Mary, Queen and Mother Center

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain its call light system in working order and according to the stipulations in the state exception granted to them, allowing use of the current call light system. This deficiency had the potential to affect all residents and affected one sampled resident who had a toe injury (Resident#1). The sample size was four. The census was 74. Review of the facility's call light policy dated 6/9/17, showed:It is the policy of the facility to provide quality long-term care to residents. All residents will have a call light within reach while in bed or sitting next to the bed. Answering call lights is the responsibility of all Nursing Staff members with priority given to bathroom call lights. A call light should not be turned off in the resident's room until the resident's needs are met. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible part after a change in condition that required an alteration in the resident's treatment plan (Resident #1). The sample size was 3. The census was 74. Review of the facility's Notification of Change Policy dated 11/28/17, showed the purpose of this policy ensures the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification: -Compliance guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's member or legal representative when there is a change requiring such notification; -Circumstances requiring notification include new treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when the facility failed to following physician orders for a left breast lumpectomy (surgical procedure to remove a potentially cancerous lump) surgical incision by not maintaining resident NPO (nothing to eat by mouth) status at midnight the night before surgery. The facility failed to obtain physician ordered treatments for the surgical site and provided treatments without a physician order. In addition, the facility failed to properly perform accurate head to toe weekly skin assessments. The sample size was 3. The census was 74. Review of the facility's Wound Treatment Management Policy, dated 11/28/17, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the [NAME] Hall in the [NAME] community between 105 degrees Fahrenheit (F) and 120 F. The [NAME] hall and [NAME] Hall are both parts of the dementia unit. The facility identified three residents with confusion, who wander and who are able to ambulate without assistance (Residents #74, #26, and #13). This affected two sampled resident rooms (Residents #40 and #85) and one spa room hand washing sink . The water temperatures at the handwashing sinks measured as high as 135.9 degrees F. In addition, staff failed to ensure hazardous chemicals were not accessible to residents on the dementia unit. There are 23 residents on the dementia unit with 22 in certified beds. The census was 93 with 85 in certified beds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (dialysis, procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) services had written communication with the dialysis center. The facility identified one resident who received dialysis services (Resident #34). The sample was 19. The census was 93 with 85 in certified beds. Review of the facility's Dialysis policy, dated 4/30/18, showed: -Policy: It is the policy of the facility to provide appropriate care to residents requiring hemodialysis. -Procedure: The facility will develop an appropriate care plan. Staff will evaluate the resident's response to dialysis and develop/revise the care plan in collaboration with the dialysis facility: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for one of five residents reviewed for unnecessary psychotropic medications (Resident #68). The census was 93 with 85 residents in certified beds. Review of the facility's Psychotropic Medication policy, dated 12/8/17, showed: -The intent of this policy is to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a significant medication error for one resident with spinal cord cancer undergoing radiation therapy (Resident #386). The facility failed to properly classify the Schedule III medication (substances that have moderate potential for abuse and dependence) Dronabinol (synthetic form of tetrahydrocannabinol (THC) medication used to treat nausea and vomiting caused by chemotherapy) in the medical record, leading to its incorrect assignment to Certified Medication Technicians (CMTs) instead of to a Licensed Practical Nurse (LPN) or Registered Nurse (RN). As a result, the CMTs documented the medication was unavailable for eight days without notifying nursing management. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility had two medication rooms and eight medication carts. Both medication rooms, three medication carts, and one treatment cart were reviewed, and issues were found with two medication carts and the treatment cart. The census was 93 with 85 in certified beds. Review of the facility's Storage of Medication Requiring Refrigeration, dated [DATE], showed date label of any multi-use vial when the vial is first accessed (needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review of the facility's Medication Administration policy, dated [DATE], showed: -Identify expiration date. If expired, notify nurse manager; [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week during the fiscal year quarter 4 2023 (July 1 - September 30). The census was 106 with 103 residents in certified beds. The administrator was notified on 1/8/24, of the past non-compliance. The facility has contracted for RN agency staff to cover for days where no facility employed RN was available. The deficiency was corrected on 10/1/23. Review of the facility's Facility Assessment Tool, last reviewed 10/18/23, showed: -Facility resources needed to provide competent support and care for the resident population every day and during emergencies: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nursing assistants (CNAs) received the required 12 hours of annual in-service training, tracked by hire date, for three of 5 CNAs sampled. The facility had 31 CNAs employed for more than a year. The census was 106 with 103 residents in certified beds. Review of the facility's Facility Assessment Tool, last reviewed 10/18/23, showed staff training/education and competencies: Required in-service training for nurse aides: -Training to ensure the continuing competencies of nurse aides, no less than 12 hours per year; -Dementia management training, training on the care of cognitively impaired individuals, and resident abuse prevention training; -Additional training offered as needed to address areas of weakness as determined in nurse aides' performance. 1. Review of CNA A's employee file, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents food that was palatable and at a safe and appetizing temperature for five residents (#32, #41, #58, #359, and #360) and residents on the rehabilitation hall. The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Record of Food Temperatures policy, dated 12/11/18 showed: -Policy: it is the policy of this facility to record food temperatures daily to ensure food is at its proper serving temperature before trays are assembled; -Guidelines: Hot foods will be held at 135 degrees Fahrenheit (F) or greater. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control and prevention practices during personal care for three of four observations of personal care provided to incontinent residents (Residents #24, #43, and #68). In addition, the facility failed to follow their tuberculosis (TB, infectious lung disease) policy and procedures, for five of 10 employee sampled. The census was 106 with 103 residents in certified beds. Review of the facility's Hand Hygiene policy, dated [NAME] 5, 2020, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident when staff failed to have a dressing on the resident's coccyx as ordered (Resident #68). The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Provision of Physician Ordered Services policy, dated 12/8/17, showed: -Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality; -Policy Explanation and Compliance Guidelines: - 1. Physician orders should be obtained for administration of all medications and treatments; -2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident, who was incontinent of bowel and bladder, received the necessary services to maintain good personal hygiene when the resident was assisted into his/her chair by the night shift and was not checked or cleaned of urinary and bowel incontinence until approximately seven hours later. The resident's brief was saturated with urine and bowel movement when assisted to be cleaned. The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Perineal Care policy, dated October 14, 2021, showed: -It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident when staff failed to change the dressing on a left lower leg wound as ordered (Resident #45). The resident's left lower leg wound was not tracked by the facility for wound healing status and condition and staff failed document assessments of the wound. The facility identified 11 residents with non-pressure wounds. The census was 106 with 103 residents in certified beds. Review of the facility's Skin Assessment policy, dated November 11, 2017, showed: -Purpose: To ensure that residents who enter the facility without pressure ulcers, do not develop pressure ulcers, skin alteration, and to institute proper interventions; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received assistance devices to prevent accidents, for one resident transferred without the use of a mechanical lift. Staff failed to use a gait belt and failed to ensure the resident was safe to transfer without the use of a mechanical lift. In addition, staff failed to evaluate the use of a Broda chair (medical reclining chair) with a tray for safety (Resident #62). The census was 106 with 103 residents in certified beds. Review of the facility's Safe Resident Handling/Transfers policy, revised 7/10/23, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served palatable and at a safe and appetizing temperature during meal service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) for two of two meals sampled. The census was 128. 1. During an interview on 10/13/21 at 12:07 P.M., three of six residents in the rehab dining area said on a scale from one to ten, the food is rated a five and is often luke warm. 2. Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/21, showed: -Cognitively intact; -Diagnoses included non-traumatic brain dysfunction and anxiety disorder. During an interview on 10/12/21 at 1:00 P.M., the resident said the food is not the best. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident is treated with dignity and respect. Staff complained about their workload and lack of knowledge of the job in front of a resident, called the resident's brief a diaper, talked about the resident's personal conditions loud enough for the roommate to hear, and talked amongst each other and not with the resident during care (Resident #102). Staff took a soda away from one resident without first discussing it with the resident or offering choices (Resident #84). Staff failed to ensure privacy during care when they failed to pull a privacy curtain resulting in a visitor walking into the room with the resident exposed and failed to close the window blinds as cars drove past the room during care (Resident #29). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and maintain complete accounting records, regarding the petty cash kept on hand, for the resident trust account for 5 of 6 recorded months. In addition, the facility failed to keep an accurate record of the money kept in the petty cash bag. The census was 128. Review of the facility petty cash forms, dated 10/15/20, 12/21/20, 3/11/21, 5/6/21 and 7/2/21, showed no documentation of an accurate account of the coins and bills kept for the petty cash. Observation on 10/15/21 at 8:35 A.M., with Receptionist R of the petty cash bag, showed two envelopes. One with the amount of $54.95 written on it and one with the amount of $4.00 written on it. A count of the both envelopes showed a total dollar amount of $112.60. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The sample size was 25. The census was 128. Review of the resident trust account for the past 12 months, from October 2020 through September 2021, showed an average monthly balance of $94,000.00. This would yield a required bond in the amount of $141,000.00 (one and one half times the average monthly balance). Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), dated 10/19/2016, showed an approved bond of $75,000.00. During an interview on 10/15/21 at 2:40 P.M., the administrator said the business office manager (BOM) is in charge of increasing the bond. The BOM is out of the office at this time. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prevent abuse and neglect, when the facility failed to ensure proper staff screening for all staff, both facility staff and contracted staff. The facility's abuse and neglect policies failed to address when services are furnished under arrangement, with a registry, contracted, or temporary agency staff; the requirement to maintain documentation of the screening that has occurred. A resident (Resident #274) alleged physical abuse occurred. The facility conducted an investigation, was not able to substantiate abuse occurred, but identified a potential alleged perpetrator (AP), Certified Nursing Assistant (CNA) O who worked for a contracted agency. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility had a process to track personal belongings upon admission and through the residents stay and to ensure personal belongings were sent with the resident upon discharge. This resulted in one resident who was discharged from the facility, being discharged without all of their personal belongings (Resident #275). The census was 128. Review of the facility's Lost or Stolen Item policy, dated 10/14/21, showed: -When a resident and/or family member reports an item lost, a search is initiated for the missing item. If the item cannot be found and the facility is found to be responsible for the lost item, the resident is reimbursed for the lost item. And if need the facility helps replace the lost item; -When a resident and/or family member reports an item stolen, a search is initiated for the stolen item. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for nine of nine residents investigated for resident assessments who were coded as having restrains. The census was 128. Review of the facility's Resident Census and Conditions of Residents Centers for Medicare and Medicaid Services (CMS) form 672, completed by the facility on 10/12/21, showed: -Census 128; -Residents physically restrained: 0. Review of the Resident Assessment Instrument (RAI) manual, showed physical restraints defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents. Facility staff failed to ensure a resident was properly spotted and monitored during a Hoyer lift (mechanical lift) transfer for one of one Hoyer lift observation (Resident #102). Staff failed to ensure a low bed was used as indicated for one resident identified as a fall risk (Resident #87). In addition, staff failed to have a system in place to ensure all residents with a wander guard were accounted for, had appropriate orders for the wander guard, and that staff checked the function of the wander guard (Residents #33 and #44). The facility identified 9 residents with a wander guard. The sample was 25. The census was 128. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who are incontinent receive appropriate treatment and services to prevent urinary tract infections or other incontinence related complications for three of four perineal care (cleansing of the area between the legs to include the buttocks and genital area) observations. Staff failed to cleanse all areas potentially soiled, failed to ensure soap was rinsed from the skin and failed to ensure the area was dry to ensure the residents remained clean, dry and odor free (Residents #102, #47 and #29). The census was 128. Review of the facility's Perineal Care policy, dated 10/14/21, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year, from hire date to hire date, for 4 of 10 sampled certified nursing aides (CNAs) reviewed. The survey findings identified failures related to CNA care for dignity, infection control, mechanical lift transfer safety and personal care. The census was 128. Review of the CNA training records, provided by the facility, showed: -CNA A hire date 11/18/19. Four hours of in-service training documented in the last year from hire date to hire date, from 11/2019 through 10/2020; -CNA B hire date 7/21/10. Zero hours of in-service training documented in the last year from hire date to hire date, from 7/2020 through 6/2021; -CNA C hire date 4/25/16. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the monthly drug regimen review (DRR) recommendations were followed timely for one resident (Resident #57) and failed to ensure DRRs were completed monthly for one resident (Resident #79) who received psychotropic medications, for two of six residents investigated for DRR as part of the unnecessary medications investigation. In addition, the facility's policy failed to identify the timeframes for the different steps in the DRR process. The facility census was 128. Review of the facility's Drug Regime Review policy, dated 11/28/17, showed: -It is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were not kept past their expiration date and treatment supplies and medications were properly labeled in four out of five medication carts observed and one of two medication rooms. The facility identified having two medication rooms and 10 medication carts. The census was 128. Review of the Medication Storage policy, dated 12/11/18, showed: -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels; -These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. 1. Observation on 10/14/21 at 1:20 P.M., of one of the two nurse medication carts identified in the [NAME] community, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. This had the potential to affect all residents with medical conditions or needs not addressed. The sample was 25. The census was 128. Review of the Facility Assessment, dated 1/16/21, showed: -Residents who do not communicate in the dominant language of the facility: 0 residents; -Who use non-oral communication devices: 0 residents; -With advance directive: 0 residents; -Diseases/conditions, physical/cognitive disabilities analysis: -Psychiatric/mood disorders: 0 residents; -Condition of the heart/circulatory system: 0 residents; -Condition of the neurological system: 0 residents; -Vision/visual loss: 0 residents; -Hearing loss: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during two of four perineal care (the cleansing of the area between the legs to include the buttocks and genital area) observations, and when staff failed to properly sanitize shared medical equipment after use for two of three mechanical lift observations (Residents #102, #47 and #29), failed to wear an approved mask that completely covered their nose, used oxygen tubing on a resident that was lying directly on the floor, failed to change gloves after touching soiled surfaces and before touching clean dressing supplies, and served a resident a drink that had a staff person's hair in it [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 1 of 5 abuse investigations reviewed. The facility failed to thoroughly investigate bruising found on a resident (Resident #64). The resident sample was 25. The census was 128. Review of the facility's abuse and neglect policy, dated 11/28/17, showed: -Investigate/Prevent/Correct/Alleged Violation: The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; -Take appropriate corrective action, because of investigation findings; -Procedure: The investigation is the process used to try to determine what happened. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for 4 of 25 sampled residents (Residents #102, #16, #33 and #115). The census was 128. 1. Review of Resident #102's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/17/21, showed: -No cognitive impairment; -No mood or behaviors; -Supervision with eating; -Diagnoses included non-traumatic brain dysfunction and anxiety disorder. Review of the resident's physician order sheet (POS), dated 10/1/21 through 10/31/21, showed an order dated, 8/6/21 for a diet: Regular and thin liquids with meat cut for patient. Review of the resident's care plan, dated 9/14/21, showed the following: -Problem: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order for a resident's full code status for one resident (Resident #79) of 25 sampled residents. The facility census was 128. Review of the Advance Directives Policy and Procedure policy, dated [DATE], showed resident wishes will be communicated to the staff via the care plan and to the resident's physician. Review of the Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated [DATE], showed: -Cognitively intact; -Required extensive assistance with mobility, toileting and personal hygiene; -Diagnoses included fractures, high blood pressure, diabetes, end stage renal disease (ESRD) and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to fully implement the facility's restorative therapy program and ensure residents received restorative