Life Care Center of Cape Girardeau

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient fluid intake to maintain proper hydration and health by not providing residents with fresh, easily accessible water at bedside, assistance with holding a water cup and cueing/offering resident's hydration for three of the four sampled residents, (Residents #1, #2, #3). The facility census was 79. Review of the facility's undated policy titled, Hydration and Nutrition, dated 09/25/25, directed staff to do the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support for one resident (Resident #1), when on [DATE] at around 10:25 P.M., staff entered the resident's room and found the resident unresponsive with no respirations. Cardiopulmonary resuscitation (CPR - a procedure performed usually involving chest compressions and assisted breathing to revive a person's life) was initiated by facility staff with notification to emergency medical services (EMS) and hospice services. The resident's facility medical record showed a full code status order was entered on [DATE], without any documentation of the resident's wishes or consent for a full code status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 88. The facility policy titled, Food Safety, reviewed 05/01/25, showed: - Food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth; - Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). The use by date is noted on the label or product when applicable; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to properly maintain the temperature of cold foods at or below 41 degrees Fahrenheit (°F) at the time of meal service, failed to implement a system to monitor food temperatures at the time of meal service, and failed to ensure refrigerator temperatures were maintained at 41 degrees or below. Failure to maintain foods at the proper temperature had the potential to affect all residents receiving meal service. The facility's census was 88. Facility policy entitled, Food Temperature Control, revised 4/28/25, showed: - Food temperatures are maintained during mealtimes to ensure residents receive safe food served at acceptable temperatures; - Food temperatures are checked at the completion of the cooking process and before food is placed on the serving line; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to cover resident catheter (tube inserted into the bladder to drain urine) bags to maintain dignity for one resident (Resident #54) out of six sampled residents and for one resident (Resident #38) outside the sample. The facility census was 88. Review of the facility's policy titled, Dignity, revised 09/26/24, showed: - Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant by putting residents to bed based on staff preference and not resident preference for one resident (Resident #54) and by failing to honor two resident's (Residents #54 and #77) preferences to be shaved regularly out of 21 sampled residents . The facility's census was 88. Review of the facility's policy titled, Area of Focus: Resident Rights, reviewed 11/14/24, showed: - At the time of admission, a resident is afforded certain rights while residing in a Long-Term Care Facility. The facility and its associates have the responsibility for ensuring these rights are always upheld while the resident is in their care. [...]

Inspectors wroteBased on interview and record review, the facility failed to refund resident funds within 30 days of discharge or expiration of residents for four residents (Residents #197, #198, #199, and #200) out of a sample of 10 residents. The facility census was 88. The facility did not provide a policy regarding expired or discharged resident funds. 1. Review of Resident #197's census showed billing stopped on [DATE]. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's balance remained at $367.14. Review of the facility maintained Resident Trust Fund Trial Balance Report, dated [DATE] - [DATE], showed: - The resident's account was closed on [DATE]; - The resident funds of $367.14 remained in the facility account for days 94 days after the resident was discharged from the facility. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for four residents (Residents #22, #25, #46 and #83) out of 21 sampled residents. The facility census was 88. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, reviewed 09/11/24, showed: - The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weights as ordered for one resident (Resident #25) out of five sampled residents and one resident (Resident #53) outside the sample. The facility census was 88. Review of the facility's policy titled, Weight Monitoring, Long-Term Care, reviewed 08/19/24, showed: - Weighing a resident in a long-term care facility is an important part of assessing a resident's health. Following a routine weighing schedule helps detect weight changes. Unless otherwise specified, a resident's weight should be recorded at the time of admission, weekly for 4 weeks, and then monthly. Keep in mind that many residents have comorbidities that cause unplanned weight changes, and some residents require more frequent weight assessments; - Weight loss in older adults can result from various conditions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #25) out of two sampled residents received timely feeding assistance and one resident (Resident #37) out of 21 sampled residents received an evening meal tray in a timely manner. The facility's census was 88. Review of the facility's policy titled, Feeding a Resident, reviewed 09/10/24, showed: - Properly trained personnel supervised by nursing assist residents as needed with meals and snacks and feed residents who are unable to feed themselves; and nursing personnel provide assistive devices to residents as directed by therapy and provide education to residents regarding the use of assistive devices; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers for three residents (Residents #25, #54, and #77) out of 21 sampled residents and one resident (Resident #53) outside the sample. The facility's census was 88. Review of the facility policy titled, Activities of Daily Living (ADLs), reviewed 09/10/24, 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; - Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure cardiopulmonary resuscitation (CPR - initiation of life sustaining measures in the event the heart stops beating) certified staff accompanied all residents with a full code (initiate CPR in the event the heart stops beating) status when transported to and from appointments in the facility van for two transport drivers (Transport Driver F and Transport Driver G) out of two sampled transport drivers. The facility census was 88. Review of the facility's policy titled, Cardiopulmonary Resuscitation, revised [DATE], showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an on-going program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This practice affected one resident (Resident #22) out of 18 sampled residents and could potentially affect all residents. The facility census was 88. Review of the facility's policy titled, Therapeutic Activities Program, revised on 04/01/22, and reviewed on 09/27/24, showed; - The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activity's component of the compressive assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and necessary care by not following through with a transfer from a wheelchair to bed after responding to a call light for one sampled resident (#54) and not following through with peri care request after responding to a resident's call light for one resident outside of the sample (Resident #78). Failure to respond to resident's request for assistance when responding to call lights could place residents at risk for skin breakdown, discomfort and cause emotional distress. This could affect all residents. The facility census was 88. The facility did not provide a policy regarding call light response times. 