Life Care Center of Grandview

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one sampled resident (Resident #1) from physical abuse out of three sampled residents. On 5/24/26 Resident #2 entered Resident #1's room and hit Resident #1 on the left knee, left eye, and top of the left side of the head resulting in Resident #1 having a red mark on his/her left eye. The facility census was 108 residents. The Administrator was notified on 6/2/26 of the past noncompliance which began on 5/24/26. The facility immediately completed education for abuse & Neglect. The deficiency was corrected on 5/26/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate medication and medical equipment storage in three medication carts out of four medication carts and in two out of two medication storage rooms. The facility census was 98 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete Employee Disqualification List (EDL-a Missouri State screening tool used to check if an individual was prohibited from working with residents due to past abuse, neglect, or misappropriation of property) background checks for ten out of ten sampled employees. The facility census was 98 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate under five percent (%) with a medication error rate of 88%. This affected two sampled residents (Resident #12 and #89) and two supplemental residents (Resident #51 and #72) out of 20 sampled residents and two supplemental residents. The facility census was 98 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one closed record sampled resident's (Resident #108) responsible party after the resident fell on 2/14/26 out of two closed record sampled residents. The facility census was 98 residents. On 3/9/26 the Administrator was notified of the past noncompliance which occurred on 2/14/26. On 2/15/26 the facility administration was notified a resident's responsible party was not notified of a change in condition and the investigation was started. The resident's family was notified on 2/15/26. No employees were allowed to work prior to reeducation. The deficiency was corrected on 2/15/26. Review of the facility's policy titled Change in Resident's Condition or Status dated 8/29/25 showed the facility must immediately inform the resident; consult with the resident's physician; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent documentation of daily activity participation and quarterly activity progress for one sampled resident (Resident #70) out of 20 sampled residents. There was insufficient documentation to show that an activity program was consistently provided for the resident or that the resident had been informed when activities were taking place. The facility census was 98 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent one sampled resident (Resident #15) with a history of intrusive and unsafe wandering out of 20 sampled residents from wandering into other resident rooms; and failed to document the frequency of the resident's intrusive and potentially unsafe wandering. The facility census was 98 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store a nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) mask in a plastic bag for one sampled resident (Resident #16) out of 20 sampled residents. The facility census was 98 residents. Review of facility policy entitled Oxygen Administration (Infection Control, Safety, and Storage) revised 9/30/25 showed:-The facility must have ensured that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. -Stored respiratory supplies in a bag labeled (i.e., residents name) when not in use. 1. Review of Resident #16's admission Record showed he/she was admitted to the facility with the following diagnosis: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) received ongoing assessments of the dialysis site; and failed to have orders for dialysis for one sampled resident (Resident #38) out of 20 sampled resident. The facility census was 98. Review of the facility policy Area of Focus: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #70) with a history of physical and sexual trauma (an event or series of events experienced by a person as physically or psychologically harmful or threatening) out of 20 sampled residents had triggers (psychological stimulus that prompts recall of previous traumatic events) identified and interventions for staff to help mitigate triggers and avoid re-traumatization in the resident's Trauma Informed Care (TIC - an approach to care that recognizes and responds to the effects of trauma on a person) care plan. The facility census was 98 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pre-treatment medication for one sampled resident (Resident #35) out of 20 sampled residents, prior to his/her dental appointment, causing a delay in his/her dental care leading to unnecessary pain between procedures. The facility census was 98 residents. Review of the facility's Physician Orders Policy, dated 2/11/26, showed:-All physician/practitioner orders, including verbal/telephone orders, were recorded in the medical record for each resident and must be signed and dated within 14 days by the ordering physician, physician assistant or nurse practitioner.-The receiving nurse, therapist, or approved dietician immediately enters the telephone or verbal orders into the clinical software. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #2, Resident #4, and Resident #11) were free from abuse when on 10/10/25 Resident #1 slapped Resident #2 in the back of the head; on 10/16/25 when Resident #3 punched Resident #4 in the face multiple times which caused Resident #4 to have a small laceration to his/her right eyebrow, bruising to his/her right orbital area of his/her face, and multiple small cuts to the back of his/her head, and on 10/23/25 when Resident #3 poured hot sauce on Resident #11's face. 13 residents were selected for sample. The facility census was 106 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #3) was allowed back to the facility when the facility completed an Immediate Notice of Involuntary Discharge when they sent the resident to a local hospital on [DATE] out of 13 sampled residents. The facility census was 106 residents. Review of the facility's policy titled Notices of Transfers and Discharges dated 8/5/25 showed no policy related to immediate notice of involuntary discharges.1. Review of Resident #3's admission Record showed that he/she was admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of significant medication error when on 9/14/24 he/she did not receive an ordered dose of his/her seizure medication Lamotrigine Extended Release (ER) 24 hour 200 milligram (mg), 2 tablets by mouth at bedtime for seizures and on 9/16/24 and 9/17/24 he/she received incorrect doses of this medication out of four sampled residents. The facility census was 104 residents. The Administrator was notified on 9/25/24 of Past Non-Compliance which occurred on 9/14/24, 9/16/24 and 9/17/24. An all nursing staff in-service was completed on medication administration and medication administration observations were completed by 9/19/24. The deficiency was corrected 9/19/24. Review of the facility policy on medication administration revised 1/1/22 showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure two sampled residents (Resident #508) were free from abuse when on 6/2/24 Resident #507 hit Resident #508 which resulted in Resident #508 having an injury to his/her bottom lip and a bruise over the left eye out of 19 sampled residents. The facility census was 115 residents. The Administrator was notified on 6/7/24 of the past noncompliance which began on 6/2/24. The facility completed education on resident abuse and interventions for all staff and residents. The deficiency was corrected on 6/4/24. Review of the facility's Abuse and Neglect policy, undated, showed: -Each resident had the right to be free from abuse, neglect, misappropriation resident property, and exploitation. -This included, but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint. [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure the safe storage and accountability of a resident's narcotic medication (controlled substance medications that can cause physical and mental dependence) card by failing to verify and sign for the delivery of medications to the East Nurses Station resulting in the missing of 30 tabs of Oxycodone HCL (Hydrochloride) (a narcotic pain medication) 10 milligrams (mg) for one sampled resident (Resident #500) out of three sampled residents. The facility census was 116 residents. The Administrator was notified on 6/7/24 of the past noncompliance which began on 5/11/24. The facility in-serviced all nursing staff on the facility drug diversion policy. The deficiency was corrected 5/29/24. [...]

Inspectors wrote5. Review of Resident #35's admission Face Sheet showed the following diagnoses: -Pressure Ulcer (is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of his/her left hip Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). -Pressure Ulcer of Sacral (sacrum, is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) Area Stage IV. Review of the resident's admission MDS dated [DATE] showed: -The resident had a BIMS score of 15 out of 15 indicating he/she was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess for, identify and provide supportive interventions for one sampled resident (Resident #18) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental disorder that develops in some people who have experienced a traumatic event), out of 23 sampled residents. The facility census was 115 residents. Review of a facility policy titled Trauma-Informed Care, dated 8/22/23, showed: -The facility would have used a multi-pronged approach to identify resident trauma including assessing for indicators upon admission, which would then be reviewed by the interdisciplinary team (IDT) to determine appropriate person-centered interventions to mitigate or eliminate triggers that may lead to re-traumatization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary and food preparation equipment; failed to change the deep fryer oil in a timely manner; and failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination), in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 115 residents with a licensed capacity for 172 residents at the time of the survey. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the pneumococcal (any infection caused by the bacteria Streptococcus pneumoniae) vaccine, for two residents (Residents #48 and #166), failed to obtain signed refusal the pneumococcal vaccine for one resident (Resident #165) and failed to administer a consented pneumococcal vaccine to one resident (Resident # 61) out of five sampled residents. The facility census was 115 residents. Review of a facility policy titled Influenza and Pneumococcal Vaccine Policy for Residents, dated 7/30/2019, showed: -The facility was to offer each resident the pneumococcal vaccine unless medically contraindicated or the resident has already been immunized. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the Coronavirus Disease 2019 (COVID-19), for three residents (Residents #48, #61, and #166) out of five sampled residents. The facility census was 115 residents. Review of a facility policy titled COVID-19 Vaccination Program Policy for Residents, dated 1/3/22, showed: -The vaccine should have been offered to each resident and staff member unless the immunization was medically contraindicated or the resident or staff member had already been immunized. -Education should have been provided to the resident or resident representative before being offered the COVID-19 vaccination. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) program under Medicaid (a joint federal and state program that gives health coverage to some people with limited income and resources ) which ensures appropriate placement of residents with known or suspected of having mental impairments when the staff failed to refer one sampled resident (Resident #48) with a newly diagnosed mental disorder to a level two review out of 23 sampled residents. The facility census was 115 residents. Review of a facility policy titled Pre-admission Screening Assessment Resident Review, reviewed 9/2023, showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR - a federally mandated program that requires all states to prescreen all people regardless of payer source or age seeking admission to a Medicaid certified nursing facility) for one sampled resident (Resident #5) out of 23 sampled residents. The facility census was 115 residents. Review of the facility PASARR policy last reviewed on 9/25/23 showed: -The facility will ensure that potential admissions are screened for possible serious mental disorders or intellectual disabilities and related conditions. -The Level I PASARR will be completed prior to admission to the facility. 1. Review of Resident #5's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans (a document that specified health care and supported needs and outlined how the facility met resident requirements) for two sampled residents (Resident #114 and Resident #9) out of 22 sampled residents and three closed records. The facility census was 115 residents. Review of the facility's Care Planning-Baseline, Comprehensive and Routine Updates policy, dated 1/4/24, showed: -The comprehensive care plan included a problem/focus statement, measurable goals, and interventions. -The comprehensive care plan must be updated with each Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and periodically. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff applied a brace to a resident's hand for one sampled resident (Resident #13) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Splints and Braces, dated 1/16/24 showed: -The use of a supportive and protective device designed for a patient's upper extremity, such as a sling, brace, or splint, helps provide support, facilitate functional use, reduce pain, maintain alignment, correct deformities, or provide protection for a healing injury. -Documentation associated with supportive and protective devices of the upper extremity includes: --Length of time the patient wore the device. --Patients ability to apply and tolerate the device. --Wearing schedule and monitoring the patient's skin integrity. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete comprehensive fall investigations to include fall prevention measures that were in place to prevent falls, documentation of root cause analysis and any pertinent details of the incidents and environmental surrounding of the falls for one sampled resident (Resident #61), who was a risk for falls out of 23 sampled residents. The facility census was 115 residents. A fall investigation policy was requested and was not received at the time of exit. Review of the facility's Fall Management policy dated 12/4/23 showed: -To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients fall indicators. -With any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who had a feeding tube and took food orally was getting adequate nutrition by not recording how much the resident took in orally and did not weigh him/her on a regular basis for one sampled resident (Resident #96) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Resident at Risk, dated 4/25/23 showed: -Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as usual body wight. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's oxygen equipment was stored in a sanitary condition when not in use, failed to ensure oxygen tubing was changed out weekly, failed to ensure residents had water in the humidifiers on the oxygen concentrator for three sampled residents, (Resident #5, Resident #9, and Resident #51) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Oxygen Administration/Safety/Storage/Maintenance, dated 9/26/23 showed: -Oxygen would have been administered in accordance with physician's orders. -Change oxygen supplies weekly and when visibly soiled. -Equipment should have been dated when setup or changed out. -Humidifier bottles should have been dated and replaced every seven days regardless of the water level. [...]

Inspectors wroteBased on interview and record review ,the facility failed to address the pharmacy's recommendation to the physician in a timely manner for one sampled resident, (Resident #23) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Medication Regimen Review (MMR), dated 8/17/23 showed: -The Consultant Pharmacist would conduct MMR if required under a Pharmacy Consultant Agreement and would make recommendations based on the information available in the residents' health record. -The Pharmacist would address copies of residents' MRR to the Director of Nursing (DON) and the attending physician and to the Medical Director. -Facility staff should have ensured that the attending physician, Medical Director, and DON were provided with copies of the MRRs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two sampled residents, (Resident # 9 and Resident #13) received dental services for broken teeth or missing teeth, and to provide a dental consultation for one sampled resident (Resident #27) who had a physician order for a consultation with an oral surgeon for dental extractions out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Dental Services, dated 8/23/23 showed: -The facility was responsible for assisting the patient in obtaining needed dental services, including routine dental services. -The facility would have provided or obtained from an outside resource routine and emergency dental services to meet the needs of each patient. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free of misappropriation for one sampled resident (Resident #2) when Certified Nurses Aide (CNA) A used the resident's debit card to charge $4,607.20 for his/her own personal use out of seven sampled residents. The facility census was 119 residents. Review of the facility's Abuse and Neglect Policy dated 10/4/22 and revised on 7/18/23 showed: -The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. -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 protect the resident's right to be free of misappropriation for one sampled resident (Resident #5) out of seven sampled residents when the resident's debit card was used for $60.00 in unauthorized purchase, declined purchase of $11.60, check 496 cashed for $875.00 and check 500 cashed for $1000.00. The facility census was 121 residents. The Administrator and the Director of Nursing (DON) were notified of past non-compliance. The facility identified the missing debit card and checkbook on 10/12/23 and began investigating. A police report was made on 10/12/23 regarding the missing debit card and checks. The resident was assisted in recovery. Continued education regarding policy and procedure for Abuse and Neglect, Misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was enough dietary staff available to ensure the lunch meal was served in a timely manner on 8/1/22. This practice potentially affected 107 residents who ate food from the kitchen. The facility census was 112 residents. 1. Record review of the undated document entitled Meal Times, showed. breakfast should be served at 8:00 A.M., lunch should be served at 12:00 P.M., dinner should be served at 6:00 P.M. and the facility served room trays first. Record review of the dietary section of the Resident Council Minutes dated 6/23/22 showed (Residents) were not getting meals on time in the evening. Record review of the dietary section of the Resident Council Minutes dated 7/28/22 showed Always late serving, no response was noted to the dietary concerns noted in the previous months minutes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the following: the buildup of grime on floors throughout the kitchen; to ensure 3 out of 4 cutting boards with numerous stains and grooves, were not used; to store utensils in a manner that was free from contamination; to clean the nozzles of the dishwasher spray wands from debris; to maintain the gaskets of a reach-in fridge in good repair; to maintain the area around the spigots of the juice machine free from the old juice stains; to maintain the ceiling of the kitchen free from dust and cobwebs (a spider's web, especially when old and covered with dust.); to maintain the outside of bottles in the storage rooms free from stains; to ensure both handwashing stations were equipped with paper towels and soap; to maintain the floor of the walk-in free from stains and grime; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three sampled residents (Resident's #61, #7, and #100) in a timely manner about a spend down plan, when their resident trust balances remained above $4,835 which is within $200 of the absolute limit of $5,035. The facility also failed to send in a Third Party Liability Form to Missouri (MO) HealthNet within 30 days of the death of two sampled residents (Resident's #1000 and #1001). This practice potentially affected three current and two discharged residents. The facility census was 112 residents. 1. Record review of Resident #7's ledger sheet dated 1/2022 through 8/2022, showed: - On [DATE], the resident had a balance of $7,167.45. - On [DATE], the resident had a balance of $6,022.92. - On [DATE], the resident had a balance of $6,086.11. - On [DATE], the resident had a balance of $7,357.05. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain bed sheets free from stains and to change those sheets for three days (8/1/22, 8/2/22 and 8/3/22) of the survey for one sampled resident (Resident #45); to maintain the rubber grip of the assistance pole in resident rooms 306, 406, in in an easily cleanable condition and without rips or tears; to maintain the floors of resident rooms 307, 309, 414, 405, 403, 401, 206, 205, and 214 free of a buildup of grime and debris; to maintain the restroom ceiling vents in resident rooms 413, the 300 Hall Ladies' Shower room and 302 free from a heavy buildup of dust; to maintain the commode riser in the 200 Hall men's shower room in an easily cleanable condition; and to maintain the mattress in Resident #159's room in an easily cleanable condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) had their call lights answered in a timely manner and received the necessary services to maintain good personal hygiene for three sampled residents (Resident #84, #37, and #56) and two supplemental residents (Resident #107 and #79) out of 29 sampled residents and seven supplemental residents. The facility census was 112 residents. Record review of the facility's policy Activities of Daily Living (ADLs) dated 7/17/21 showed the facility must provide care and services for bathing, dressing, grooming, and oral care. 1. Record review of Resident #84's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff maintained current cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure consisting of chest compressions, often combined with artificial breathing, to manually preserve intact brain function, circulation and breathing to an unresponsive person) certification; to know if CPR certified staff were available each shift who could provide CPR to residents who needed it, and to monitor which staff had maintained CPR certification. The facility census was 112 residents. Record review of the undated Facility Abuse and Neglect Standards of Care policy, showed the facility must develop and implement written policies and procedures that include training as required. A CPR Policy and Procedure was requested and not received prior to the survey exit. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff to provide treatment and services including answering call lights timely for two sampled residents (Residents #84 and #37) and two supplemental residents (Residents #107 and #70) out of 29 sampled residents and seven supplemental residents. The facility census was 112 residents. 