Lincoln County Nursing & Rehab

Inspectors wroteBased on record review and interview, the facility failed to ensure two residents (Resident #74 and #25) were free from verbal abuse. On 03/30/26, Housekeeper A yelled at Resident #74 after the resident requested assistance with care and screamed and cursed at Resident #25 when the resident confronted him/her about how he/she talked to Resident #74. The facility census was 85. The administrator was notified of the past noncompliance on 04/09/26, which occurred on 03/30/26. On 03/30/26, the facility terminated Housekeeper W from employment at the facility for the allegation of staff to resident abuse and inserviced all staff on abuse prevention. Review of the facility's undated policy, Abuse Policy, showed the following: -Each resident will be free from abuse. Abuse can include verbal, mental, sexual or physical abuse; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 85. During an interview on 04/16/26 at 8:45 A.M., the Administrator said the facility did not have a policy directly addressing RN coverage. Review of the facility assessment, updated 01/09/26, showed the facility resources needed to provide competent support and care for the resident population every day and during emergencies included RN coverage eight hours per day. Review of the Centers for Medicare and Medicaid Services (CMS) [NAME] report for Quarter 1, 2026 (reporting period 10/1/25 - 12/31/25) showed the facility did not meet the eight-hour per day RN requirement on 10/19/25, 10/26/25, 10/31/25, 11/01/25, 11/15/25, 11/16/25, 11/22/25, 11/28/25, 11/29/25, 12/12/25, 12/13/25, 12/14/25, 12/21/25, 01/24/26 and 01/29/26. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal food items, store food per manufacturer's instructions, or store food items off the floor. Staff did not practice proper hand and glove hygiene, sanitary dish handling, and consumption of personal food and beverage items. Staff did not maintain surfaces and equipment free from a buildup of grease and debris. Staff failed to ensure an air gap was present at the facility's ice machine drains to prevent possible backflow from the drain back into the ice machines. The facility census was 85. 1. Review of the facility policy, Storage of Dry Food and Supplies, dated May 2015, showed the following:-The dietary department will store food and supplies according to facility guidelines and state regulations; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received mail on regular mail delivery days, as identified by the United States Postal Service (USPS), including Saturdays. The facility census was 85. Review of the facility's undated policy, Resident Rights, showed the following:-It is the purpose of this facility to meet the Federal and State Mandate in respect to resident rights;-The residents have a right to a dignified existence, self-determination and communication with and access to people and services inside and outside the facility;-The residents have a right to communicate freely; During a group interview on 04/15/26 at 2:00 P.M., Resident #15 and Resident #68 said residents did not receive mail on Saturdays. Resident # 68 said the Business Office Manager (BOM) went to the post office to get the mail Monday through Friday. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide residents with a safe, clean, and homelike environment, including providing housekeeping and maintenance services necessary to maintain an orderly and comfortable interior. The facility census was 85. Review of the undated facility policy, Cleaning Floors, showed the following:-Spills need to be mopped up immediately;-Sweep the floor, pushing all debris forward, using dustpan to remove debris;-Mop one small area at a time, beginning at the rear of the room in a figure eight motion. Use a scraper to remove stubborn stains and debris on the floor. Be sure to mop under and around equipment, along walls, and in corners. 1. Observation on 04/15/26 at 8:17 A.M., in occupied resident room [ROOM NUMBER], showed a hole in the drywall under the PTAC (packaged terminal air conditioner) unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for five residents (Resident #68, #37, #44, #75, and #73), in a review of 18 sampled residents, and for one additional resident (Resident #7). The facility census was 85. Review of the facility policy, Medication Administration, revised 02/07/2013, showed the following:-Purpose:-Medications are given to benefit a resident's health as ordered by the physician;-Guidelines:-Administer medication;-Important: If the resident refuses medication, indicate failure to administer medication on the medication record by circling initials and making a notation on the back of the medication record (include date, time, what occurred, initials, and title);-Record the medication given on the medication sheet. Review of the undated facility policy, Physician Orders, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Residents #60 and #62), in a review of 18 sampled residents, and two additional residents (Residents #31 and #45), who required assistance with activities of daily living (ADLs), received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 85. Review of the facility's undated policy, Activities of Daily Living, showed the following:-The purpose was to assist resident in achieving maximum function;-The policy did not address bathing/showering, dressing or clothing changes. Upon request, the facility provided no other policy related to bathing/showering, dressing or clothing changes. 1. Review of Resident #45's Progress Notes, dated 11/28/25 at 12:52 P.M., showed the resident's family member said the resident had a stroke a few years ago. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three nurse aides (NA J, NA I and NA K), in a review of seven staff reviewed, completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 85. During an interview on 04/16/26 at 8:45 A.M., the Administrator said the facility did not have a policy directly addressing the use of NAs and the timeframe to become certified. 1. Review of the current employee list, provided by the facility, showed NA J's date of hire was 08/20/25. Review of NA J's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. Review of the facility schedule for April 2026 showed NA J was scheduled to work as an NA from 6:00 A.M.to 6:00 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review at least every 12 months for three certified nurse assistants (CNAs) and failed develop a process to identify weaknesses and to provide regular in-service education based on the outcome of these reviews. The facility census was 85. Review of the facility policy, Employee Evaluations, dated July 2006, showed the following: -Employee evaluations are primarily viewed as an important management tool, helping to evaluate and increase the quality of an employees' performance and make decisions about work assignments;-Evaluations give guidance to employees on areas of performance where they can improve;-Using the Employee Evaluation form in conjunction with a current job description, the supervisor should review all employees upon the following time schedule: -90 days after the initial date of hire; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications available for administration on the Certified Medication Technician (CMT) cart for halls B/E/F, CMT medication room, and stock medication room were not expired. The facility census was 85. Review of the facility's undated policy, Storage of Medications, showed the following: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines;-Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 1. Observation on 04/14/26, at 6:07 P.M., of the CMT medication cart for halls B/E/F showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current infection control standards for three residents (Resident #8, # 9 and #62) in a review of 18 sampled and three additional residents (Residents #7, #31, and #34). Staff failed to follow enhanced barrier precautions (EBP) by not wearing appropriate personal protective equipment (PPE) while providing personal care for Residents #34 and #7. Staff failed to perform hand hygiene and change gloves as indicated by facility policy while providing personal care for Residents #8, #9, #31 and #62. The facility census was 85. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one resident (Resident #8), in a review of 18 sampled residents, with dignity and respect when staff told the resident to urinate and defecate in his/her incontinence brief. The facility census was 85. Review of the facility's undated policy, Resident Rights, showed the following:-It is the purpose of this facility to meet the Federal and State Mandate in respect to resident rights;- The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility;-A facility must protect and promote the rights of each resident;-Resident Rights are to be fully respected and adhered to. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy for notifying the physician and resident representative when one resident (Resident #88) had a change in condition. The facility census was 85. Review of the undated facility policy, Condition Change, Resident, showed the following: -Purpose: To observe, record and report any condition change to the attending physician so that proper treatment can be implemented;-Guidelines:1. After all resident changes in physical or mental function, monitor the following: -Observe and inquire if resident has pain. -Observe for personality changes. -Observe for alterations in consciousness. -Observe for generalized weakness. -Observe for gait, posture or balance disorder. -Take vital signs and include temp. -Observe for abdominal pain. -Observe for dyspnea (shortness of breath) or variations in respiration (irregular).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a hydration program, including offering fluids to one resident (Resident #37), who required extensive assistance with drinking, in a review of 18 sampled residents, to ensure adequate hydration and failed to develop a plan of care to address the resident's need for assistance to drink. Resident #37 had dry lips and frequently requested water/fluids to drink. The facility census was 85. Review of the facility's undated policy, Hydration, showed the following:-Each resident is supplied with sufficient fluid intake to maintain proper hydration;-Fresh water is distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be given assistance by the staff.;-Guidelines--Assess the resident's need to be on hydration program. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a system to identify and communicate trauma-informed services for one resident (Resident #6), who had a diagnosis of post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events), in a review of 18 sampled residents, to mitigate or eliminate triggers that may cause re-traumatization. The facility census was 85. The facility did not provide a policy related to trauma-informed care. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to maintain the highest practical well-being for one resident (Resident #1) with a diagnosis of vascular dementia (a person has problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), in a review of five sampled residents. The facility failed to identify situations that triggered the resident causing aggression and combativeness. The facility failed to identify non-pharmacological interventions to help the resident when he/she was combative or refused care. While staff provided incontinence care on 9/18/25, the resident became upset and combative. Staff continued to provide care and transferred the resident with a sit to stand lift while the resident continued to hit staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain comfortable positioning in bed for one resident (Resident #4), nail care for one resident (Resident #10) and bathing for three residents (Resident#1, #5, and #14) who required assistance to perform their activities of daily living, in a review of 14 sampled residents. The facility census was 71. Review of the facility's Bath (Bed) policy, undated showed care of fingernails is part of the bath, be certain nails are clean, and licensed nurses cut fingernails of diabetic residents. 1. Review of Resident #4's undated face sheet, showed the following: -The resident admitted on [DATE]; -Diagnoses included flaccid hemiplegia affecting left dominant side (the left side of the body is completely limp and unable to move effectively) caused by a stroke. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to meet residents' needs, including bathing for three residents (Resident #14, #5, and #1), in a review of 14 sampled residents. The facility census was 71. Review of an email from the Administrator on 1/23/25 showed the facility did not have a policy on staffing. 1. Review of the facility assessment, dated 7/1/24, showed the following: -The facility had an average daily census of 60; -Forty residents required assistance of one to two staff with bathing; -Eighteen residents were dependent on staff for bathing: -Twenty-four residents required assistance of one to two staff for transfers; -Fourteen residents were dependent on staff for transfers; -Based on the average census of sixty, the staffing criteria was 112 certified nurse aide (CNA) hours per day. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and effective medication system when morphine (narcotic with a high potential for abuse) prescribed for Resident #1 and Resident #2, had been tampered with, a card of oxycodone (a potent semisynthetic opioid agonist prescription medication used to treat severe pain) was missing from the facility emergency medication kit, when staff failed to document the narcotic count was completed before and after their shift, and when an Ozempic (prescription injectable medication used to treat type 2 diabetes: and for weight loss) insulin pen was found to be tampered with and the contents replaced by another type of insulin for Resident #4. The facility census was 71. Review of the undated facility policy for Storage of Medication showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 71. Review of the facility policy for Food Temperatures dated 5/2015 showed: -The Dietary Manager or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled; -Keep the temperature of hot foods no less than 140 degrees Fahrenheit (F) during meal service; -Hot foods should be at least 120 degrees F when served to the resident; -Keep the temperature of potentially hazardous cold foods no greater than 40 degrees F. Prepare cold items a day in advance when possible. Please items in freezer 45 minutes before service and use ice baths when needed; [...]

Inspectors wroteSurveyor:[NAME] Based on observation, interview, and record review, the facility failed to have a system in place to ensure staff served hot beverages at an appropriate temperature, in an appropriate cup and placed within one resident's (Resident #63), of 24 sampled residents, reach. The resident sustained a third degree burn and required treatment for the burn. The facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice, and as necessary, to reduce the risk of falls for two residents (Resident #42, and #52). Resident #42 was sent to the emergency room after he/she experienced a dislocated right shoulder and a laceration above his/her right eye requiring sutures, injuries requiring treatment at the hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to routinely assess pain as ordered for one resident, (Resident #38), in a review of 24 sampled residents. The facility failed to make the resident aware he/she had as needed (PRN) medication available for pain and failed to offer PRN pain medications when the resident complained of pain. The resident was agitated and unable to sleep due to pain. The census was 67. During an interview on 05/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy related to pain management. 1. Review of Resident #38's face sheet showed the resident had diagnoses that included joint pain, surgical amputation and acquired absence of left leg above the knee. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #40), who was admitted to the facility with mental illness, received appropriate person-centered and individualized treatment and services to meet his/her assessed needs. Resident #40 presented with behaviors including entering another resident's room (Resident #21) wearing no pants and only a brief, taking a cigarette from another resident and lighting it in the tea room and throwing the lit cigarette in a trash can causing trash to ignite, smoking in his/her room, and yelling and cussing at another resident (Resident #15). The resident frequently made threatening gestures (threats or attempts to choke) other residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the floors and walls in good repair and failed to maintain a homelike environment in the facility. The facility census was 67. Review of the undated facility policy, Housekeeping Department, Seven Steps of Cleaning a Resident Room, showed tasks to be completed included the following: -Emptying trash; -Clean and disinfect the bathroom; -Sanitize floor; -Report any needed maintenance work; -The policy did not identify how often the tasks were to be completed. Request for a homelike environment policy was requested of the facility but none provided. 1. Observation on 5/19/24 at 4:04 P.M., in occupied resident room [ROOM NUMBER] (area near window), showed the following: -Resident #59 resided in this room; he/she was lying in his/her bed; -A musty odor was present in the room; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure systems were in place to clearly document residents' choice for code status. The facility also failed to clearly communicate the choice of code status to direct care staff so staff knew immediately what actions to take in the event of an emergency for six residents (Residents #8, #9, #20, #59, #66 and #68), in a review of 24 sampled residents, for nine additional residents (Residents #1, #16, #18, #25, #32, #34, #45, #58 and #64), and for one closed record (Resident #71). [...]