1. Review of Resident #54's medical record showed: - An admission date of 02/25/25; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the certified nurse assistants (CNAs) an annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for one CNA (CNA D) out of two sampled CNAs. The facility census was 88. Review of the facility's policy titled, CNA 12 hours of Inservice Training, dated 06/11/24, showed: - CNA training must be sufficient to ensure continuing competence and be no less than 12 hours per year; - Training must address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; - CNA in-service hours will be calculated annually by their employment date rather than the calendar year; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This deficient practice affected two medication carts out of three sampled medication carts. The facility census was 88. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, revision date of [DATE], showed: - Only authorized facility staff should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas; - Facilities should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the spread of infection during care for two residents (Resident #71 and #83) out of three sampled residents and failed to ensure oxygen tubing was clean for one resident (Resident #53) out of one sampled resident. The facility's census was 88. Review of the facility policy titled, Oxygen Administration (Infection Control, Safety, & Storage), revised, 04/08/25, showed: - Change oxygen supplies (e.g., cannula (a thin, flexible tube inserted in the nostrils used to deliver supplemental oxygen), tubing, humidifier) weekly and when visibly soiled. Equipment should be labeled with the resident name and dated when setup or changed out; - Store oxygen and respiratory supplies in a bag labeled when not in use. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in five rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 88. The facility did not provide a policy for overbed lighting safety. 1. Observation on 05/19/25 at 11:08 A.M., of room [ROOM NUMBER] showed: - Seven stuffed animals on top of the light fixture above the bed by the door; - Eight stuffed animals on top of the light fixture above the bed by the window. 2. Observation on 05/19/25 at 11:15 A.M., of room [ROOM NUMBER] showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information on the location of the State Long-Term Care Ombudsman program (a statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights were preserved and respected). This practice could have potentially affected all residents in the facility. The census was 88. Review of facility's policy titled, Resident Rights,reviewed 11/19/24, showed: - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Observation on 05/21/25 at 2:00 P.M., of the facility showed: - The prior Ombudsman information posted on the wall past the entrance of the facility; [...]

Inspectors wroteBased on record review and interview the facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support for one resident (Resident #1) when on [DATE] the Phlebotomist came in around 5:00 A.M. and came to nurse's station and said the resident would not wake up. Licensed Practical Nurse (LPN) E went to the room and the resident did not have a pulse. LPN E and Certified Nurse Aid (CNA) C went to the nurse's station to check the report sheet for code status. The resident was a full code. LPN E returned to the room to begin Cardiopulmonary Resuscitation (CPR) while CNA C checked the electronic medical record for code status and called the code overhead. After a few compressions, CNA C returned to the room and stated the resident was a Do Not Resuscitate (DNR) according to the electronic records. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents or residents' authorized representatives were given access to view medical records in a timely manner when staff failed to give one resident (Resident #5) out of 6 sampled residents, access to view the resident's medical record within the required 24 hours after a request had been made. This had the potential to affect all the residents in the facility. The facility's census was 94. The facility did not provide a policy regarding medical records requests. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 01/17/25, showed: - A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders by not administering medications as ordered for one resident (Resident #1) out of six sampled residents. The facility's census was 94. Review of the facility's policy titled, Reordering, Changing, and Discontinuing Medication Orders, dated 07/01/24, showed: - Facilities are encouraged to reorder medications electronically or by fax whenever possible; - Facility is encouraged to follow verbal reorders with a faxed copy to the pharmacy; - Electronic Orders (e-Refill): Authorized facility staff may use Omniview (Trademark) to electronically reorder resident; - Facility staff should review the transmitted re-orders for status and potential issues and pharmacy response; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents #1 and #2) out of five sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices related to pain management. The facility's census was 94. Review of the facility policy titled, Pain Assessment and Management, last revised 09/12/23, showed: - Facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive-centered care plan, and the residents' goals and preferences; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received required physician's visits for one resident (Resident #3) out of five sampled residents. The facility census was 94. Review of the facility policy titled, Physician Services Guidelines, last revised 03/10/23, showed: - The physician must make an initial comprehensive visit no later than 30 days after admission; - A physician must visit the patient at last every 30 days for the fist 90 days after admission and at least every 60 days thereafter. 1. Review of Resident #3's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the environment remained free of accident hazards by not ensuring staff utilized a hoyer lift and an appropriate vehicle to accommodate a wheelchair for one resident (Resident #1) resulting in increased pain and anxiety out of three sampled residents. The facility census was 99. The facility did not provide a policy for transfers. 1. Review of Resident #1's medical record showed: - An admission date of 10/30/24; - Diagnoses of muscle weakness, reduced mobility, history of falling, and chronic kidney disease (long standing disease of the kidneys); - No documentation of a lift assessment. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by the facility staff), dated 11/16/24, showed: - The resident required maximal assistance with mobility. [...]