1. Record review of Resident #84's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of: history of Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system) and neuromuscular dysfunction of the bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). During an interview on 7/12/22 at 9:29 A.M., the resident said: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure recipes for seafood casserole and pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) carrots, were available for dietary staff to follow. This practice potentially affected 107 residents who ate food from the facility kitchen. The facility census was 112 residents. 1. Record review of the requested recipe for 100 servings of Baked Seafood Casserole dated 4/18/22, later provided by the Dietary Manager (DM) showed: - Ingredients included: -- 18 pounds (lbs.) 12 ounces (oz.) of imitation crab meat. -- 9 lbs. 8 oz. of shrimp. -- 2 and ¼ quart and ½ cup mayonnaise. -- 1 quart and ¼ cup chopped green peppers. -- 2 cups minced onions. -- 3 quart ½ cup fine chopped celery. -- 1 tablespoon (Tbsp.) and 1 and ¼ teaspoons (tsp) salt. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the hot items (seafood casserole and the carrots) at the lunch meal were at or close to 120 ºF (degrees Fahrenheit), potentially affecting at least 4 residents on the 200 Hall. The facility census was 112 residents. 1. Observation on 8/1/22 from 1:11 P.M. through 1:13 P.M., showed: - Lunch was delivered to Resident #84. - Resident #84 refused his/her the meal. - The state surveyor asked for permission to measure the temperature of the hot food items on his/her plate. - Resident #84 said yes, the state surveyor could check the temperature. - The temperature of the carrots was 109.9 ºF and the temperature of the seafood casserole was 108.8 ºF. During an interview on 8/1/22 at 1:16 P.M., Certified Nurse's Assistant (CNA) A said he/she did not see anyone from dietary come out and check the food temperatures. [...]

Inspectors wroteBased on observation, interview and interview, the facility failed to have a call light system that was accessible for two sampled residents (Residents #5 and #44) out of 29 sampled residents, who wanted to use a call light but did not have one available for them, and two residents (Residents #67 and #92), who required assistance from facility staff to transfer from their beds. The facility census was 112 residents. 1. Record review of Resident #5's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 7/23/22, identified the resident as: - A resident who was somewhat cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. [...]

Inspectors wroteBased on interview and recorded review, the facility failed to transcribe and verify advance directive orders for Full Code (all life saving measures, such as cardio-pulmonary resuscitation (CPR), are attempted if a person suffers cardiac or respiratory arrest) or Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) and updated the medical record and care plan to reflect the correct code status, for one sampled resident (Resident #11) out 29 sampled residents. The facility census was 112 residents. 1. Record review of Resident #11 admission Face-Sheet as of [DATE] showed he/she was admitted to the facility on [DATE] with the following diagnoses: -History of stroke affect the left side. -Heart failure. -Was full code status. -Was his/her own responsible person. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the beneficiary notification was provided to one sampled resident (Resident #84), and/or his/her responsible party once the resident was discharged from Medicare out of three sampled residents selected for review. The resident sample was 29 residents. The facility census was 112 residents. 1. Record review of Resident #84's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke with paralysis, diabetes, anemia (low iron), muscle weakness, arthritis, wounds, urinary tract infection, vitamin D deficiency, lack of coordination and abnormal gait. Record review of the resident's Beneficiary Protection Review showed: -The start date for the resident's Medicare Part A skilled services was [DATE]. -The last covered day of Medicare Part A service was [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of property when on 6/23/22 Certified Nurse's Assistant (CNA) E took Resident #61's debit card and made unauthorized purchases totaling $278.97 out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's undated Abuse and Neglect Policy showed: - Each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation of any type by any one. - 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 observation, interview and record review, the facility failed to ensure the care plan for one sampled resident (Resident #77) was updated to show the resident developed a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); to include the resident and/or resident's representative during the development of their individualized care plan for two sampled residents (Resident #56 and #61) out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's policy 'Comprehensive Care Plans and Revisions' dated 3/2/22 showed the care plan was to be prepared by an Interdisciplinary Team (IDT) that included the resident and the resident's representative. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #58) who had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and identified as a resident who required turning and repositioning every two hours received the necessary treatment of turning and reposition to promote healing, out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's policy 'Skin Integrity and Pressure Ulcer/Injury Prevention and Management' dated 8/5/21 showed staff were to reposition residents every 2-4 hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision during medication administration by leaving the resident's medication at bedside for one sampled resident (Resident #91) out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's Administration of Medications Policy revised 5/6/22 showed: -The facility will ensure medication are administered safely and appropriately per physician order to address resident's diagnoses, signs and symptoms. -A Physician order that include dosage, route, frequency, duration, and other required consideration for administration of medications. 