Inspectors wroteBased on interview and record review, the facility failed to employee a qualified activity professional to oversee the activity program for the facility. The facility employed an activity director but she has not completed an approved activity professional training program. This practice affected all residents in the facility. The facility census was 67. Request was made for the activity director job title responsibilities and qualifications and none were provided. The facility provided a job description for an assistant activity director. Review of the employee list with job titles, showed the activity director department head was the activity director. 1. Review of the Activities Director's employee file on 5/22/24, showed no current certification in therapeutic recreation or activities professional. The employee also did not have a state certification. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for one resident (Resident #41) in a review of 24 sampled residents and for one additional resident (Resident #61). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors for Resident #61, failed to respond timely to call lights, and failed to provide restorative therapy when the restorative aide (RA) no longer worked at the facility for Resident #28 and #41. The facility did not have a Registered Nurse (RN) eight consecutive hours a day seven days a week. The facility did not consistently have nursing staff as identified in the facility assessment, or provide the education, training, and competencies as identified in the facility assessment. The facility census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education, test, and return demonstrations, as identified by the facility on the facility assessment, to ensure competent staff. The facility census was 67. Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below: -Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurses (RN) will do a return demonstration to observe their ability; -Mobility and fall/fall with injury prevention: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents. The facility census was 67. Review of the facility assessment, updated 5/20/24, showed the facility resources needed to provide competent support and care for the resident population, every day and during emergencies, included RN coverage eight hours per day. Review of the facility's RN payroll and RN agency staffing sheets, dated March 2024, showed the facility did not have evidence of any RN hours on 3/4/24, 3/9/24, 3/10/24, and 3/31/24. Review of the facility's RN payroll and RN agency staffing sheets, dated April 2024, showed the facility did not have evidence of any RN hours on 4/19/24, and only had 6.75 hours (did not fulfill the eight hour requirement) on 4/5/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills set to carry out the function of the food and nutrition services. This practice effected all residents in a facility. The facility census was 67. Review of the facility job description, titled Dietary Manager, dated May 2006, showed the minimum qualifications and education for the position included the completion of an approved Certified Dietary Managers Course. Review of the employee list with job titles, showed the dining services department head was the dietary manager. 1. Review of the dietary manager's employee file on 5/23/24, showed the following: -Date of hire was 1/23/23; -No certification showing the DM was a certified dietary manager (a federal requirement for long-term care facilities); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety. Staff failed to label and date, opened food items. Staff failed to store food items off the floor. Staff failed to properly clean the ice machine and ensure an air gap was present at each ice machine drain. Staff failed to ensure food service equipment and surfaces were appropriately cleaned. Staff failed to follow proper hygienic practices when preparing and serving food to residents, including using hair restraints appropriately, and hand hygiene technique. The facility census was 67. 1. Review of the dietary service manual dated April 2006, Food Storage Guidelines showed the following: -Dietary employees will follow safe food handling guidelines to prevent the spread of foodborne illness; [...]

Inspectors wroteBased on observation, interview, and record review, the administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 67. 1. Observations during survey from 05/19/24 through 05/23/24 showed the following: -No record of infection control logs; -No yearly staff education regarding care of residents with dementia; -No yearly staff education on abuse and neglect; -Yearly required training hours for certified nursing assistants not provided; -No organized Quality Assurance and Performance Program (QAPI); -No facility hired licensed nursing staff; utilizing all agency staff as licensed nursing staff; -Cardiopulmonary resuscitation status not consistent throughout a resident's medical record for numerous residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, develop and implement a Quality Assurance and Performance Improvement Plan (QAPI) to monitor and evaluate system problems. The facility census was 67. Request for a Quality Assurance (QA)/QAPI policy was made of the facility and none provided. Review of a binder, provided by the administrator, on 5/23/24 at 3:54 P.M., labeled QAPI, showed the last meeting minute notes were dated January 2023. No current, facility specific, QAPI plan was included in the binder for review. During an interview on 5/23/24, at 3:54 P.M., the Interim Administrator said the following: -He started at the facility 5/7/24; -The QAPI policy/program/plan as requested on entrance was not provided to the state agency (SA) because the facility does not have a policy or recent minutes or completed QAPI information that he could find; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. The facility census was 67. Request for a Quality Assurance (QA)/QAPI policy was made of the facility and none provided. Review of a binder, provided by the administrator, on 5/23/24 at 3:54 P.M., labeled QAPI, showed the last meeting minute notes were dated January 2023. During an interview on 5/23/24, at 3:54 P.M., the Interim Administrator said the following: -He started at the facility 5/7/24; -The QAPI policy and QAPI members were not given to the state agency (SA) team as requested on entrance because the facility did not have a policy or recent minutes that he/she can find; -The last QAPI minutes he found were dated 1/23/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of a Quality Assurance and Process Improvement (QAPI) committee that included the appropriate attendees. The facility census was 67. Request for a Quality Assurance (QA)/QAPI policy was made of the facility and none provided. Review of a binder, provided by the administrator, on 5/23/24 at 3:54 P.M., labeled QAPI, showed the last meeting minute notes were dated 1/23/23. During an interview on 5/23/24 at 3:54 P.M., the Interim Administrator said the following: -He started at the facility 5/7/24; -The QAPI policy and QAPI members were not given to the state agency (SA) team as requested on entrance because the facility does not have a policy or recent minutes that he can find; -The last QAPI minutes he found were dated 1/23/23; -He interviewed current staff and no staff report being on a QA/QAPI committe; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current infection control for six residents (Resident #20, #46, #13, #4, #39 and #68), in a review of 24 sampled resident and six additional residents (Resident #34, #14, #49, #38, #6 and #28). Staff failed to follow Enhanced Barrier Precautions (EBH) for one resident (Resident #20) who had an indwelling catheter. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for five residents (Resident #46, #34, #14, #49 and #13) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for the amount of sugar it contains) after use, and failed to place the glucometer on a clean surface after use and cleaning. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the infection preventionist (IP) completed specialized training in infection prevention and control that worked at least part time at the facility. This practice effected all residents in a facility. The facility census was 67. Review of the facility's undated policy, Antibiotic Stewardship Champion Program, showed the following: -The community will select an antibiotic stewardship champion (ASC) who will be responsible for implementing and maintaining the antibiotic stewardship champion program; -The ASC will obtain certification through the Center for Disease Control and Prevention (CDC) for nursing home infection preventionist. Review of the Center for Disease Control website, Nursing Home Infection Preventionist Training, showed a required program of completion of 23 modules and sub-modules to obtain certification. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program that included goals and various elements of the program. This included how the facility intents to implement the program, the staff's role in the facility's QAPI program and how to communicate concerns, problems or opportunities for improvement to the facility's Quality Assessment and Assurance (QAA) Committee. The facility census was 67. Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below: -Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective training program for all staff, which included training on the standards, policies and procedures for the infection prevention and control program, that was appropriate and effective, and as determined by staff need. The facility census was 67. Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below: -Infection prevention and control: Identification and containment of infections, and prevention. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurses (RN) will do education and a return demonstration to observe their ability; -Facility conducts monthly in-service meetings with staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides received the required 12 hours of in-service education annually. The facility also did not provide or identify dementia training on the facility assessment. The facility did not provide annual abuse and neglect training. Two of two Certified Nurse Assistants (CNA)s (CNA C, and CNA PP) sampled did not have the required 12 hours of in-service education. The facility census was 67. Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below: -Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a training program for all staff, which includes at a minimum, training on behavioral health care and services that was appropriate and effective, as determined by staff need and the facility assessment. The facility census was 67. Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below: -Mental health and behavior: [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently address and respond to concerns brought forth by the resident council. The facility census was 67. Review of the undated facility policy, Grievance Protocol, showed the following: -Purpose: to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; -The Social Services Director (SSD) is responsible for the program, although the administrator is ultimately responsible for the proper implementation of the program. The SSD informs the administrator of each incident; -Any member of the social services staff can complete the grievance complaint report. The appropriate situations for use of the grievance complaint report are: a. Resident articles that are lost or cannot be located - continual concern of lost resident items b. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure one resident (Residents #39), in a review of 24 sampled residents, and one additional resident (Resident #48), were able to voice grievances to the facility without discrimination, fear of discrimination, or reprisal. The facility failed to assist two sampled residents (Residents #36 and #46) and one additional resident (Resident #34) on how to file a grievance or complaint. The facility census was 67. Review of the facility's admission packet showed the following: -Any person(s) who believes that he/she or any class of individuals has been subjected to discrimination as prohibited by section 504 of the Rehabilitation Act of 1973 may file a complaint pursuant to the procedures set forth below, on his/her own behalf, on behalf of another person or on behalf of handicapped person as a class; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for three residents (Resident #54, #42, and #52), in a review of 24 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 67. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, specific to the resident, for three residents (Resident #4, #20, and #68) in a review of 24 residents. The facility census was 67. Review of the undated facility policy, Care Plan Comprehensive, showed the following: -Purpose: An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -Guidelines: The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update interventions in the comprehensive care plan for three resident's (Resident #17, #52 and #42), in a review of 24 sampled residents. The facility census was 67. Review of the undated facility policy, Comprehensive Care Plan, showed the following: -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: a. When a significant change in the resident's condition has occurred; b. At least quarterly; c. When changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/28/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for one sampled resident (Resident #59), in a review of 24 sampled residents and seven additional residents (Resident #45, #14, #1, #38 and #25). Staff failed to ensure medications were available for administration, did not follow physician orders when laboratory orders were not obtained as ordered, when staff left medications at bedside with residents who did not have may keep at bedside orders, and when staff administered oxygen without a physician's order. The facility census was 67. Review of the facility policy, Medication Administration Guidelines, revised 2/7/13, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided two residents (Resident #4 and #28) in a review of 24 sampled residents and two additionally sampled resident (Resident #26 and #61), that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene. The facility census was 67. Review of the facility's undated policy, Activities of Daily Living (ADL), showed the following: -Purpose: To assist residents in achieving maximum function; -The policy did not address the frequency of showers or bathing. Review of the facility's undated policy, A.M. Care (Early Morning Care), showed the following: -Purpose: To provide cleanliness, comfort and neatness; -Take the resident to the bathroom or provide peri-care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to design an activity program to meet the needs, interests, physical, mental and psychosocial well being for two residents (Resident #22 and #52), in a review of 24 sampled residents and one additional resident (Resident #44). Staff failed to ensure evening and weekends, as well as activities focusing on dementia residents were occurring. The facility census was 67. During an interview on 5/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy related to the activities program. 1. Observation of the posted activity calendar for the month of May 2024, on 5/19/24 at 5:45 P.M., showed the following: -Every Saturday: weekend packet and Bingo at 2:00 P.M.; -Every Sunday: devotionals with a resident at 10:30 A.M. and Bingo at 2:00 P.M.; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain foot health for two residents (Resident #9 and #36) in a sample of 24 residents and one additional sampled resident (Resident #34). The facility census was 67. Review of the facility's undated policy, Nail Care of (FINGERS AND TOES), showed the following: -Purpose: To provide cleanliness, comfort, prevent spread of infection; -The Nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease. Review of the facility assessment, updated 5/20/24, showed the facility out-sourced providers included one average visit per month by a podiatrist. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to assist three residents (Resident #28, #41 and #68), in a review of 24 sampled residents, with mobility and/or limited range of motion, to attain or maintain their highest level of functioning. The facility census was 67. Review of the facility's undated policy, The Restorative Nursing (RNA) Program, showed the following: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -A pro-active approach is necessary to prevent future negative outcomes; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents for the use of bed rails/assist bars prior to installation, to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, assess residents for entrapment risk and failed to assess for continued safe use of bed rails for one resident, (Residents #39), in a review of 24 sampled residents and two additional residents (Resident #15 and #44). The facility census was 67. Review of the facility's undated policy, Bed Rails, showed the following: -The objective of the bed rail use policy is to determine if resident use is safe and appropriate; -Overview of FDA potential zones of entrapment with FDA dimension recommendations; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two nurse aides (NA NN and NA OO), completed a nurse aide training program within four months of their employment as an NA in the facility. The facility census was 67. During an interview on 5/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy regarding certification of nurse aides. The facility followed the regulatory guidance. 1. Review of NA NN's employee file showed his/her employment as an NA started on 11/13/23 (approximately six months and one week from the time of hire to the time of review). Review of the state NA registry showed no evidence the employee was certified as a nurse aide. 2. Review of NA OO's employee file showed his/her employment as an NA started on 10/3/23 (approximately seven months and three weeks from the time of hire to the time of review). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each Certified Nurse Assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified two CNAs employed by the facility for more than a year. Two of two CNAs (CNA C, and CNA PP) sampled did not have the required 12 hours of in-service education. The facility census was 67. Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below: -Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' monthly pharmacy drug regimen recommendations were reviewed or followed up on for three residents (Resident #20, #13, #8), of 24 sampled residents. The census was 67. Review of the facility policy, Consultant Pharmacist Reports, dated July 2021, showed the following: -Medication Regimen Review: The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #55 and #8) and one additionally sampled resident (Resident #6), with orders for as needed (PRN) psychotropic medications, in a review of 24 sampled residents, were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days. The facility failed to attempt a gradual dose reduction (GDR) on psychotropic medications or document a clinical justification to continue current dosage for three residents (Resident #54, #66 and #13). The facility census was 78. Review of the undated facility policy, antipsychotic medication use, showed the following: -Purpose: Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition; -Guidelines: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 67. Review of the facility policy, Dietary Services, dated April 2006, showed the facility will serve each resident nutritious food properly prepared and appropriately seasoned, in accordance with the physician's order and as recommended by the National Research Council. 1. During an interview on 5/19/24 at 4:30 P.M., Resident #9 said the food was not always served warm and was cold a lot of the time. During interview on 5/19/24 at 4:19 P.M., Resident #26 said the food was always served cold. During an interview on 5/19/24 at 4:48 P.M., Resident #41 said the food was terrible and was cold. Sometimes the food was overcooked and hard. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 67. Review of the facility's undated policy, Antibiotic Stewardship Program, showed the following: -The infection preventionist(IP)/designee will be responsible to audit the clinical assessment documentation at the time of antibiotic prescription; -The IP/designee will be responsible for auditing of completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy and indication; -The IP/designee will monitor antibiotic imitation. This is done by taking the number of new antibiotic starts for a single infection,dividing by total number of resident days, and multiplying by 1000; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete inspections of bed frames, mattresses and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment for one resident (Resident #39 ), in a review of 24 sampled resident and two additional residents (Resident #15 and #44), who used bed rails/assist bars. The facility census was 67. Review of the undated facility policy, Bed Rails, showed the following: -The objective of the bed rail use policy is to determine if resident use is safe and appropriate; -Overview of Food and Drug Administration (FDA) potential zones of entrapment with FDA dimension recommendations: -Zone 1: within the rail: any open space between the perimeters of the rail can present a risk of head entrapment. FDA recommended space: less than 4 3/4; -Zone 2: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in a manner that enhanced resident dignity for one resident (Resident #63), in a review of 24 sampled residents, and for one additional anonymous resident (Resident #100). The facility census was 67. Review of the undated facility policy, Resident Rights, 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. 1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/18/24, showed the following: -The resident was cognitively intact; -He/She had limited functional range of motion to bilateral upper and lower extremities; -He/She required maximal assistance with upper body dressing; [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or resident representative when the resident's trust account reached $200 less the Supplemental Security Income (SSI) resource for one resident that received Medicaid benefits for one resident (Resident #4), in a sample of 24 residents. The facility census was 67. Review of an undated blank sampled letter for notification of fund balance, provided by the facility, showed the facility would notify the resident and/or resident representative of the resident's current balance when the balance was within $200.00 of the Medicaid resource limit. If the amount in the fund exceeded the Medicaid resource limit of $5,726.00, the resident may lose eligibility for Medicaid or SSI. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of an allegation of abuse per facility's policy after one resident (Resident #55), of 24 sampled residents, reported an allegation of abuse. The resident alleged Certified Nurse Assistant (CNA) DD slapped him/her in the face while providing cares. The facility census 67. Review of an undated facility policy, titled, Abuse Prohibition Protocol Manual, Investigation Section 7, showed the following: -It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated; -Procedure: The investigation is the process used to try and determine what happened. The designated facility personnel will begin the investigation immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for one sampled residents (Resident #52), in a review of 24 sampled residents. The facility census was 67. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessment of each resident's functional capacity and health status; -The RAI process has multiple regulatory requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to have documentation of a Level I (level of care) PASARR (Pre-admission Screening and Resident Review), failed to file for a Level II PASARR (an in-depth assessment of the resident's mental health and intellectual needs) when conditions/diagnoses changed or were added, and failed to notify the appropriate state-designated authority for a significant change PASARR evaluation and determination for one resident (Resident #6), in a review of 24 sampled residents, when the resident reported suicidal thoughts and ideations and required hospitalization. The facility census was 67. Record review of the Missouri Department of Health and Senior Services (DHSS) guide titled, PASARR Desk Reference, dated [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #20), in a review of one resident who had an indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder), and who had a history of urinary tract infections (UTI), was provided with the proper care of the urinary catheter device when staff allowed the collection bag and tubing to touch the floor. The facility also failed to provide urinary incontinence care in a manner to prevent the spread of bacteria that cause infections for one resident, (Resident #28), who also had a history of UTI's, in a review of 24 sampled residents. The facility census was 67. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #68), in a review of 24 residents, and one additional resident (Resident #16), received oxygen therapy consistent with professional standards of practice and the residents' plan of care. The facility census was 67. Review of the facility's undated policy, Oxygen Administration, showed the following: -Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Nasal Cannula: Connect tubing to humidifier outlet and adjust liter flow as ordered. Place prongs of cannula into the resident's nares. Adjust the plastic slide to hold cannula in place; -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #13), in a review of 24 sampled residents, remained free from unnecessary drugs when the facility failed to have adequate indications for multiple blood thinning medications. The facility census was 67. The facility provided no policy for unnecessary drug use following request. 1. Review of Resident #13's undated physician order sheets (POS) showed the following: -Plavix (a blood thinning medication) 75 milligrams (mg) once a day, started 7/28/23; -Xarelto (a blood thinning medication) 20 mg, started 10/1/23. (Review showed no diagnosis for the use of the blood thinning medications.) Review of the resident's progress note, dated 10/29/23 at 1:45 P.M., showed the pharmacy consultant wrote see report. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer insulin according to manufacturers' recommendations to ensure staff administered the prescribed insulin dose for one resident (Resident #27) in a review of 24 sampled residents and two additional residents (Resident #44 and #45). The facility census was 67. During an interview on 05/22/24, at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy for Insulin Pen administration. Review of the, How to use your Lantus SoloStar Pen information sheet, revised 08/2022, showed the following: -Wipe the [NAME] tip (rubber seal) with an alcohol swab; -Dial a test dose of 2 units; -Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured when staff left medications unattended and out of sight, on top of the medication cart, with residents in the vicinity of the medications. The facility census was 67. Review of the facility policy, Medication Administration Guidelines, revised [DATE], showed the policy did not address the storage of medications. Review of the undated facility policy, Medication Administration, showed the policy did not address the storage of medications. Request for a medication storage policy was requested but none received. 1. Review of Resident #40's face sheet showed he/she had dementia. 2. Observation on [DATE] at 10:53 A.M., showed the following: -Licensed Practical Nurse (LPN) N sat inside the nursing station doing paperwork; [...]