Inspectors wrotejw KW Based on observation, interview, and record review, the facility failed to identify and treat a facility acquired pressure ulcer (injury to the skin and underlying tissue from prolonged contact with pressure) for one resident (Resident #2) out of five sampled residents. The facility's census was 105. Review of the facility's policy titled, Skin Wound, dated 08/25/21, showed: - Based on comprehensive assessment of a resident, the facility must ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations of individual needs and preferences to ensure one resident (Resident #2) of five sampled residents has an acceptable bed with the correct width and length that encourages independent bed mobility. The facility census was 105. Review of the facility policy titled, Care of Bariatric Resident, dated 04/18/23, showed: - Severe obesity- weighing more than 250 pounds (lbs) or a body mass index of 40 kilograms (km) and is synonymous with the term bariatric; - The facility should consider the activation of bariatric protocols when admitting a resident who is 250 lbs or more; - Education should also address any negative feelings or fear related to the care of bariatric residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to safely transfer a cognitively impaired resident (Resident #1) out of five sampled residents, to the emergency room (ER). Facility staff sent the resident, unescorted, to the ER in a city cab instead of an ambulance after the resident experienced a medical problem. The facility census was 105. The facility did not provide a policy on safe transportation. 1. Review of Resident #1's admission Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by the facility staff), dated 07/31/24, showed: - An admission date of 07/25/24; - Cognitively impaired; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide needed care and services to promote the healing of an open abdominal surgical wound for one resident (Resident #37) out of one sampled resident. The failure to thoroughly assess, document, treat and monitor the resident's condition contributed to the resident being hospitalized with sepsis (widespread infection causing organ failure and dangerously low blood pressure) and wound infection. The facility census was 100. The facility did not provide a policy regarding skin assessments, wound management or treatment. 1. Review of Resident #37's medical record showed: - An admission date of 02/13/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders and provide treatment for two residents (Resident #37 and #71) out of six sampled residents with pressure injuries (injury to the skin and underlying tissue resulting from prolonged pressure on the skin). Resident #37 was admitted from the hospital with a sacral (above the tailbone) wound. The facility failed to complete a comprehensive assessment upon admission and failed to obtain physician orders to treat the wound. The resident was hospitalized 19 days after the facility admission with an infected, unstagable (the stage is unclear due to the base of the wound is covered with dead tissue) sacral wound. The facility census was 100. Review of the facility's policy titled, Skin Integrity & Pressure Ulcers/Injury Prevention and Management, reviewed 03/31/23, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 100. Review of the facility's Food Safety Policy, dated 11/28/17 and revised 04/26/23, showed: - Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth; - Pre-packaged food is placed in a leak-proof, pest proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product when applicable. [...]

