Maywood Terrace Living Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) out of six sampled residents, was free from a significant medication error when on 4/1/26 the resident was administered five milliliters (mL) of Methadone HCL Oral solution (a long acting synthetic opioid used for chronic pain) instead of 0.5 mL that was ordered. The facility census was 48 residents. Review of the facility's policy, Administering Medications, dated April 2019 showed:-The Director of Nursing (DON) supervises and directs all personnel who administer medications.-Medications to be administered in accordance with prescriber's orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage and labeling of narcotic medication to include the date and resident's name when opened for one sampled resident (Resident #18) and one supplemental resident (Resident #37) out of 13 sampled residents and 12 supplemental residents that were stored in one of one medication carts; failed to ensure there were no expired medications in the medication room refrigerator, failed to ensure that expired medical dressing supplies were disposed of, failed to ensure an opened insulin pen was dated, labeled, and properly stored, failed to ensure that resident's personal food and drink items, supplements, and medications were not stored in the same refrigerator and failed to ensure proper defrosting was done in one out two medication storage rooms. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain nozzles of the dishwasher spray wand free of debris; failed to maintain the vent over the clean side of the dishwasher free of a heavy buildup of dust; failed to discard one damaged mitten; failed to ensure there was an air gap between the drain from the ice machine and the floor drain; failed to ensure the container of utensils didn't have debris at the bottom of the utensil container; failed to ensure the lemon juice was refrigerated; failed to ensure the light fixtures in the kitchen were free from a dust buildup; failed to have the correct kind of sanitizer test strips available; failed to maintain two cutting boards free from numerous grooves and indentations; failed to ensure both light bulbs for the range hood illuminated; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices to prevent cross contamination were implemented during resident indwelling urinary catheter (a flexible, thin tube inserted into the bladder to drain urine when a person cannot urinate naturally) and incontinence care for two sampled resident (Resident #5, and #6) and during wound care for one sampled resident (Resident #6); failed to ensure appropriate hand hygiene was performed during incontinence care for one resident (Resident #35); failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use the proper Enhanced Barrier Precaution (EBP) signage for one resident with an indwelling medical device (Resident #10) and failed to ensure that the Personal Protection Equipment (PPE) carts in hall were adequately stocked; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the plumbing system to ensure the hot water temperatures were kept at or above 105 F (degrees Fahrenheit) in resident rooms 31, 34, 25, 23, 24, 19; and below 120 F in resident room [ROOM NUMBER], 13, 12, 11, 9, 7, and 4; failed to install an inline temperature gauge (a thermometer which provides real-time, precise monitoring for liquids or gases within pipes, hoses, and industrial systems) on the water heaters which served the [NAME] and North halls; failed to place handles on the faucets on the janitor's closets. The practice of not maintaining the system to ensure the temperature of hot water, stayed within the range of 105 F to 120 F, potentially affected all residents. The facility census was 49 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floor in the restroom of resident room [ROOM NUMBER] in good repair; failed to maintain the fans free of a heavy buildup of dust in resident rooms [ROOM NUMBER], Resident #10's room, Resident #9's room, the therapy room, and failed to prevent a torn sling (a specialized fabric harnesses used with mechanical lifts to safely transfer individuals with limited mobility between beds, wheelchairs, toilets, and showers) from being used to transfer Resident #3. This practice potentially affected at least 15 residents who reside in or used those areas. The facility census was 49 residents. 1. Observation on 3/10/26 at 9:30 A.M., showed a 10 inch (in.) long by 0.5 in wide area of floor damage in the restroom of resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess and document resident care areas on the Facility Matrix for two sampled residents (Resident #3 and #35) for respiratory care, opioid and insulin use and failed to ensure an accurate assessment was completed and behavior was selected as a care plan area for one sampled resident (Resident #53) with known and documented behaviors prior to and after admission out of 13 sampled residents. The facility census was 49 residents. 1. Review of Resident #53's Face Sheet showed the resident was admitted with diagnoses that included:-Neurocognitive disorder (a progressive, incurable brain disease characterized by abnormal deposits of protein, known as Lewy bodies, in neurons. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the care plan for Activities of Daily Living (ADL's) included the preference for bathing/showering was assessed and documented for one sampled resident (Resident #24); and failed to ensure bathing was completed and documented twice weekly by nursing staff for five sampled residents (Resident #32, #24, #3, #10, and #35) out of 13 sampled resident's. The facility census was 49 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the facility census and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift and to update the posting daily for view by residents, family members and visitors. The facility census was 49 residents. Policies for all areas of staffing were requested on 3/16/26 and were not received at the time of exit.1. Observation on 3/9/26, 3/13/26 and 3/16/26 showed there was no posting of the facility staffing that included facility name, date, census, the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure hot foods on room trays for at least 5 residents on the [NAME] Hall were maintained at or above a temperature of 120 F (degrees Fahrenheit). The facility census was 49 residents. 1. Observation on 3/12/26 at 8:16 A.M., showed the pancakes were 152.7 F and the sausage patties were 170.6 F on the steam table. Observation on 3/12/26 at 9:01 A.M., showed the food cart was loaded with the meals for room trays and was delivered to the [NAME] Hall for delivery to the residents. Observation on 3/12/26 at 9:17 A.M., showed the pancakes had a temperature of 88.7 F and the sausage had a temperature of 85.8 F on a room tray that was refused by a resident. Observation on 3/12/26 at 9:24 A.M., showed the pancakes had a temperature of 86.3 F on a room tray that refused by Resident #18. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required 12 hours of nurse aide in-service training either at the time of hire or within the last 12 months that included the topics of dementia (a progressive mental disorder causing confusion, and impairment of control, memory, judgement, and impulses), Abuse, Neglect and Exploitation (ANE) and behavior management (focuses on person-centered, non-pharmacological approaches to address challenging behaviors (e.g., aggression, wandering) as communication of unmet needs) for four out of five sampled nursing staff Certified Nursing Assistants (CNA D and CNA J), Licensed Practical Nurse (LPN) C and Registered Nurse (RN) A. The facility's census was 49 residents. A policy for staffing competencies and in-service training was requested on 03/16/26 but has not been provided to date.1. [...]

Inspectors wroteBased on interview and record interview, the facility failed to ensure the right to be informed when one sampled resident (Resident # 41) out of 13 sampled residents, was not provided information demonstrating the risks and/or benefits of the medication Xanax (a medication used to treat anxiety caused by depression (a mental health condition creating persistent feelings of sadness, hopelessness, and loss of interest in activities), anxiety disorders and panic disorder. The facility census was 49 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedrails were provided and utilized in accordance with resident needs, physician orders, and care plan for one sampled resident (Resident #3) who was approved for the use of bedrails out of 13 sampled residents. The facility census was 49 residents. A bedrail policy was requested on 3/16/26 and was not provided at the time of exit. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Third Party Liability (TPL- a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account) forms were completed and sent to Missouri (MO) Healthnet (a state agency which administers the provision and payment of services for Missouri's Medicaid program) within 30 days of death for two discharged residents (Resident #101 and #102). The facility census was 49 residents. 1. Review of Resident #101's Resident Trust Transaction History dated 2/1/26 through 3/11/26, showed he/she:-Passed away on 2/1/26.-Had $20.15 left in his/her account. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice when staff obtained the blood pressure (the force of circulating blood pushing against the walls of your arteries as the heart pumps it around the body) using a wrist cuff while the residents' arms remained in a dependent (lowered) position, which could result in inaccurate readings for two sampled residents (Resident #41 and #48) out of 13 sampled residents. The facility census was 49 residents. A policy for blood pressure equipment usage was requested but not provided by the date of exit. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's urinary catheter (a flexible, thin tube inserted into the bladder to drain urine when a person cannot urinate naturally) drainage bag (a medical device that connects to a catheter to collect urine draining from the bladder) was placed below the resident's bladder during a transfer and during incontinence care for one sampled resident (Resident #5); and failed to ensure a suprapubic urinary catheter (is a flexible tube inserted into the bladder through the abdominal wall) tubing was not dragging on the ground while up in wheelchair; failed to ensure the suprapubic catheter was addressed in a care plan; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and properly label respiratory equipment to include nasal cannula (a lightweight, flexible tube with two prongs inserted into nostrils used to deliver supplemental oxygen to people with breathing difficulties) and nebulizer mask/mouthpiece (a medical devices