Marymount Manor

Inspectors wroteBased on interview and record review, the facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when staff failed to accurately complete neurological (neuro) evaluations (pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; and equality of hand grip strength) if the fall was unwitnessed or if the resident had an incident in hitting their head, for three of three residents sampled. [...]

Inspectors wroteBased on interview and record review, facility staff failed to accurately code five (Resident #13, #18, #28, #60 and #73) of five sampled residents who received an antiplatelet (used to prevent and treat cardiovascular diseases) on the Minimum Data Set (MDS), a federally mandated assessment tool. The facility census was 79. 1. Review of the facility's MDS policy, undated, showed the facility will complete MDS assessments in accordance with state guidelines. Review of the Resident Assessment Instrument (RAI) manual, used to facilitate accurate and effective resident assessment practices, version 1.19.1, dated October 2024, showed the manual instructed staff to not code antiplatelet medications such as clopidogrel (antiplatelet) as an anticoagulant. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain professional standards of documentation when staff failed to complete weekly skin assessments for three (Resident #5, #17, and #54) of three residents. Staff failed to administer eye medication per policy for two (Resident #7 and #55) out of two sampled residents. The facility census was 79. 1. Review of the facility's Skin Assessment policy, dated July 2021, showed: -In order to prevent skin breakdown and promote health of our residents, it is the policy of the facility to perform skin assessments on a weekly basis by a Registered Nurse (RN) or Licensed practical nurse (LPN); -The LPN or RN are to visually inspect all areas of the body and note/document any abnormalities. [...]