Inspectors wroteBased on record review and interview, the facility failed to give appropriate Centers of Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMA-10055) in writing to one Resident (Resident #63) reviewed when the facility initiated discharge from Medicare Part A services and the resident remained in the facility. The facility census was 67. Review of the facility undated admission agreement related to ABN showed when a resident is not covered Medicare Part A because daily skilled service is not needed: 1. Approval of Quality Assurance Nurse is required; 2. SNF-ABN (form CMS-10055) is issued; 3. Generic notice of Medicare Non-Coverage (form CMS-10123) is issued. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when one additional resident (Resident #6) and one closed record (Resident #56), were transferred to the hospital. The facility census was 67. 1. Review of Resident #6's face sheet showed he/she was his/her own person. Review of the resident's progress notes, dated 4/5/23 at 9:13 P.M., showed staff documented the resident came to the nursing station holding his/her chest and complaining of chest pain, left jaw pain, and left arm pain at 7:40 P.M. Vitals were taken, physician and assistant director of nursing (ADON) called, and 911 called for ambulance. The resident left the facility at 8:05 P.M. via ambulance. When asking the resident who he/she wanted staff to contact, he/she said, no one at this time. The resident was taken to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or legal representatives of their bed hold protocol at the time of transfer for one additional resident (Resident #6) and one closed record (Resident #56), who were transferred to the hospital. The facility census was 67. Review of the undated facility policy for Bed Hold Policy Guidelines showed this facility will notify all residents and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 1. Review of Resident #6's face sheet showed he/she was his/her own person. [...]

Inspectors wroteBased on observation and interview, the facility failed to post required nurse staffing information, which included the facility name, total actual hours worked by both licensed and unlicensed nursing staff to include Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nurse Assistants (CNA)s directly responsible for resident care and the resident census on a daily basis. The facility census was 67. Request was made for a facility policy regarding posted staffing and none was provided. 1. Observation on 5/19/24 at 3:34 P.M., showed the following: -Dry erase board at the nursing station, dated 5/18/24, with two names under nurses and one name beside Certified Medication Technician (CMT), a name at the bottom of the board and five more names without labels; -The dry erase board did not include the facility name, staff titles, actual hours worked or the facility census; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two additional sampled resident s (Resident #34 and #48), fully understood the binding arbitration agreement (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) prior to signing the agreement. Additionally the facility failed to ensure required elements for the binding arbitration agreement were part of the facility policy. The facility census was 67. Review of the undated facility admission packet showed the following: -Alternative Dispute Resolution Addendum: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 10 residents was free from abuse when Certified Medication Technician (CMT) B yelled and cussed directly at the resident and told the resident he/she was just going to have to fucking wait, wagged his/her finger in Resident #1's face and lunged at the resident. Resident #1 said he/she felt threatened, frightened and abused. The facility census was 70. Review of the facility undated Abuse Policy showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents would be protected from abuse, neglect, and harm while they were residing at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #3), in a review of 10 sampled residents, received care and treatment in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Staff failed to assess the resident, notify the physician and obtain treatment following a change in condition when the resident had ongoing diarrhea, vomiting and increased weakness. The resident required hospitalizaiton for a hypokalemia (a critically low potassium level which can be life threatening), and moisture related skin breakdown. Upon return to the facility, staff failed to ensure supplemental potassium medication and a nutritional supplement were obtained and administered as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 10 sampled residents, received care and treatment to prevent pressure ulcers (a 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 received necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing. The resident, who staff determined was at risk for developing pressure ulcers, developed pressure ulcers to both the right and left heels, the coccyx (tailbone area), left posterior calf (lower back leg area) and right lower leg. The facility census was 70. Review of the facility's undated policy, Pressure Ulcer Care and Prevention, showed the following: -Purpose: [...]

Inspectors wroteBased on observaton, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of two resident (Resident #3 and #10) in a review of 10 sampled residents. The facility failed to provide Resident #3 incontinence care and provide appropriate care and services to ensure known moisture related skin breakdown treatment was implemented and failed to ensure safe transfers from the wheelchair to bed. The facility also failed to ensure Resident #10 received care and treatment to prevent pressure ulcers (a 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 received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an accurate reconciliation of narcotic (controlled) medications was maintained in the facility 's Stat-Safe (automated emergency medication supply system) and failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. The facility census was 70. Review of the facility undated policy, Medications, Scheduled II - V (controlled substances based on their abuse potential and potential for addiction); -The purpose was to provide medication for residents as prescribed and to comply with State and Federal guidelines regarding these medications; -Schedule II-V medications must be kept in medication cart lock box or double lock box maintained in medication room; [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation of narcotic medications when the consultant pharmacist completed a monthly audit of the facility Stat-Safe (automated emergency medication supply system) on 3/4/24 and notified facility administrative staff of a discrepancy involving 21 doses of Schedule II (controlled substance) narcotics. The facility census was 70. Review of the facility undated Abuse Policy showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could included verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide/designate a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 69. 1. During review of electronic mail, on 01/04/24 at 3:30 P.M., and interview on 01/08/24 at 3:37 P.M., the administrator said the facility did not have a specific staffing policy, the facility goes by federal guidelines. The administrator provided the facility assessment but was unaware of what the staffing hours numbers on the facility assessment indicated. 2. Review of the Facility Assessment, updated 06/22/23, showed the following: -Facility resources needed to provide competent support and care for resident population every day and during emergencies: staffing to meet care needs included: -a Registered Nurse (RN) - eight hours per day based on average census; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of three residents (Resident #8, #9 and #10), in a review of 11 sampled residents, when the facility failed to provide regular baths or showers and did not respond to resident call lights in a timely manner. Additionally, staff failed to provide incontinence care for one resident (Resident #8). The facility also failed to maintain staffing hours per day, based on average census and per the facility assessment, to meet resident care needs. The facility census was 69. Review of electronic mail on 01/04/24 at 3:30 P.M., and interview on 01/08/24, at 3:37 P.M., the administrator said the facility did not have a specific staffing policy and the facility goes by federal guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection in a review of ten sampled residents. Staff failed to obtain physician orders for a newly identified pressure ulcer, failed to conduct and document assessment of the resident's pressure ulcers to determine if the wounds were deteriorating and required a change in treatment, and failed to complete dressing changes as ordered by the physician. The pressure ulcers deteriorated and became infected. Staff failed to begin treatment of the infection with antibiotics as ordered by the wound consultant nurse practitioner. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified individual in the role of infection preventionist (IP) who has completed specialized training in infection prevention and control. The facility census was 70. Review of the facility's policy, Infection Prevention and Control program, undated, showed the following: -The facility maintains an organized, effective facility wide program designated to systematically identify and reduce risk of acquiring and transmitting infections among residents, visitors and healthcare workers. This program involves collaboration of many programs and services within the facility and designated to meet the intent of regulatory and accrediting agencies; -The IP responsibilities for infection prevention and control include, but may not be limited to the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders in a timely manner for rehabilitation services for two residents (Resident #2 and #3) in a review of ten sampled residents. The facility census was 70. Review of the facility policy physician orders, undated, showed the following: -The following information is provided to assist in recording physician's orders; -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion or errors; -Physician orders are needed for physical therapy (PT), speech therapy(ST) and occupational therapy (OT). 1. Record review of Resident #2's undated face sheet showed the following: -The resident admitted to the facility on [DATE]; -Diagnoses included repeated falls, abnormalities of gait and mobility, dementia and cerebral infarction (stroke). [...]

