Maryville Rehabilitation & Health Care Center

Inspectors wroteBased on interview and record review the facility staff failed to follow the facility staffing policy of two staff members during the daytime hours for the Memory Care Unity (MCU) when Licensed Practical Nurse (LPN) A left the MCU, leaving Certified Nurse's Aide (CNA) A as the only staff member on the MCU when Resident #1 put his/her hand over Resident #2's mouth and hit Resident #3's arms with his/her hand. This deficient practice affected three of three sampled residents. The facility census was 44. On 07/30/26, the Administrator was notified of the past noncompliance which began on 07/22/26. Upon discovery, the facility administration immediately conducted an investigation, and corrective actions were implemented to include staff training regarding dementia care, staffing on the memory care unit, and abuse and neglect. The noncompliance was corrected on 07/23/26. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a dignified existence for one resident, who resided on the Special Care Unit, (Resident #1), when Certified Nurse Aide (CNA) A took a picture of Resident #1, without resident or family/guardian consent and shared it with a coworker. The facility census was 48Review of the facility provided Resident Rights Policy dated 12/2024 showed:-Each resident residing in this community has the right and will be afforded the right to a dignified existence;-It is the responsibility of all who work in this community including employees, to protect the rights of each resident;-Resident Rights include privacy and confidentiality. Review of Resident #1's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) showed:-He/She had significant cognitive loss; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1) right to be free from misappropriation of property, when an employee did not follow policy for accurate narcotic (highly addictive prescription medication) count, did not visualize liquid narcotic medication during count procedures and the resident was missing 40 milligrams (mg) of morphine sulfate (liquid narcotic medication that is highly addictive) medication on 06/29/26 and no documented use. The facility census was 45. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient staff to prevent one resident (Resident #2) who resided on the Special Care Unit, from exiting the facility unattended, sustaining a fall in the courtyard, obtaining a 6 inch abrasion to his/her arm and caused extreme pain, while unaccompanied by staff. The facility census was 48. Review of the facility provided Skilled Fall Policy dated 05/2025 showed:-The fall program promotes safety, prevention and education of both staff and residents; -Each resident will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide an appropriate discharge for one resident, (Resident #1), of six sampled residents, when the facility refused to allow the resident to return to the facility after hospitalization, based on the resident's behaviors prior to hospitalization. The facility census was 46. Review of the facility provided, undated Notice of Transfer/Discharge form showed:-You may only be transferred or discharged from this nursing facility for one of the following reasons: the safety of individuals in this facility is endangered; -This facility plans to transfer/discharge you to the following location. The facility did not provide a policy on Discharge. Review of Resident #1's admission Minimum Data Set (MDS: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide follow up care in a timely manner after one resident, Resident #2, sustained a fall, had reported signs of pain, did not receive treatment for four days and subsequently had a fractured hip. The facility census was 43. Review of the facility policy titled, Skilled Fall, Policy dated 05/2025 showed each resident of this community who experiences a fall will be treated and assessed to adequately treat any current injuries. Review of the facility policy titled, Significant Condition Change and Notification, dated 12/2024, showed:-To ensure the resident's medical practitioner was notified of resident changes such as: [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect one resident (Resident #1) from misappropriation, when $600 of the resident's money went missing from the Social Services Designee's (SSD) office. The facility did not reimburse the resident for the missing money until 03/10/26. The facility census 43. Review of the facility's Abuse Prevention, and Prohibition Policy, dated November 2025, showed:-This facility prohibits mistreatment, neglect, or abuse or residents; [...]