Inspectors wroteBased on observations, interview, and record review, facility staff failed to provide appropriate respiratory care and services, when staff failed to change oxygen tubing or properly clean and maintain oxygen concentrators for two (Resident #77, and #81) out of three sampled residents and failed to obtain an order and care plan oxygen use for one (Resident #17) of three sampled residents. The facility census was 79. 1. Review of the facility's Oxygen Therapy policy, dated 06/05/25, showed: -Label humidifier with date and nurse initials; -Place a storage bag on the side of the concentrator to store oxygen tubing between use and not in use; -Change clean storage bag weekly and as needed; -The policy did not contain direction or guidance how often to change the oxygen tubing. Review of the facility's Nebulizer Mask Policy, undated, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the environment remained safe and free of accident hazards for eight residents (Residents #11, #17, #18, #19, #31, #40, #41 and #70) out of eight sampled residents who use side rails when staff did not obtain an order, signed consents for side rails, and failed to complete entrapment assessments. The facility census was 79. 1. Review of the facility's Bed Rails policy, dated 09/05/17, showed: -Assess the resident for risk of entrapment from bed rails prior to installation; -Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; -Ensure bed dimensions are appropriate for resident's size and weight; -Regularly check for areas of possible entrapment; -Ensure there is no gap wide enough to entrap a resident's head or body; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 79. 1. Review of the facility's policy titled, Resident Services dated 01/2024, showed the facility provides sufficient licensed nursing and ancillary services 24 hours a day, including a Registered Nurse for at least eight consecutive hours daily. 2. Review of the facility's RN staff schedule, dated March 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Sunday, 03/02/2025; -Sunday, 03/16/2025; -Sunday, 03/30/2025. 3. Review of the facility's RN staff schedule, dated April 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Sunday, 04/13/2025; -Sunday, 04/27/2025. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure expired medications were destroyed or returned appropriately and ensure multi-dose medications were dated when opened in two of three medication storage carts and one of two medication storage rooms and failed to store one liquid medication labeled keep in refrigerator in the refrigerator. The facility census was 79 residents. 1. Review of the facility's Storage of Medication policy, dated 2022, showed staff are directed as follows: -The nursing staff shall be responsible for maintaining medication storage; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate or alert staff of residents who required EBP, failed to place appropriate signage to alert staff of EBP needs, and failed to place appropriate personal protective equipment (PPE) in close proximity for four residents (Resident #4, #5, #32, and #54) of five sampled residents who had a wound and failed to ensure sanitary conditions for one (Resident #14) out of two residents with a catheter. The facility's census was 79. 1. Review of the facility's EBP policy, dated 04/2024, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to document the administration of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for four residents (Resident #16, #54, #70, and #71) out of 10 sampled residents and failed to document the administration of the influenza (contagious respiratory infection caused by a virus) vaccine for four residents (Resident #13, #16, #70 and #71) of ten sampled residents. The facility census was 79. 1. Review of the Facility's Pneumococcal Vaccination Policy and Procedure, dated 12/12/2023, showed the communities will offer pneumococcal vaccination on admission and annually. The resident may refuse to receive the vaccination. The Community will get consent form the resident or responsible party. If the resident agrees to the vaccination the community will provide the vaccination on admission and annually. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike when staff failed to maintain resident rooms in good repair. Facility census was 79. 1. Review of the facility's Homelike Environment policy, dated March 2017, showed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include clean, sanitary and orderly. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #11, #18, and #70) out of three residents sampled. The facility census was 79. 1. Review of Marymount Manor Senior Living Community Handbook, dated July 9, 2021, showed the Bed Hold Policy: -Before there is a transfer of a resident to a hospital or resident goes on a therapeutic leave, the resident and family or Durable Power of Attorney (DPOA) will be notified twice. First will be during the admission process by the reading of the Bed Hold Policy. Second notice will be provided to the resident and family or DPOA at the time of transfer to the hospital. A copy of this policy will be sent with other papers accompanying the resident to the hospital. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for eight residents (Resident #12, #17, #18, #19, #29, #31, #41, and #70) out of twelve sampled residents. The facility census was 79. 1. Review of the facility's Care Planning policy and procedure, dated January 2020, showed: -A care plan will be developed upon admission per Centers for Medicaid and Medicare Services (CMS) guidelines; -The care plan will be updated quarterly and annually per CMS guidelines to ensure that there is a continuity of care, and is in accordance with the individuals needs; -The care plan will be updated with a significant change of status condition; -The care plan must be based on the resident assessment, choices, and advanced directives, if any; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for residents who reside on the memory care unit. The facility census was 79. 1. Review of the facility's policy titled, Memory Care Policy, undated, showed staff were directed to do the following: -Activities are done three times a day, seven days a week on memory care. -We include crafts, spiritual, emotional, cognitive, social, physical, creative, and independent activities; -We offer a one-to-one program to those who choose to not attend group activities or who cannot attend group activities. 2. Review of the Memory Care Unit Activity Calendar, dated June 2025, showed: -Tuesday, 06/10/25; 10:00 A.M. This day in History, 10:30 A.M. Seek and Find, 3:00 P.M., Iced Tea and Snack Social; -Wednesday, 06/11/25; 10:00 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 79. 1. Review of the facility's Daily Staff Postings policy, dated 10/27/2015, showed information to be posted on the form to include the total number and total hours of the Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurses Aide's (CNA) staffed. The policy did not contain information to include the facility census. 2. Review of facility's daily staffing sheets, dated March 1-31, 2025, showed the sheets did not contain the facility census. Review of facility's daily staffing sheets, dated April 1-30, 2025, showed the sheets did not contain the facility census. Review of facility's daily staffing sheets, dated May 1-31, 2025, showed the sheets did not contain the facility census. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 79. 1. Review of the facility's policy titled, Antibiotic Stewardship, dated 8/9/17, showed as a facility, Marymount will do the following to improve antibiotic use: -Commit resources for monitoring antibiotic use and providing feedback to staff; -Identify and empower the medical director and/or consultant pharmacist to assist in the leadership stewardship activities; -Have clear policies to improve prescribing practices for staff to ensure residents are not started on antibiotics unless needed; [...]

