personal hygiene for a resident who was unable to use a urinal and/or stand over a bedside commode or toilet (Resident #36). In addition, the facility failed to ensure residents were shaved and their fingernails were cleaned/trimmed as needed. (Residents #71, #54 and #73). The sample was 20. The census was 82. Review of the facility Activities of Daily Living (ADLs) policy, reviewed on 5/5/21, showed: -Purpose, to ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's physical, mental and psychosocial needs; -A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living; -Hygiene, bathing, dressing, grooming and oral care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper placement of indwelling urinary catheters (a tube inserted into the bladder for purpose of continual urine drainage). The facility identified four residents as having indwelling urinary catheters. Of those four, one was chosen for the sample and issues were found (Resident #61). The sample size was 20. The census was 82. Review of the facility's Indwelling Urinary Catheter and Management Policy/Procedure, dated November 20, 2020, showed the following: -Critical Notes: Life Care Centers of America has approved the following information as an addendum to the Lippincott procedure: 1). [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to execute appropriate technique while administering medications via gastrostomy (g-tube, a surgical opening into the stomach from the abdominal wall for the insertion of food and fluids) to one resident observed (Resident #23). Staff failed to follow standard, recommended practice when checking for g-tube placement and did not raise the head of bed (HOB) while administering medications to the resident via g-tube. The sample was 20. The census was 82. Review of the facility's Medication Administration through an Enteral Tube policy, effective date 4/4/19, showed: -Purpose is to set forth the procedures for medication administration through an enteral tube; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 31 opportunities observed, 2 errors occurred, resulting in a 6.45% error rate (Resident #38). The sample was 20. The census was 82. Review of the facility's Administration of Medications policy, revised on 5/6/20, showed: -All medications to be administered as ordered; -A physician order includes dosage, route, frequency, duration, and other required considerations; -Federal regulation is to have less than 5% error rate. Review of the facility's Reordering, Changing, and Discontinuing Orders, policy revised on 10/31/16, showed: -Facilities are encouraged to reorder medications electronically. Review of Resident #38's Electronic Health Record (EHR), showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility to maintain medical records that are complete, accurately documented, readily accessible and systematically organized for four of 20 sampled residents (Residents #379, #56, #227 and #12). The census was 82. 1. Review of Resident #379's medical record, showed the following: -admission date [DATE], discharged to county medical examiner on [DATE]; -Diagnoses included Stage 4 Pressure Ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (dead tissue separating from living tissue) or eschar (dead tissue) may be present on some parts of the wound bed. [...]