Inspectors wroteBased on interview, and record review, the facility failed to prevent an injury for one Resident (Resident #1) of the four sampled residents, when the facility staff did not follow the resident's care plan and did not properly transfer the resident, causing a fracture to the right lower leg. The facility census was 48. Review of the undated facility policy titled Transfers Training Policy showed:- Transfers are assessed to determine each resident needs;- Transfer assist needs are located on the resident's care plan;- Always check the resident's transfer requirements before transferring the resident;- All mechanical lifts require two people. If the plan of care is not followed, progressive disciplinary action will proceed up to and including termination. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a safe environment for one (Resident #1) of five sampled residents, and failed to follow their hot liquids policy, when a staff member brought in a personal coffee pot at the nursing station area and the nursing staff provided a hot coffee to the resident without checking the temperature before serving and leaving the resident unsupervised. The resident spilled the coffee and sustained burns to his/her chest and abdomen. The facility census was 44. On 9/2/25, the Administrator was notified of the past noncompliance incident which occurred on 08/25/25. [...]

Inspectors wrote4. Review of Resident #1's MRR, dated 4/2/25 showed: - The pharmacist recommended Bupropion XL 300 mg every day, Clonazepam 0.5 mg three times daily and Risperidone 0.25 mg twice daily for review; the physician responded the dose had recently been changed, no changes. Review of the resident's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included cerebral palsy (CP), seizure disorder and anxiety; - The resident received antipsychotics on a regular basis; - 4/17/25 - GDR documented as contraindicated. Review of the resident's POS, dated June, 2025 showed; - Start date - 3/6/25 - Risperidone 0,25 mg., one tab by mouth every morning and at bedtime related to mood disorder due to known physiological condition, unspecified. Review of the resident's MAR, dated June, 2025 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond that was equal or greater than one and one-half times the average monthly balance for the residents' trust fund (RTF) account for the last 12 consecutive months from June 2024 to May 2025. The facility census was 46. The facility did not have a policy regarding surety bonds. Record review on 6/19/25 of the RTF account for the last 12 consecutive months from June 2024 to May 2025 showed: -The facility's current approved bond amount equaled $50,000; -The average monthly balance for the RTF account equaled $36,248.59 (which was determined using the total of each ending balance for the last 12 month bank statements plus the petty cash ending balances and divided by 12 months); -An average monthly balance of $36,000 required a bond of at least $54,000; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement their Abuse and Neglect policy when they failed to obtain criminal background checks results prior to staff working with residents and check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of ten sampled staff (Certified Nurse Aide (CNA) A, CNA B, Assistant Director of Nursing (ADON), Certified Medication Technician (CMT) A, Housekeeping Aide (HA) A, Licensed Practical Nurse (LPN) A, CNA C, and HA B.). The facility census was 46. Review of facility policy, Abuse, Prevention, and Prohibition Policy, dated 12/2024, showed: [...]

Inspectors wrote4. Review of Resident #20's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included cancer and multiple sclerosis. Review of the resident's POS, dated June, 2025 showed: - Start date: 6/15/25 - Clean oxygen concentrator filter with water and allow to air dry weekly every night shift every Sunday; - Start date: 6/15/25 - Oxygen at 2 liters per nasal cannula (2L/NC) to keep oxygen saturation greater than 95% every shift; - Start date: 6/15/25 - Change oxygen tubing every Sunday night on the night shift. Review of the resident's Medication Administration Record (MAR), dated June 2025 showed: - Clean oxygen concentrator filter with water and allow to air dry weekly every night shift every Sunday; - Oxygen at 2 liters per nasal cannula (2L/NC) to keep oxygen saturation greater than 95% every shift; - Change oxygen tubing every Sunday night on the night shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a facility-wide system to monitor the use of antibiotics administered to residents with various infections conditions. The sample size was three Resident #8, #12 and #23. The census was 46. Review of the facility's policy titled Infection Prevention and Control Program dated 2019 showed: -The mission of the program is 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; -An antibiotic stewardship program includes antibiotic use protocols and a system to monitor antibiotic use; -Antibiotics stewardship and review including reviewing data to monitor the appropriate use of antibiotics in the resident population; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected one of the 12 sampled residents, (Resident #3). The facility census was 46. The facility did not provide a policy for perineal care. 1. Review of Resident #1's urinalysis (UA, test to analyze urine contents), dated 2/20/25 showed the presence of bacteria indicative of a possible urinary tract infection (UTI). Review of the resident's urine culture and sensitivity ( UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 2/20/25, showed the presence of organisms indicative of a possible UTI. [...]