Inspectors wroteBased on interview and record review, facility staff filed to ensure the residents' medical records included documentation the resident or resident's representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine, and each dose of COVID-19 vaccine administered to the resident, if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for five residents (Resident #12, #16, #70, #71, and #77) of nine sampled residents. The facility census was 79. 1. Review of the Facility's COVID-19 Vaccine Policy - Residents, date 4/21/2023, showed residents who reside in Marymount Manor will be offered upon admission and annually for their consent to be provided a COVID-19 vaccination. 2. Review of Resident #12's medical record showed: -admitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow their abuse and neglect policy by not reporting an allegation of sexual abuse within the required time frame. This affected one resident (Resident #2). The sample was 9. The census was 80. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated 12/14/18, showed: -The facility is committed to protecting residents from mistreatment, neglect, abuse and misappropriation of resident property; -The following policy has been put in place to insure protection and prevention from such treatment: -1. All employees hired are subject to a criminal record check; -a. Results of criminal record check will be reviewed by the Administrator and appropriate department manager to determine employment eligibility; -b. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their written policy permitting residents to return to the facility after they have been hospitalized , for one of 9 sampled residents (Resident #1). The census was 80. Review of the facility's Discharge Procedures policy, undated, showed: -Discharge Procedures - The facility shall permit each resident to remain in the facility unless: -The transfer or discharge is appropriate because the resident's welfare and the resident's needs cannot be met by the facility; -The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; -The safety of individuals in the facility is endangered; -The health of individuals in the facility would otherwise be endangered; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. This failure has the potential to affect all residents. The facility census was 74. 1. Review of the facility's Warewashing and Storage policy dated January 2019, showed the policy directed staff to allow all washed and sanitized dinnerware, utensils, preparation and service supplies to air dry prior to storage. Observation on 03/27/24 at 9:18 A.M., showed Dietary Aide (DA) V pulled a rack of sanitized plastic cups from the mechanical dishwasher, stacked the cups together while wet and then placed the cups on a service tray on a utility cart. Observation on 03/27/24 from 9:23 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during incontinence care for three (Resident #48, #65, and #37) out of three sampled residents. Facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two residents (Resident #67 and #30) out of three sampled residents to prevent the spread of infection causing contaminants. The facility census was 74. 1. Review of the facility's policy titled, Hand Washing/Use of Gloves Policy and Procedure, undated, showed the purpose of this procedure is to provide guideline to employees for proper and appropriate hand washing techniques that will aid in the prevention of transmission of infections. To prevent the spread of infectious disease, when to wash/sanitize hands: [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 74. 1. Review of the facility's policy titled, Antibiotic Stewardship, undated,showed as a facility, the facility will do the following to improve antibiotic use: -Review and monitor for trending during weekly risk meeting; -Commit resources for monitoring antibiotic use and providing feedback to staff; -Develop facility-specific standards for empiric antibiotic use, based on data from the facility; -Review antibiotic appropriateness and resistance patterns on a regular basis. Review of the facility's antibiotic stewardship program showed facility staff did not track antibiotic trends. [...]

Inspectors wroteBased on observation, interviews, and record reviews, facility staff failed to provide reasonable accommodation of needs for one resident (Resident #53) to ensure the water cup was obtainable and in reach, so the resident could drink independently and failed to ensure acceptable table heights to encourage meal independence for two residents (Resident #68 and #37) out of 18 sampled residents. The facility census was 74. 1. Review of the facility's policies showed staff did not provide a policy for accommodation of needs. 2. Review of Resident #53's quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with only set up help needed for meals; -Residents ability to stand or walk, not attempted due to medical condition or safety concern; -No impairment to upper extremity. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms and the memory care unit common areas. Facility census was 74. 1. Review of the facility's policy titled, Maintenance Service, dated 12/19, showed staff were directed to do the following: -Maintenance services shall be provided to all areas of the building, grounds, and equipment; -Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #38, #44, #63 and #78) out of 24 sampled residents. The facility census was 74. 1. Review of facility's policies showed staff did not provide a policy for comprehensive care plans. 2. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/17/24, showed staff assessed the resident as: -Cognitively intact; -Somewhat important to have books, newspapers and magazines to read, to do things with groups of people, and do favorite activities; -Very important to listen to music he/she likes, to be around animals such as pets and get outside to get fresh air when the weather is good; -Not very important to keep up with the news or particpate in religious services or practices. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's care needs for four residents (Residents #47, #56, #78, and #79) of 18 sampled residents. The facility census was 74. 1. Review of facility's policies showed staff did not provide a policy for comprehensive care plans. 2. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/17/24, showed staff assessed the resident as: -Severe cognitive impairment; -Did not contain documentation of bed rail use; -Required supervison or touching assistance from staff with rolling left to right; -Required partial to moderate assistance from staff with moving from sitting on side of the bed to lying flat on the bed; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends and staff failed to provide an ongoing program of activities designed to meet the residents' interests for residents who reside on the memory care unit. This had the potential to affect all residents. The facility census was 74. 1. Review of the facility's policy titled, Activity Department, dated 08/17/21, showed staff were directed to do the following: -The facility takes a holistic approach to the care of all its residents. In order to have this approach, the facility maintains an Activity Department for it's residents. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the resident environment remained as free of accident hazards four resident's (#37, #47, #54 and #66) out of eleven sampled resident's when staff failed to apply the residents foot pedals to prevent accidents and propelled the residents in his/her wheelchair. The facility census was 74. 1. Review of the facility's policy titled, Wheelchair Safety, undated, showed staff were directed as follows: -It is often the responsibility of the facility staff to assist a resident from point A to point B via wheelchair/[NAME]-walker/pedal broda throughout the facility. It is utmost importance that facility staff assist with propelling the resident in the safest manner possible; -At no time should a resident be propelled by anyone while their feet are dragging on the floor. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to complete entrapment assessments, review risk and benefits, side rail assessment and/or obtain consent for the use of bed rails for four (Resident #37 #47, #56, and #79) out of four sampled residents. The facility census was 74. 1. Review of the facility's Bed Safety and Bed Rails policy, dated June 2018, showed: -Assess the residents for risk of entrapment from bed rails prior to installation; -Review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation; -Ensure that the beds dimensions are appropriate for the resident's size and weight; -Following the manufacturers recommendations and specifications for installing and maintaining bed rails; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three Nurse Aide's ((NA) NA A, NA B and NA C) completed the nurse aide training program within four months of his/her employment in the facility. The census was 74. 1. Review of the facility's Nursing Assistant Facility Requirements policy, undated, showed individuals must successfully complete a nursing assistant training program approved by the department or shall enroll in and begin the first available approved training program which is scheduled to commence within (90) days of the date of the CNAs employment and which shall be completed within four (4) months of employment. 2. Review of NA A's Certified Nurse Aide (CNA) training report, showed a hire date of 09/06/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 3/28/24 at 1:37 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medications in a safe an effective manner when staff did not date the opened medication in the medication cart and staff placed nonmedication in medication strorage room refrigerator. This had the potential to affect all residents. The facility census was 74. 1. Review of the facility's policy titled, Storage of Medication, dated 2022, showed staff were directed to do the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure resident's personal privacy was protected, when they left the Medication Administration Records (MAR) open and unattended in a public hallway. Facility census was 74. 1. Review of facility's policies showed staff did not provide a policy for privacy during medication pass. 2. Observation on 03/25/2024 at 11:40 A.M., showed Licensed Practical Nurse (LPN) M left the MAR open and unattended with resident information exposed. Observation showed staff and residents walked past the cart. 3. Observation on 03/27/24 at 11:07 A.M., showed Registered Nurse (RN) E left the MAR open and unattended with resident information exposed. Observation showed staff and residents walked past the cart. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for three (Resident #15, #54 and #73) out of three sampled residents. The facility census was 74. 1. Review of the facility's Discharge/Transfer Policy, undated, showed the written notice should include: -The reason for the transfer or discharge; -The effective date of transfer or discharge; -The resident's right to appeal the transfer or discharge to the director of the Department of Health and Senior Services hearing official withing thirty days of receipt of the notice; -The address to which the request for a hearing should be sent to Administrative Hearings Unit; -That filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise; [...]