1. Record review of Resident #91's Face sheet showed he/she was admitted to the facility on [DATE] had diagnosis including: -Acquired absence of left eye. -Cancer of the face. -Cognitive communication Deficit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of a Suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) drainage bag (catheter bag, a bag that hold drained urine) and to ensure to follow physician orders for care and monitoring of SP catheter for one sampled resident (Resident #84) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system); and to ensure a resident's suprapubic catheter drainage bag was monitored for fullness and the catheter drainage bag was emptied in a timely manner for two sampled residents (Resident #37 and Resident #58), who had been recently treated for an urinary tract infection out of 29 sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were carried over for colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen stoma) care to include the type of appliances, skin barriers and skin care; and to document a detailed assessment of the colostomy site for one sampled resident (Resident #37) out of 29 sampled residents. The facility census of 112 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were complete for the resident's tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called enteral feeding or tube feeding) to show how the facility was to care for the tube site, the parameters for removing the resident's tube feeding, and monitoring the tube to ensure patency for two sampled residents (Resident #94 and Resident #8); to document the adjustment of the resident's nutritional caloric needs when the resident was not receiving tube feeding for one sampled resident (Resident #94), who received continual tube feeding; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #59) had a current physician's order for the administration of oxygen; to ensure the oxygen tubing, nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) and breathing treatment face masks were covered when not in use for two sampled residents (Resident #94 and #44); and to ensure physician's orders for breathing treatments were obtained and followed for one sampled resident (Resident # 44) out of 29 sampled residents. The facility census was 112 residents. Record review of Food and Drug Administration (FDA).gov's article Pulse Oximeters and Oxygen Concentrators dated 2/19/21 showed: -Too much oxygen can cause oxygen toxicity (lung damage that happens from breathing in too much supplemental oxygen; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician's dialysis orders included the dialysis access site and how the nursing staff were supposed to treat and monitor the site, to include frequency of monitoring; to consistently document monitoring of the resident's dialysis site; to maintain ongoing communication with the dialysis center for continuity of care; to ensure communication was available to nursing staff so they were aware of the resident's treatments and to ensure the care plan showed the correct dialysis access site, monitoring and care for one sampled resident (Resident #94) who received dialysis, out of 29 sampled residents. The facility census was 112 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store items in the resident use refrigerator which were not labeled with a date they were placed in the fridge or a resident's name, or had expired according to the date on the package. The facility also failed to maintain the resident use refrigerator free of food stains within the refrigerator. This practice potentially affected an unknown number of residents whose food was stored in that refrigerator. The facility census was 112 residents. 1. Record review of the facility's policy entitled Food from Outside Sources, revised on 6/6/22, showed: - Food stored in the refrigerator should be labeled with the resident's name and room number. - Adhere to expiration date on prepackaged food items; items should be discarded if past expiration date. Observations on 8/2/22 at 1:50 P.M. showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one trash container in the kitchen was closed, when not in use. This practice affected the kitchen. The facility census was 112 residents. 1. Observations on 8/1/22 at 9:32 A.M., 11:41 A.M., and 1:50 P.M. showed one trash container without a lid. During an interview on 8/2/22 at 11:45 A.M., the Dietary Manager (DM) said the lid had been missing about 30 days or so, he/she was not sure where it was misplaced, and he/she has not had time to search for it. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Chapter 5-501.113 entitled Covering Receptacles, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent conditions such as the existence of molded potatoes, wet floor mats next to the hand washing sink close to the dish washing area and the existence of a volume of food particles on the dishwasher drainage tray which could harbor gnats (small flies) in the kitchen; to clean up dead insects carcasses in from the floor of dietary storage room [ROOM NUMBER] and to clean up dead insects from the floor of the 500 Hall sprinkler room. This practice affected two non-resident use areas, the kitchen and adjoining storage rooms and the 500 Hall sprinkler room. The Facility census was 112 residents. 1. Observations on 8/1/22, showed: - At 9:18 A.M., numerous gnats flew around in the kitchen with more gnats around the potato storage area. [...]