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview, and record review, the facility failed to consistently assess the potential root cause of residents' falls and evaluate current interventions and/or develop and implement meaningful interventions to reduce the potential for falls for three residents (Residents #20, #27, and #46), in a review of 26 sampled residents. Residents #27 and #46 required sutures (also known as stitches used to hold body tissues together and approximate wound edges after an injury) to repair lacerations (a deep cut or tear in the skin) acquired as a result of falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN), other than the Director of Nursing (DON), for at least eight consecutive hours per day seven days a week, as well as failed to ensure the DON did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. The facility census was 68. The facility did not have a specific policy addressing RN coverage and DON duties for facilities with an average daily census of 60 or more. 1. Review of the facility assessment updated 10/21/22 showed an average daily census of 70. 2. The facility did not maintain a timesheet for the DON. 3. Review of the facility staffing sheets (posted staffing sheets) dated September 2022 showed the following: -There was no RN scheduled for eight consecutive hours on 9/24/22: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to prepare and serve the meals timely. The census was 68. Review on 10/24/22, of the meal time schedule, showed the following: -Staff was to serve breakfast at 7:30 A.M.; -Staff was to serve lunch at 12:30 P.M.; -Staff was to serve supper at 5:30 P.M. During interview on 10/24/22 at 9:35 A.M., Resident #34 said he/she never knew when meals were going to be served because staff served breakfast between 9:30 A.M. to 10:00 A.M., and served lunch anywhere from 12:30 P.M. to 2:00 P.M. Review of the kitchen staffing schedule showed no dietary staff was scheduled to work day shift in the kitchen on 10/24/22. Observation on 10/24/22 at 10:25 A.M. showed the administrator was in the kitchen preparing and serving the breakfast meal (two hours and 25 minutes after the scheduled meal time). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The facility census was 68. Observation of the kitchen area on 10/24/22 between 10:25 A.M. and 2:12 P.M. showed the following: -The deep fryer was dirty with dark grease and food debris; -The bottom and the legs of the mixer had dried yellow crusty substance on it; -Maintenance walked through the kitchen by the food preparation table as staff prepared food in the kitchen. The maintenance staff had facial hair and did not wear a beard restraint or a hair net to cover the hair on his/her head; -An opened bottle of enchilada sauce (one-half full) sat on a shelf in the dry food pantry. The lid on the enchilada sauce said to refrigerate after opening; -The lid on the mustard container had a black-brownish ring all the way around it; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, develop and implement a Quality Assurance and Performance Improvement Plan (QAPI) to monitor and evaluate system problems. The facility census was 68. Review of the documentation provided as a policy noted a QAPI template from Health Quality Innovators with a disclaimer statement on page three that read, The QAPI plan template is offered to nursing facilities as a guideline for developing QAPI plans and for informational and educational purposes only. Review of the facility provided binder for review noted multiple pages of a template shown as an example to develop a facility specific QAPI plan. No facility specific QAPI plan was included in the binder for review. During an interview on 10/27/22, at 5:07 P.M., the administrator said the following: -The facility QAPI plan was in the binder he provided for review; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. The facility census was 68. The facility did not have a written QAA program policy. Review of the facility provided records showed the facility did not have documentation of a QAA program. The facility did not provide information that they had identified or addressed any quality assurance issues. During an interview on 10/27/22, at 5:15 P.M., the social services director said if there are any issues in the building, they are discussed in the daily meeting. If an emergency arises, she would let the administrator know immediately. She was not aware of a formal process to address concerns. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to interact with one resident, (Resident #22) in a dignified and respectful manner when staff used inappropriate language while assisting a resident with clothing and presented with inappropriate actions towards the resident when serving his/her meal, failed to promote dignity when staff ignored two residents (Resident #344 and #355) when assisting the residents with a meal talking socially to other staff, rather than engaging the residents, and failed to ensure all residents at a table were served meals timely so one resident (Resident #31) did not have to sit for an extended period of time as tablemates were served and ate their meal in a sample of 26 residents. The facility census was 68. Review of the undated facility policy, Resident Rights, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed consistently address and respond to concerns brought forth by the resident council, including residents in attendance, (Resident #2, #10, #42, and #50). The facility census was 68. Review of the facility's Resident Council policy, dated 3/5/12, showed the following: -Monthly meetings will be held with minutes of the meetings documented; -Recommendations for changes by the council will be given to the Administrator who will evaluate the recommendations. -Concerns and needs are addressed as voiced by members of the council. Review of the Resident Council Minutes, dated 8/11/22, showed the following: -Request for evening staff to resupply tea room and servicing room and silverware so it's ready on time; -Request for ice carts to have a labeled canister for ice scoop; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable environment by failing to ensure walls in resident rooms, fixtures in bathrooms, and ceiling vents were kept in good repair. The facility census was 68. Observation on 10/24/22 at 10:49 A.M. in occupied resident room [ROOM NUMBER], showed the wall was marred with exposed drywall behind the beds. Observation on 10/24/22 a 10:49 A.M. in occupied resident room [ROOM NUMBER], showed the wall next to the bed was marred with multiple scrapes and with exposed drywall and drywall compound in two separate areas. Observation on 10/24/22 at 10:55 A.M. in occupied resident room [ROOM NUMBER], showed the wall was marred and had drywall compound on the wall behind the bed closest to the window. Observation on 10/24/22 at 11:07 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete appropriate background checks for four employees (LPN CC, Housekeeper Supervisor, RN O, CMT R) in a review of 10 new employees hired prior to employment. Further review showed the facility failed to check the Certified Nurse Assistant (CNA) Registry for any Federal indicators of abuse, neglect or misappropriation of property for six new employees (LPN CC, Laundry Staff DD, RN O, CNA H, and CMT R) prior to employment. The facility census was 68. Review of an undated document titled How to Hire an Employee, provided by the facility on 10/27/22, showed the following: - FCSR (Family Care Safety Registry) - if the prospective employee is registered, run the background check, print the form; -If the prospective employee is not registered, fax the D & B Legal form to D & L Legal Service to have background checked; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive assessments timely for four residents (Resident #104, #105, #254, and #356) in a review of 26 sampled residents. The facility census was 68. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, revised October 2019, showed the following: -The Omnibus Budget Reconciliation Act (OBRA) required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning; -Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status had occurred or a significant correction to a prior comprehensive assessment is required; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for seven of 26 sampled residents (Resident #1, #2, , #3, #27, #104, #105, and #355). The facility census was 68. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care for seven residents (Resident #31, #3, #27, #11, #50, #1 and #104) of 26 sampled residents. The facility census was 68. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed the following: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident ' s highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided scheduled showers for four residents (Residents #1 #28, #34, and #355) who required assistance to complete their own activities of daily living (ADL), failed to check and change/toilet one resident timely (Resident #35), and failed to perform complete perineal care for one resident (Resident #20), in a review of 26 sampled residents. The facility census was 68. Record review of the facility's shower policy from Nursing Guidelines Manual, dated March 2015, showed the purpose was to maintain skin integrity, comfort and cleanliness. Review of the undated facility policy, Perineal Care, showed the following: -Purpose to cleanse the perineum and to prevent infection and odor; -Female perineal care: a. Ask resident to separate legs and flex knees; b. Put on disposable gloves; c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reposition one resident (Resident #25), in a review of 26 sampled residents, and failed to identify a Stage II pressure ulcer (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue. May also present as an intact or open/ruptured blister). The facility failed to complete weekly skin assessments as directed in the facility's policy and the plan of care for one additional resident (Resident #36) with existing pressure ulcers, and failed to follow physicians orders for pressure relieving boots and wound treatments. The facility failed to reposition one resident (Resident #355), who was identified as at risk for developing pressure ulcers, per his/her plan of care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility also failed to ensure food items were prepared according to the recipe to conserve nutritive value, flavor and appearance. The facility census was 68. 1. During an interview on 10/24/22 at 9:43 A.M., Resident #32 said the food was terrible and cold. During an interview on 10/24/22, at 10:20 A.M., Resident #257 said the food was always cold and did not taste good. Many times the food was overcooked. During an interview on 10/24/22 at 10:57 A.M., Resident #7 said the food was lousy. During an interview on 10/24/22 at 1:45 P.M., Resident #47 said a lot of the food did not taste good and the vegetables were mushy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents on a pureed diet received food in the proper form in accordance with his/her physician's orders. The facility census was 68. Review of the menu for the noon meal on 10/24/22 showed residents on a pureed diet were to receive pureed turkey noodle casserole and pureed Brussel sprouts. Review of the recipe for the pureed turkey noodle casserole showed process until smooth. Review of the recipe for the pureed Brussel sprouts showed process until smooth. Observations on 10/24/22 between 12:57 P.M. and 1:10 P.M., showed the administrator pureed the turkey casserole and Brussel sprouts separately in the blender. Observation on 10/24/22 at 2:14 P.M. of the test tray showed the pureed turkey casserole and the pureed Brussel sprouts were chunky. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infectious causing contaminants and when indicated by professional standards of professional practice during personal care for four residents (Resident #20, #34, #11, #3) in a review of 26 sampled residents and one additional resident (Resident #36). The facility also failed to ensure a foley catheter (a tube inserted into the bladder to drain urine) drainage tube was not touching the floor while the resident lay in bed for one resident (Resident #3). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for four residents (Resident #12, #27, #257, and #356) of 26 sampled residents. The census was 68 residents. Review of the facility's undated policy, Immunizations, showed the following: -Pneumococcal: PCV20 (PREVNAR 20) an PPSV23 (Pneumococcal Polysaccharide vaccine); -Pneumococcal Vaccination in persons ages 65 and older years, unless contraindicated will be administered according to the following guidelines when determining the vaccination status: 1. Adults 19-[AGE] years old with certain medical conditions or other risk factors who have NOT already received a pneumococcal conjugate vaccine should receive either: a. A single dose of PCV15 followed by a dose of pneumococcal polysaccharide vaccine (PPSV23), or b. A single dose of PCV20. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each side of the hall. The facility census was 68. Observations on 10/24/22 between 10:32 A.M. and 3:02 P.M. showed the following: -A 3-foot section of handrail and another 5-foot section of handrail next to the staff restroom at the top of B Hall were loose from the wall and not secured; -A 7-foot section of handrail outside the therapy department on C Hall was loose from the wall and not secured; -A section of handrail outside the beauty shop and resident room [ROOM NUMBER] (D Hall) was loose from the wall and not secured; -A 5-foot section of handrail outside resident rooms [ROOM NUMBERS] (D Hall) was loose from the wall and not secured; -A 4-foot section of handrail outside the clean linen room on F Hall was loose from the wall and not secured. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by the facility staff, for one resident (Resident 255 ), in review of 26 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 68. [...]

Inspectors wroteBased on interview and record review the facility failed to revise care plans with changes in resident needs for two residents (Resident #27, #255) in a review of 26 sampled residents. The facility census was 68. Review of the facility's Care Plan Policy dated March 2015 showed the following: -Purpose: An individualized comprehensive care plan that ·includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. -Guidelines: The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident maybe expected to attain; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Weight Champion Program to ensure weights were monitored weekly per the recommendation of the dietician after a significant weight loss was identified for one resident (Resident #2) in a review of 26 sampled residents, reweigh the resident when a weight variance was identified or document/address the resident's meal consumption. The facility census was 68. Review of the facility's policy, Weight Champion Program, undated, showed the following: -The purpose of this program is to take a proactive stance against weight loss and collaborate to decrease weight loss numbers; -The weight champion will be responsible for keeping the weight variance report from Matrix, as well as being custodian of the Daily, Weekly and Monthly facility weight lists; -The champion is responsible for: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one resident's (Resident #12) dialysis arteriovenous (AV) shunt/fistula (access used to artificially connect a vein with an artery, so that a higher blood flow is created to allow blood to be pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) daily and after he/she returned from dialysis treatments in a review of 26 sampled residents. The facility failed to include care of the resident's dialysis shunt/fistula on the resident's care plan. The facility census was 68. Review of the facility's undated policy, Dialysis, Care of a Resident Receiving, showed the following: -To utilize the following guideline to provide care for a resident that is receiving dialysis; -Care of the AV shunt/fistula/graft: keep the area clean and dry; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident representative when two residents (Resident #13, #45), of 26 sampled residents were transferred to the hospital. The facility census was 68. Review of the facility's undated Discharge/Transfer of Resident from the Nursing Guidelines Manual showed the following: -To leave the facility with plans or intention to return (i.e., transfer to an acute care facility for appropriate care); -To provide safe departure from the facility and to provide sufficient information for aftercare of the resident. -Equipment: 1. Transfer form, if necessary (for acute facility transfer) 2. Discharge summary and post discharge plan of care forms (for discharge to home, lower level of care or other long term care facility) 3. Inventory list 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative for two resident (Resident #13 and #45) in review of three sampled residents, when the facility initiated a transfer to the hospital. The facility census was 68. Review of the facility's undated Discharge/Transfer of Resident from the Nursing Guidelines Manual showed the following: -To leave the facility with plans or intention to return (i.e., transfer to an acute care facility for appropriate care); To provide safe departure from the facility and to provide sufficient information for aftercare of the resident. Discharge guidelines: 1. Explain discharge guidelines and reason to resident and give copy of Transfer & Discharge Notice as required. Include resident representative. [...]