Inspectors wroteBased on observation, record review and interview, facility staff failed to ensure staff provided three dependent residents (Resident #44, #63 and #78) out of 24 sampled, that were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain adequate grooming. The facility census was 74. 1. Review of the facility's policy titled, Activity of Daily Living (ADL), dated 08/17/17, showed it is the standard of the facility to promote the highest level of health and hygiene for the residents residing at the facility, while promoting the upmost independence. In order to adhere to this standard, it is the policy that any resident that is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed when a resident (Resident #1) experienced a change in condition. Staff received orders for intravenous (IV) fluids on 11/24/23 due to abnormal blood chemistry. Staff did not administer the ordered IV fluids. The facility also did not administer an additional ordered fluid intake of 240 milliliters three times a shift (shifts were 12 hours) ordered to be administered for three days or obtain ordered vital signs every shift for three days. The staff did not notify the resident's physician or nurse management of the inability to administer the IV fluids. As a result, the resident continued to decline during the night. On 11/26/23 the day shift nurse observed the resident as extremely lethargic, unresponsive, and sent the resident to the hospital emergently. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow acceptable standards of nursing practice, when staff failed to assess Resident #1's skin and document or report changes in the resident's skin condition to the physician. The resident was at risk to develop skin impairment. The resident admitted to the hospital on [DATE] and was observed with an untreated wound to the sacrum (tailbone) and an additional area to the right buttock. The facility failed to have a system in place to ensure skin assessments were being performed by licensed nursing staff, to detect changes in residents' skin so prompt care and treatment could begin. The sample size was seven. The census was 85. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered for one of 7 sampled residents (Resident #4). The facility failed to assess and monitor the resident for pain, notify the resident's physician when the pain medication was not delivered, and to notify the physician of increased pain. This resulted in the resident, with a history of a compression fracture in a bone in the spinal column, to experience increased pain, causing the resident to cry, have difficulty sleeping, and limiting his/her desire to move. The census was 85. Review of the facility's undated physician order policy, showed: -Policy: to transcribe and follow physician orders accurately; -Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the alarm on the fire egress doors on the memory care unit were monitored while inoperable. One resident was observed to attempt to exit out the egress door (Resident #7) and one additional resident was identified as risk for elopement (Resident #6). The facility did not have designated staff monitoring the egress doors. The memory unit census was 24. 1. Review of the facility's Resident Services Policy (RSP) policy, provided as the staffing policy, dated 3/27/17, showed: -Resident Services: The facility will provide services by sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate staffing to meet the needs of the residents, when residents scheduled to receive showers on the memory unit and the 200 hallways did not receive the scheduled showers. The sample was 7. The census was 85. Review of the facility's Resident Services Policy (RSP) policy, provided as the staffing policy, dated 3/27/17, showed: -Resident Services: The facility will provide services by sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans; -Employment, advertising and incentives: the facility will advertise employment needs in various social media and new outlets. A staffing committee reviews staffing needs on a weekly basis and updates advertisements as needed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL, bathing dressing, toileting) received the necessary services to maintain adequate personal hygiene by not providing showers for six residents (Resident #6, #2, #4, #3, #5 and #1). The sample was eight. The census was 81. Review of the facility's ADL policy, dated 8/17/17, showed: -It is the standard, of the facility to promote the highest level of health and hygiene for the residents residing at the facility, while promoting the upmost independence. In order to adhere to this standard, it is the policy that any resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; [...]