Inspectors wroteBased on interview and record review the facility failed to protect two residents who resided on the Memory Care Unit (Resident #1 and #5) from physical abuse by Resident #2, when Resident #2 pulled Resident #1's hair and hit Resident #5 with a water pitcher full of water, causing redness and mental distress for Resident #5. The facility census was 49. Review of the facility policy Abuse, Prevention, Prohibition Policy dated 3/2025 showed: -Each resident has right to be free from abuse; -Residents must not be subjected to abuse by anyone, including other residents; -The facility prohibits mistreatment or abuse of residents; - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. On 5/7/25, the Administrator was notified of the past noncompliance situation which occurred on 4/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four residents (Resident #1, #2, #3, and #4) out of five sampled residents were free from abuse when three staff members took photos of four residents (Resident #1, #2, #3, and #4) and one staff member took a video (Resident #2) and posted it to social media. Two of the pictures taken had a demeaning comment written on the pictures about the residents (Resident #1 and Resident #2). Three of the four residents had a diagnosis of dementia and all four residents were unaware that they had been recorded or had their pictures taken and posted to a social media platform. The facility census was 44. On 3/11/25, the Administrator was notified of the past noncompliance which began on 02/10/2025. The facility administration immediately conducted an investigation and corrective actions were implemented. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1), who resided on the Special Care Unit (SCU), from abuse when Certified Medication Technician (CMT) A hit Resident #1 in the face with an open hand. The facility staff then allowed the Alleged Perpetrator (AP) to stay in direct contact with Resident #1 and without supervision for over 2.5 hours. The facility census was 54. On 12/11/24, the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which began on 12/11/24. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The IJ was corrected on 12/11/24. Review of the undated facility Abuse Prevention and Prohibition Policy showed: -The facility prohibits mistreatment, neglect or abuse of residents; [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, failed to take food temperatures on the steam table before food service and when cooking items, failed to reheat foods to safe temperatures before serving, stored glasses with openings facing up, stored eggs on the floor, did not properly sanitize food preparation surfaces in kitchen, did not have a thermometer in refrigeration unit, did not ensure proper parts per million (PPM) sanitation levels were reached while using a 3 compartment sink, did not wash hands after contamination, did not have paper towels available at hand washing sink, and when dietary staff did not wear hairnets prior to entering kitchen. The facility census was 59. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to respect resident rights of six residents out of the 15 sampled residents, when the facility failed to provide grooming for three residents ( #312, #36, #44) and failed to respect the privacy of three residents (#25, #40, #43). The facility census was 59. Facility did not provide a dignity policy. Review of facility policy, shaving the resident, undated, showed: To remove facial hair and improve the resident's appearance and morale. Review of facility policy, resident rights, undated, showed: -Residents will be provided the highest level of care and service; -Each resident shall be treated with consideration, respect a full recognition of his/her dignity, and individuality. -Right to dignified existence 1. Review of Resident #312's admission face sheet showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were offered a choice of when they would like to get up in the morning. This affected two of the 15 sampled residents (Residents #30, and #43). The facility census was 59. Review of the facility's Resident Rights Policy, dated 6/12/24 showed in part: -Each resident shall be treated with consideration, respect, and full recognition of his/her individuality; -Each resident shall not have the right to self determination which includes the right to a choice of schedules and accommodations for preferences. 1. Review of Resident #30's Quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 4/13/24 showed: -Moderate cognitive impairment; -Partial assistance with showers and personal hygiene; -Substantial assistance with dressing and transfers; [...]