therapy (RT) as ordered. The facility identified 57 residents that should receive RT services. Of those 57, two were sampled and concerns were found with one (Resident #115). The census was 128. Review of the facility's Restorative Nursing Program, dated 10/22/19, showed the following: -Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level; -Restorative Nursing Program, refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days without further evaluation of the resident for one (Resident #79) of six residents sampled for the unnecessary medication review. The facility census was 128. Review of the Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/21, showed: -Cognitively intact; -Required extensive assistance with bed mobility, toileting and personal hygiene; -Diagnoses included fractures, high blood pressure, diabetes, end stage renal disease (ESRD) and depression; -Antidepressant medication taken daily; -Opioid medication taken six of seven days. Review of the resident's electronic medical record, reviewed on 10/14/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, three errors occurred resulting in an 11.5% error rate (Residents #29 and #125). The census was 128. 1. Review of Resident #29's medical record, showed: -Diagnoses included peripheral vascular disease (poor blood flow to the extremities) and high blood pressure; -An order dated 6/8/21 and discontinued 10/12/21, for potassium chloride (supplement) 10 milliequivalents (mEq), 1 tablet once a morning; -An order dated 6/7/21 and discontinued 10/12/21, for Lasix (furosemide, water pill) 40 milligram (mg), 1 tablet once a morning. Observation on 10/14/21 at 9:35 A.M., showed Certified Medication Technician (CMT) X administered the resident's medications, to include potassium chloride 10 mEq and furosemide 40 mg. [...]

Inspectors wroteBased on observation, interview and record review, facility to ensure each resident had fluids readily available during meal service, including one resident who had a current urinary tract infection (Resident #60). The resident sample was 25. The facility census was 128. 1. Review of the Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/31/21, showed: -Cognitively intact; -Diagnoses included stroke, high blood pressure, diabetes, aphasia (difficulty swallowing), hemiplegia (weakness or paralysis on one side of the body), malnutrition and depression; -Limited assistance with eating with one person physical assistance. Review of the resident's care plan, revised on 8/3/21, showed: -Problem: Resident has a history of urinary tract infection; -Goal: Resident will not exhibit signs of urinary tract infection; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents. The sample was 25. The census was 128. Observation on 10/12/21 at 12:53 P.M., 10/13/21 at 1:35 P.M., 10/14/21 at 4:06 P.M., 10/15/21 at 9:00 A.M. and 10/18/21 at 10:30 A.M., showed no survey binder readily available or sign indicating where the binder is located. During an interview on 10/14/21 at 1:30 P.M., seven members of the resident council said they did not know where the survey binder was located. During observation and interview on 10/18/21 at 12:16 P.M., the administrator said the survey binders where located at the front desk and on each community. The binder at the front desk it not available unless you ask. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing in a prominent place readily accessible to residents and visitors on a daily basis. The facility's census was 128. Observations from 10/12/21 through 10/15/21 and 10/18/21, showed the facility did not post the nurse staff posting sheet in a prominent place readily visible and accessible to residents and visitors. During interview on 10/18/21 at 12:16 P.M., the administrator said the nurse staffing sheet was supposed to be posted on the communication boards on each community. At approximately 1:00 P.M., the administrator and surveyor walked to the communication board on both the [NAME] and [NAME] communities. The administrator confirmed there was no required nurse staffing posted. The staffing coordinator is responsible posting it; [...]

Inspectors wroteBased on interview and record review, the facility failed to have signed authorization for management of personal funds for six of nine residents reviewed (Residents #78, #5, #2, #47, #103 and #85). The facility held funds for 77 residents. The census was 128. 1. Review of Resident #78's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/21, showed admission date of 2/11/21. Review of the facility's authorization for management of personal funds, showed no documentation of authorization for the resident trust fund (RTF) account from the resident or the resident's representative. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed an admission date of 8/20/19. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure notification to the resident and the resident's representative in writing of a discharge, including the reason for the discharge, the effective date of the discharge, the location to which the resident is discharged and a statement of the resident's appeal rights. The facility also failed to follow their transfer or discharge protocol for two of two sampled residents investigated for hospitalizations (Residents #68 and #113) who were discharged to the hospital and returned to the facility. The census was 128. [...]