Inspectors wroteBased on observation, interviews and record review facility staff failed to perform hand hygiene as often as necessary to prevent cross-contamination and failed to store food in a manner to prevent cross-contamination, spoilage and out-dated use. Facility staff also failed to maintain the kitchen's physical environment and equipment in a sanitary condition. The facility census was 83. 1. Review of facility's undated policy on Food Service Handwashing showed hands will be washed before serving food, after collecting soiled dishes/food waste, prior to handling food trays, and any time hands become visibly soiled. Observation on 9/27/22 at 10:10 A.M., showed Dietary Aide (DA) Y placed soiled dishes on the dirty side of the mechanical dishwasher, removed clean dishes from a dishwasher rack and placed dishes on a cart. [...]

Inspectors wroteBased on resident and staff interview and record review, facility staff failed to notify seven sampled residents (Resident #3, #19, #27, #28, #39, #45 and #76) in a timely manner about the spend down plan for balances in excess of the Medicaid threshold. The facility census was 83. 1. Review of the facility's Policy and Procedure for Residents Funds Letter, revised 7/1/22 showed the facility bookkeeper will send out a letter to the resident or resident representative anytime a resident's trust fund balance is over five-thousand dollars. Review also showed, phone calls can be used as a supplement but not a substitute for the letter. 2. Review of facility Trust Fund Balance reports from January 2022 through September 2022 showed the following residents with balances that remained above $5,101.85 which is within $200 of the Medicaid eligibility absolute limit of $5,301.85: [...]

Inspectors wroteBased on staff interview and record review, facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check prior to start date for four out of 8 sampled employees. The facility census was 83. 1. Review of the facility's Abuse, neglect, exploitation or mistreatment policy, undated, showed: -This facility will not knowingly employ an individual convicted of resident abuse or misappropriation of resident property; -The facility will not knowingly employ any direct care staff convicted of any of the crimes listed in the healthcare worker background check act, or with findings of abuse, neglect or exploitation listed on the nurse aide registry; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide person-centered, measurable time frames to meet the residents' individual needs and goals identified in the comprehensive care plans for ten (Resident #26, #47, #50, #53,#55, #65,#73, #78, #336, and #337) out of 18 sampled residents. The facility census was 83. 1. The facility did not provide a care plan policy. 2. Review of Resident #26's comprehensive care plan, dated 8/21/22, showed the record did not contain measurable time frames to address the residents' individual care area problems, goals and/or how staff are to assist the resident to meet the goals. 3. Review of Resident #47's comprehensive care plan, dated 7/27/22, showed the record did not contain measurable time frames to address the resident's care area problems. 4. [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, facility staff failed to provide appropriate personal hygiene care for five residents (Resident #25, #51, #56, and #58) out of 18 sampled residents. The facility census was 83. 1. Review of the facility's bathing policy, undated, showed shower staff are directed as follows: -Residents will remain clean, dry, and free of odors; -A shower/bathing schedule will be maintained at each nursing station to reflect day/shift for each shower assigned; -Accommodations will be made for requested days/time; -Certified nurse assistants will complete a visual assessment of a resident a report any abnormal findings; -A charge nurse will do a skin assessment and report of abnormal findings; -Shower schedules will be reviewed by clinical mangers to ensure necessary steps have been taken. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to have a system in place to monitor residents on the memory care unit (MCU), with a history of wandering, from exiting the facility unnoticed. Staff removed the wander alert system (alarm used to notify staff if a resident tries to exit the facility) and unlocked an exit door residents had access to. Additionally, staff failed to ensure residents on the memory care unit remained free of accident hazards when they did not to remove a disposable razor from Resident #16's room. Further, facility staff failed to properly propel nine residents (Resident #333, #26, #47, #35, #37, #68, #21, #40 and #14) in their wheelchair, and provide care to one (Resident #9) in a manner to prevent accidents. The facility census was 83. 1. [...]