Inspectors wroteBased on interviews and record review, the facility failed to consider the views of resident council and act promptly upon grievances and recommendations made by the group concerning issues of resident care and life in the facility when the facility failed to demonstrate their response and rationale for such responses when they did not maintain documentation of resident concerns, facility's attempt to resolve concerns, or the facility's follow up actions. This affected all the residents serving on the resident counsel and potentially other residents of the facility. The facility census was 59. Review of facility policy, resident rights, undated, showed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to inform residents how to file a grievance or complaint, take prompt efforts to resolve resident grievances voiced in resident council meetings when the same problems were voiced multiple months with no resolutions and failed to follow up with one resident's family member (Resident #43) with resolution regarding a grievance made to the facility. The facility census was 59. Review of nursing home resident right's, undated, showed: -Right to raise grievances: -Present grievances without discrimination or retaliation, or fear of it; -Prompt efforts by the facility to resolve grievances, and provide a written decision upon request. Review of facility policy, resident grievances, undated, showed: -Resident has the right to exercise his or her rights as a resident of the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for two residents (Resident #15 and #44) to address dehydration and falls (resident #15) and code status (Resident #44). The facility census was 59. Review of facility policy, care plan comprehensive, undated, showed: -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. -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. 1. Review of Resident #15's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/22/24, showed: -He/She was severely cognitively impaired; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to administer medications within the appropriate time frame, which affected three of the 15 sampled residents, (Resident #21, #28 and #29). The facility census was 59. Review of the facility's undated policy for the medication administration guidelines showed: - It is the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL) received the necessary assistance with bathing, incontinent care. This affected four out of the 17 sampled residents, when the facility staff failed to ensure two residents (Resident #4 and #43) received regular showers, failed to provide complete incontinence care for two residents (Resident #33 and #40) The facility census was 59. Review of the facility's undated Perineal Care policy showed: -Wash hands and apply clean gloves; -Using a clean wipe separate and cleanse all skin folds that have came in contact with urine or feces; -Wash from front to back. Review of the facilty's undated Resident Rights policy showed; -Residents have the right to dignified existence; [...]

Inspectors wroteBased on observation, interviews, and record review, the staff failed to ensure residents remained free from accident hazards and failed to provide adequate supervision to prevent accidents. Staff failed to ensure one resident was served the accurate therapeutic ordered diet (Resident #27) and staff failed to ensure medication was administered when a controlled medication was left on a resident's card table for two days (Resident #49). This affected two of fifteen sampled residents. Additionally, the facility failed to ensure staff used proper techniques to reduce the possibility of injuries during the use of sit to stand (a lift that allows residents who can bear weight to transfer from a sitting position to a standing position) transfer, which affected Resident #43. The facility census was 59. Facility did not provide a policy regarding prevention of accidents. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sufficient staffing to provide services to residents to maintain highest practicable physical, mental, and psychosocial well-being when residents did not receive showers which affected one of the 15 sampled residents, (Resident #43), meal service was late which affected all the residents, activities were not offered due to activity director being pulled to cover the floor, and medications were late which affected Resident # 21, #28 and #29. The facility census was 59. The facility did not provide a policy for staffing. The facility did not provide a policy for showers. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/12/24 showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (5%). Facility staff made nine medication errors out of 28 opportunities for error, resulting in a medication error rate of 32.14%. This affected five of 15 sampled residents, (Resident #3, #4, #12, #48 and #53). The facility census was 59. Review of the manufactures guidelines for Novolog insulin FlexPen dated July 2023 showed: -Clean the area with an alcohol swab and let dry; -Hold the needle in the skin for at least 6 seconds before removing the needle. Review of the manufactures guidelines for Levimir FlexTouch insulin pen dated March 2024 showed in part: -Clean the area with an alcohol swab and let dry; -Hold the needle in the skin for at least 6 seconds before removing the needle. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. Additionally, the staff failed to discard a vial of the Influenza Vaccine after it had expired and failed to ensure medication had had a pharmacy label on it. The facility census was 59. Review of facility policy, storage of medications, undated, showed: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medicaiton carts. -All mobile medication carts must be under visual control of the staff at all times when not stored safetly and securely. Carts must be either in a locked room or otherwise made immobile. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately staff the kitchen with enough dietary staff to ensure the cleanliness of the kitchen, and meals were served to residents in a timely manner. This has the potential to affect all residents of the facility. The facility census was 59. Facility did not provide a policy regarding dietary staffing. 1. Review of Resident # 40's Significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/7/24, showed: - Cognitive skills intact; - He/She was independent with eating - Diagnoses included high blood pressure, gastroesophageal reflux disease (GERD) (A digestive disease in which stomach acid or bile irritates the food pipe lining), and anxiety. Review of the resident's care plan, revised 4/25/24 showed: [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to three (resident #40, #43, and #312) of fifteen sampled residents. The facility census was 59. Review of facility policy, food temperatures, dated April 2015, showed: -Hot foods should be at least 120 degrees Fahrenheit when served to the resident. 1. Review of Resident # 40's Significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/7/24, showed: - Cognitive skills intact; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the call light system was accessible for residents in their rooms when call lights were out of reach for two of the 15 sampled residents, (Resident # 43 and #44). The facility census was 59. Review of facility policy, use of call light, undated, showed: -When providing care to residents, be sure to position the call light conveniently for the resident's use. -Tell the resident where the call light is and show him/her how to use the call light. -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/12/24 showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; [...]

Inspectors wroteBased on observation the facility failed to protect the resident's right to personal privacy when a nurse left the medication cart computer screen unattended, unlocked, and visible with resident personal information accessible to anyone near the computer screen. The facility census was 59. Review of facility policy, electronic medical records, undated, showed: -Only authorized persons who have been issued a password and a user identification (ID) code will be permitted access to the electronic medical records system. -The facility electronic medical records system has: -safeguards to prevent unauthorized access; -individual password and user ID codes and permission is established to ensure only authorized persons enter appropriate data; -will not permit a change on the record once it had been locked without the approval of the person that completed the assessment. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify, assess and document a pressure ulcer (an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these) for one of the 15 sampled residents, (Resident #43). The facility census was 59. Review of the facility's undated policy for wound care and treatment showed, in part: - The purpose of the facility is to prevent and treat all wounds; - There must be a specific order for the treatment; - Prevention strategies - On - going skin assessment with weekly documentation of status. Minimize dry skin. Apply house moisturizer to areas of dry skin, after and as needed. Avoid massage over bony prominence's. Minimize friction and sheer through proper positioning transferring and turning. Develop and implement method of communicating position changing; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served to meet the needs of the residents when staff failed to serve food items for each diet type when staff failed to prepare food according to the menu and failed to serve the correct portion sizes per the menu. This had the ability to affect all residents. The facility census was 59. Review of facility policy, menus, dated May 2015, showed: -Menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the recommended dietary allowances; -Any unusual or complex diet not printed on the menu or listed in the Manual shall be written by the consulting dietician based on physicians orders. Review of facility menus, day 16 lunch, showed: -Regular baked chicken: portion size 3 ounces (oz); -Pureed baked chicken: portion size/serving utensil #8 scoop; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food in a form designed to meet individual needs when residents were served food not consistent with their dietary orders (Resident #27). This affected one of fifteen sampled residents. The facility census was 59. Review of facility policy, menus, dated May 2015, showed: -Menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the recommended dietary allowances; -Any unusual or complex diet not printed on the menu or listed in the Diet Manual shall be written by the consulting dietician based on physicians orders. Review of facility policy, diet communication form, dated April 2006, showed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care in a manner to prevent infection or the possibility of infection when staff failed to wash hands between dirty and clean tasks which affected one of the 15 sampled residents, (Resident #43). The facility census was 59. Review of the facility's undated policy for handwashing showed: - The purpose is to reduce transmission of organisms form resident to resident, nursing staff to resident and resident to nursing staff; - The policy did not indicate when staff should wash or sanitize their hands. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/12/24 showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. The facility census was 51. Review of policy, storage of medications, undated, showed: -An unattended medication cart must remain locked at all times. In the event the nurse is distracted from task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. Observation on the C hall used as the COVID isolation unit, on 11/30/23 at 1:02 P.M., showed the medication cart lock was sticking out from medication cart and the drawers were not locked. No facility employees were found on the C wing hall. Five residents were residing on the COVID unit. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen, failed to label food when it was opened, failed to temperature check foods, and failed to ensure staff washed their hands when contaminated. The facility census was 51. Review of the facility policy, Sanitizing the three-compartment sink, dated 5/15 showed: -Ensure the sanitizing water is at the appropriate level, is being monitored, documented, and used correction, according to the instruction below: - Fill third compartment of 3-compartment sink with water to the line as indicated on the sink. - Dip test paper into solution and hold for 10 seconds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments, obtain informed consent and physician orders for use of side rails for three of 15 sampled residents. (Residents #10, #26, and #38). The facility census was 50. Review of the undated facility provided policy regarding physical restraints showed: -Equipment: side rails (bed rails) -Guidelines: assess residents need for use; obtain physician's order. -Side Rails: involve the resident and the resident's representative in planning for side rail use. - The policy did not include direction for staff regarding assessment, obtaining consent or obtaining a physician order. 1. Review of Resident #10 Quarterly Minimum Data Set (MDS a federally mandated assessment completed by facility staff) dated 7/10/22 showed: -Brief Interview of Mental Status (BIMS) of 0. [...]

Inspectors wroteBased on record review, observation, and interview; the facility failed to prepare and serve foods that were attractive and palatable to residents at or above 120 degrees Fahrenheit (F). The facility census was 50. Review of facility Food Temperature's policy, dated May 2015, showed: -Hot food should be at least 120 degrees F when served to the resident. Observation on 10/11/22 at 12:06 P.M. showed: -The hot box (A hot box is an improvised appliance to heat up food) was not plugged in as the hall trays were beginning to be dished up and placed inside to be sent to the Dementia unit. -One tray was sitting on top of the hot box instead of being inside. It was covered with an insolated top with no insolated or heated bottom. Observation on 10/12/22 at 12:31 P.M. showed: -Sample hall tray contained Parmesan chicken with green beans, red bliss potatoes, and dinner roll. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff cared for residents in a dignified manner, when they failed to ensure that two residents received facial grooming for the removal of unwanted facial hair (Resident #43, and Resident #253) and failed to ensure that one resident (Resident #45) was able to sit at an appropriate sized table height to accommodate independent eating during meals in the main dining. The facility census was 50. Review of the facility's posted Resident Rights policy showed: Each resident has the right to be treated with dignity and respect. All staff activities and interactions with residents must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's preferences and choices. 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure staff provided necessary care and services in accordance with professional standards of practice for two residents (Resident #12 and #31) out of the sampled thirteen residents when the staff failed to place a hand roll in the contracted hand of one resident to prevent further contractures and failed to apply heel protectors for Resident # 12 and staff failed to apply compression socks every morning before the resident was out of bed for Resident #31. The facility census was 50. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 7/15/22 showed: -Dementia; -Extensive assistance of two staff members for Activities of Daily Living (ADL's); -Incontinent of bowel and bladder; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide appropriate treatment and services to maintain the ability to communicate for one resident (Resident #38) of 15 sampled residents. Facility census was 50. The facility did not provide a policy on communication. 1. Review of Resident #38 Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 9/16/22 showed: -BIMS of 14, indicates no cognitive impairment -Hearing highly impaired -No hearing aide -Extensive assistance with bed mobility and dressing. -Dependent on staff for transfers and toilet use. -Limited assistance with personal hygiene. - Diagnosis of heart failure, Diabetes (a disease where the pancreas doesn't produce enough insulin to control the amount of glucose, or sugar,in the blood.),Depression and Chronic Obstructive Pulmonary Disease (COPD: [...]