Inspectors wroteBased on interview and record review, the facility failed to get the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form signed no later than two days before covered services ended for one resident (Resident #21) out of two sampled residents. The facility's census was 100. The facility did not provide a policy regarding SNF ABN forms. 1. Review of Resident #21's SNF ABN form showed: - The resident discharged from skilled Medicare services on 10/24/24, and remained in the facility; - The resident received and signed the form on 10/26/24; - The facility failed to provide the SNF ABN form to the resident at least two calendar days before the skilled Medicare services ended. During an interview on 03/15/24 at 2:25 P.M., the Social Service Assistant said he/she had the SNF ABN form signed when he/she found out a resident was being cut off. During an interview on 03/15/24 at 2: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 100. The facility did not provide a policy. 1. Observations of room [ROOM NUMBER] showed: - On 03/13/24 at 3:57 P.M., and 03/14/24 at 8:14 A.M., food particles, three empty medication dispensing cups, an unidentified yellow pill/tablet, and dirt under the resident's bedside chair. One French fry and shredded cheese on the floor by the electric cords to the bed; - On 03/15/24 at 9:43 A.M., food particles, three empty medication dispensing cups, an unidentified pill/tablet tablet, and dirt under the resident's chair at the bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the office of the Missouri State Long-Term Care Ombudsman (an advocate for residents in a long-term care facility) when residents were sent to the hospital for six residents (Resident #10, #14, #31, #34, #64, and #127) out of 6 sampled residents. The facility's census was 100. Review of the facility's policy titled, Ombudsman Program, revised 10/06/22, 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 and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment of an excoriated skin area for one resident (Resident #10) out of one sampled resident. The facility also failed to follow physician's orders for one resident (Resident #34) and failed to obtain weights as ordered for three residents (Resident #41, #89 and #111) out of 20 sampled residents. The facility census was 100. Review of the facility's policy titled, Indwelling Urinary Catheter (a tube placed into the bladder to drain urine) - Foley (an indwelling catheter) Management, dated 08/24/23, showed: - Based on comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers for eight (Resident #9, #30, #34, #36, #64, #89, #122, and #183) out of 20 sampled residents. The facility's census was 100. Review of the facility policy titled, Activities of Daily Living, dated 08/23/23, showed: - A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; - Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 1. Review of Resident #9's medical record showed: - An admission date of 02/23/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. This had the potential to affect all residents. The facility's census was 100. Review of the facility's policy titled, Storage and Expiration (exp) Dating of Medications, Biologicals, dated [DATE], showed: - Only authorized facility staff should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas; - Facilities should ensure that medications and biologicals are stored in an orderly manner; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of the Antibiotic Stewardship Program (a program that measures and improves how antibiotics were prescribed by clinicians and used by patients) and that its policies were reviewed annually. This had the potential to affect all residents in the facility. The census was 100. Review of the facility's policy titled, Antibiotic Stewardship, showed: - The antibiotic stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or adverse events. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two Certified Nurse Assistants (CNA) CNA A and CNA B out of two sampled CNAs. The facility's census was 100. Review of the facility's policy titled, Required Inservice for Nurse Aides, dated 09/13/22, showed: - Certified Nurse Aide training must be sufficient to ensure continuing competence and be no less than 12 hours per year; - Associates will be notified when they are deficient in in-service hours and arrangements will be made to make up the deficient training requirements prior to the next annual performance review. 1. Review of CNA A's in-service record showed: - A hire date of 06/03/20; - A total of six hours of annual in-service training for March 2023 through March 2024; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers for three (Resident #1, #2, and #3) out of four sampled residents. The facility's census was 98. Review of the facility policy titled, Activities of Daily Living, dated 08/23/23, showed: - A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; - Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 1. Review of Resident #1's medical record showed: - An admission date of 09/08/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to obtain daily/weekly weights for three residents (Residents #7, #8, and #9) of eleven sampled residents. The facility census was 102. Review of the facility policy titled Weights and Heights, dated 07/17/2021, directed staff to: - Follow facility protocol to determine who is assigned resident weights and heights; - Maintain consistency when obtaining repeated weights (weight at same time of day, with same equipment, with resident wearing similar clothing); - Notify the nurse if the weight obtained is significantly different from the prior weight (greater than 3 pounds (lbs.) for a weekly weight, or greater than 5 pounds for a monthly weigh), reweigh as needed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 81. Record Review of the facility's Food Safety Policy, dated 11/28/17 and revised 9/08/22, showed: - Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth; - Pre-packaged food is placed in a leak-proof, pest proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product when applicable. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for four residents (Resident #6, #38, #50 and #73) out of 18 sampled residents. The facility census was 81. 1. Record review of Resident #6's medical record showed: - An admission date of 11/02/16; - Diagnoses of hemiplegia (severe or complete loss of strength on one side of the body that can affect arms, legs, and facial muscles) and hemiparesis (severe or complete loss of strength on one side of the body that can affect arms, legs, and facial muscles) following cerebral infarction (stroke or disrupted blood flow to the brain due to problems with the vessels that supply it), affecting right dominant side, muscle weakness, and lack of coordination; - An evaluation for bed rails on 9/18/22; - Care plan did not address bed rails. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage dumpsters and trash receptacles were covered for four of four days of observation. The facility census was 81. 1. Observation of the main kitchen on 10/03/22 at 11:25 A.M. showed the following: - An uncovered 32 gallon trash can located in the dishwashing section rolled partially under the countertop, filled with trash near the rim; - An uncovered 32 gallon trash can located near the food prep table and sink filled with trash near the rim. 2. Observation of the main kitchen on 10/04/22 at 9:02 A.M. showed the following: - Two uncovered 32 gallon trash cans located near the rear food prep table and sink, filled with trash near the rim. 3. Observation of the main kitchen on 10/04/22 at 10:29 A.M. showed the following: [...]