Inspectors wroteBased on staff interview and record review, facility staff failed to ensure the attending physician and the Family Nurse Practitioner (FNP) saw nine of eighteen sampled residents (Residents #26, #47, #50, #53, #55, #65, #73, #78, and #337) every thirty days for the first ninety days, then every sixty days after that. Facility staff also failed to ensure the physician documented his/her notes regarding their visit/examination of the residents. This could lead to residents not receiving timely assessments and the appropriate care by a qualified provider. The facility census was 83. 1. Review of the facility's Physician Services policy, revised 01/12/14, showed the following: - Upon admission, a history and physical examination shall be performed within seven days unless performed within thirty days prior to admission; [...]

Inspectors wroteBased on observation, staff interview, and record review, facility staff failed to store and label medication in a safe and effective manor in one of two medication storage rooms and in one of two medication storage carts. The facility census was 83. 1. Review of the facility's Medication Storage and Labeling Policy, dated revised 2/22/22, showed staff were directed: -Expiration dates must be checked prior to administration; -Expired medications are removed from the area of care immediately, and disposed of according to facility medication disposal policy, per state and federal guidelines. 2. Observation on 9/29/22 at 10:56 A.M., showed the medication storage room on the 300 hall contained: -One 200 tablet bottle of women's multivitamin with and an expiration date of 6/22; -One 100 tablet bottle of oyster shell calcium 250 milligram (mg) with an expiration date of 1/22. [...]

Inspectors wroteBased on observation, interviews, and record reviews facility staff failed to properly maintain the temperature of hot foods at or above 120 Degrees Fahrenheit (°F) and cold foods at or below 41° F for six residents (Resident #25, #51, #73, #67, #66, and #336) at the time of meal service. Facility staff failed to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents. Further, staff failed to prepare food in a palatable manner. The facility census was 83. 1. Review of the facility's policy Meal Service Temperatures, dated revised January, 2020, showed staff were directed as follows: - meals temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for three residents (Residents #3, #6, and #331). Additionally the facility failed to change, date and bag respiratory equipment for one resident (Resident #38). The facility census was 83. 1. Review of the facility's Hand Washing policy, revised 12/22/13, showed it directed staff to wash their hands whenever they are soiled with body substances, before performing invasive procedures, and when each resident's care is completed. Review of the Hand Washing Inservice and Competency handouts, held 7/22/22 through 8/10/22, showed the following: -Gloves do not take the place of hand washing; -Wash/sanitize hands after contact with blood, body fluids, secretions, mucous membranes, or broken skin; [...]

Inspectors wroteBased on observation and resident and staff interview, facility staff failed to post the telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect) in a form and manner accessible to resident and the resident's representative. The facility census was 83. 1. Review of the facility policies showed the facility did not provide a policy regarding posting the hotline number. Observations of the facility on 9/27/22 through 9/30/22, showed facility staff did not post the name, address, and toll free telephone number for the DHSS hotline accessible to the residents or residents representative. Observation on 9/30/22 at 1:24 P.M., showed the resident family room did not contain the name, address, and toll free telephone number for the DHSS hotline accessible to the residents or residents representative. Observation on 9/30/22 at 1: [...]

Inspectors wroteBased on observation, staff interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 83. 1. Review of the facility's Daily Nursing Hours Posting Policy, dated 9/29/22, showed the following: -Purpose: to provide transparent nursing staffing information visible to residents and visitors; -The facility will post total nursing hours daily. The posting will include: - Date; - Census; - Number of individuals for each nursing job classification (Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant); [...]