that fits over the nose and mouth, delivering liquid medication as a fine mist to the lungs) and tubing when not in use; and failed to ensure monitoring and weekly changing of oxygen nasal cannula tubing that was dated 6/26/25 for one sampled resident (Resident #32) who was at risk for respiratory distress out of 13 sampled residents. The facility census was 49 residents. Review of the facility's Oxygen safety policy revised on July 2024 showed: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to secure and obtain a signed copy of the dialysis (a treatment to remove extra fluid and waste when kidneys fail) contract; and failed to ensure dialysis communication forms were completed and reviewed by facility staff and the dialysis clinic for one sampled resident (Resident #32) out 13 sampled residents. The facility census was 49 residents. Review of the blank dialysis communication form located at the west nursing station showed: -A reminder to complete the top section of the dialysis communication form.-To ensure the bottom section was completed by dialysis, if returned uncompleted then call dialysis for the documentation.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) had a personalized care plan to ensure services to promote the resident's highest level of functioning and psychosocial needs for one sampled resident (Resident #41) out of 13 sampled residents. The facility census was 49 residents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure to follow standard of practice and safe administration/use of a Basaglar insulin KwikPen (a disposable, prefilled insulin pen containing insulin glargine a long-acting insulin used to manage blood sugar levels. The subcutaneous pen-injector provides 24-hour basal insulin coverage) for one supplemental resident (Resident #21), out of 12 supplemental residents. The facility census was 49 residents. Review of the facility's Administering Medications Policy revised on April 2019 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) sausage for one sampled resident (Resident #22) was at a smooth consistency; and failed to ensure the recipe for pureed sausage included the quantities of liquids or thickeners needed. This practice affected one resident. The facility census was 49 residents. 1. Review of the facility recipe for pureed sausage, dated 2025 showed:-Ingredients: 1 cooked sausage patty.-Directions: Place the number of servings needed, from the regular prepared recipe into a clean and sanitized food processor and blend until smooth.--If the consistency needed thinning, gradually add an appropriate hot liquid (i.e. broth, gravy, hot milk, sauce, reserved cooking liquid).--If the consistency needed thickening: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve one sampled resident (Resident #24) out of 13 sampled residents, a meal that was compatible with his/her chosen preferences. The facility census was 49 residents. 1. Review of Resident #24's meal ticket dated 3/12/26, showed the resident:-Was to receive a regular diet and a regular texture.-Had a statement of double portions.-Was to receive NO PORK OF ANY KIND. Observation on 3/12/26 at 8:58 A.M., showed the resident was served a plate with pork sausage and pancakesDuring an interview on 3/12/26 at 9:09 A.M., the resident, who was identified by his/her admission Minimum Date Set (MDS a federally mandated assessment tool completed by the facility for care planning) dated 2/20/26, as a resident who was cognitively intact, said eating pork was against his/her religion. During an interview on 3/12/26 at 9:58 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Hospice care and services were documented in the resident's Hospice record and communicated to the facility staff to ensure coordination of care for one sampled resident (Resident #7) out of 13 residents. The facility census was 49 residents. Review of the facility's Hospice policy and procedure dated July 2017, showed:-Their facility had an agreement in place with at least one Medicare certified hospice to ensure the residents who wish to participate in a hospice program may do so. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly account for the delivery of 120 tablets of Oxycodone (a narcotic controlled substance for pain) 20 milligram (mg) from the pharmacy for one sampled resident (Resident #1) out of three sampled residents. The facility census was 41 residents. A Policy and Procedure was requested for Controlled Substances and was not received prior to exit on 3/19/25. 1. Review of Resident #1's Face Sheet showed that he/she was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome and spinal stenosis (narrowing of the spinal canal that caused pressure on the spinal cord). Review of the resident's electronic Physician Orders dated 2/2025 showed he/she had order for Oxycodone 20 mg, one tablet four times a day for pain. Review of the resident's care plan, revised 3/4/25 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room clean; failed to ensure food preparation items/equipment were kept in a sanitary condition; failed to keep trash dumpsters lidded; and failed to maintain plastic cutting boards in good order to avoid food safety hazards (cross-contamination), in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 44 residents with a licensed capacity for 86 residents at the time of the survey. 1. During an interview on 7/9/24 at 9:33 A.M. the Administrator said the facility did not currently have a Dietary Manager (DM). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Facility Assessment timely to determine resources necessary to meet the needs of the residents, such as assessments of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community based risk assessment. A total of 12 residents were sampled. The facility census was 44 residents. Review of the facility policy titled Facility Assessment Tool, dated 8/8/17 showed: -Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and resources the facility needs to care for their residents. 1. Review of the Facility assessment dated [DATE] revised 10/26/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to employ an Infection Preventionist (IP) on at least a part-time basis. The facility census was 44 residents. Review of the facility Infection Preventionist policy, revised September 2022 showed: -The infection preventionist was employed on site and at least part time. -The infection preventionist was scheduled with enough time to properly assess, develop, implement, monitor and manage the Infection Prevention and Control Program (IPCP). 1. During an interview on 7/16/24 at 10:50 A.M. the Administrator said: -He/she had worked at the facility for one month. -He/she was the IP. -He/she had worked on IP activities about three and one half hours per week. -Prior to him/her working at the facility, the previous Administrator was the IP. During an interview on 07/16/24 12:05 PM facility Corporate Nurse said: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped with a complete, functioning call light system throughout the facility, specifically with audible notification, to ensure the ability to meet the residents' needs in a timely manner. This deficient practice had the potential to affect all residents who resided in the facility. The facility census was 44 residents with a licensed capacity for 86 residents at the time of the survey. 1. Observation on 7/9/24 at 9:58 A.M. during the facility resident room inspections showed resident room [ROOM NUMBER] had its hallway ceiling call light lit along with the corresponding call light board at the nursing station, with no audible notification heard there or at the room. Observation on 7/9/24 at 1:55 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff were available at all times for two sampled residents (Resident #4 and #21) who reside on the dementia (a slowly progressive disease of the brain characterized by impairment of memory and reasoning) Special Care Unit (SCU). The facility census was 44 residents. 1. Review of the facility census for 7/2/24 showed sixteen residents lived on the SCU. Review of the facility's staffing sheets for 7/9/24 showed a Licensed Practical Nurse (LPN) and two Certified Nurse Assistants (CNAs) were scheduled to be on the SCU from 7:00 A.M. to 7:00 P.M. Observation on 7/9/24 at 11:55 A.M. showed: -Several residents from the SCU were in the main common area at tables listening to music with multiple staff with them. -At 12:00 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post staffing information in a location that was easily accessible to residents on the Long Term Care (LTC) and Rehabilitation units of the facility and to ensure staffing data was posted for visitors including the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 44 residents. Review of the facility's Nurse Staffing Posting Information, revised August 2022 showed: -The facility would have posted on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible that provided direct care to residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication were stored, labeled and dated correctly in medication room and two sampled medication carts out of three medication carts. The facility census was 44 residents. Review of the facility Medication and Storage Policy revised 2/2023 showed: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary method. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs and can cause mild to severe illness) and/or pneumococcal (a serious wide ranging bacterial infection that can cause severe illness) vaccination status was verified as having been administered or refused and that risks and benefits of vaccination were presented residents or their representatives for four sampled residents (Resident #22, #25, #40, #42) out of 12 sampled residents. The facility census was 44 residents. Review of the facility Influenza Vaccine policy, revised March 2023 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four residents (Residents #25, #35, #40, and #42) were offered COVID-19 (an infectious disease caused by the SARS-CoV 2 virus) vaccination, that education was provided regarding the benefits and risks of the COVID-19 vaccine and signed consent, or refusal obtained from the resident or the resident's representative, for four out of 12 sampled residents. The facility census was 44 residents. Review of the facility Coronavirus Disease (COVID-19) Vaccination of Residents policy, revised May 2023 showed: -Each resident is offered the COVID-19 vaccination unless the immunization is medically contraindicated, or the resident is fully vaccinated. -The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form CMS-10055) for two sampled residents (Resident #8 and #31) out of three sampled residents who were discharged from Medicare part A services. The facility census was 44 residents. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly assessment for two sampled residents (Resident #5 and #7) and to complete a significant change Minimum Data Set (MDS-a federally mandated assessment completed by facility staff) for one resident (Resident #7) out of 12 sampled residents. The facility census was 44 residents. Review of facility policy entitled Resident Assessment revised October 2023 showed: -A comprehensive assessment of each resident was completed at intervals designated by the Omnibus Budget Reconciliation Act (OBRA) regulations and Prospective Payment System (PPS) requirements. -Data from the Minimum Data Set (MDS) was submitted to the Internet Quality Improvement Evaluation System (iQIES). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident falls were accurately reflected on their Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) for one sampled resident (Resident #4) out of 12 sampled residents. The facility census was 44 residents. Review of the facility's Resident Assessments policy, revised October, 2023 showed: -Federally mandated and required assessments must be performed for all residents of Medicare and Medicaid certified homes. -The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments. -Any persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for wound care on a surgical wound for one sampled resident (Resident #7) out of 12 sampled residents. The facility census was 44 residents. A policy for following physicians orders was requested and not received from the facility. 1. Review of Resident #7's annual Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/14/23 showed the resident: -Was severely cognitively impaired. -Had a surgical wound. Review of the resident's Care Plan dated 3/11/24 showed: -The resident had a healing surgical wound. -The wound was related to a right above the knee amputation. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation to determine the root cause of a resident's fall, to document monitoring and neurological assessments after a resident reported an unwitnessed fall, and to update the resident's care plan with appropriate interventions and monitor the effectiveness of interventions to prevent additional falls for one sampled resident (Resident #29) out of 12 sampled residents. The facility census was 44 residents. Review of facility policy entitled Accidents and Incidents-Investigating and Reporting revised July 2017 showed: -All accidents or incidents that involved residents that occurred on our premises would be investigated and reported to the administrator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitizing of the indwelling catheter (tubing inserted in the bladder to drain urine) drainage port and hand hygiene during catheter tubing and drainage bag change and failed to have complete physician's orders for the size of the catheter for one sampled resident (Resident #21) out of 12 sampled residents. The facility census was 44 residents. Review of the facility's Catheter Care, Urinary Care policy, revised 8/2022 showed: -The policy goal was to prevent urinary-associated complications including Urinary tract infections. -Use aseptic technique when handling or manipulating the drainage system. -Keep catheter tubing and drainage bags off the floor. -Empty collection bag every eight hours using a separate clean collection container for each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #35), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 12 sampled residents. The facility census was 44 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow through on the pharmacy consultant identified irregularities in the resident's medication orders without an appropriate diagnosis or indication for use during the pharmacists monthly Drug Regimen Review (DRR) for one sampled resident (Residents #29) out of 12 sampled residents. The facility census was 44 residents. Review of facility policy entitled Medication Regimen Reviews (MRR) revised May 2010 showed: -The consultant pharmacist reviewed the medication regimen of each resident at least monthly. -The consultant pharmacist performed a MRR for every resident in the facility that received medications. -The MRR involved a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors, and other irregularities. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's physician reviewed the pharmacist's recommendations for a Gradual Dose Reduction (GDR) of the resident's psychotropic medications (drugs which affect psychic function, behavior, or experience) on the Drug Regimen Review (DRR) for one sampled resident (Resident #7) and failed to failed to follow through on the pharmacy consultant identified irregularities in the resident'psychotropic medication orders without an appropriate diagnosis or indication for use during the pharmacists monthly DRR for one sampled resident (Resident #26) out of 12 sampled residents. The facility census was 44 residents. Review of the facility's Medication Regimen Review (MRR) policy dated 5/2019 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to completely assess and document one resident's (Resident #1) skin upon admission to the facility and notify the resident's physician of a scab (crust that forms over a sore or wound) on the resident's left heel at the time of the resident's facility admission, failed to ensure treatments were completed for the resident's left heel and edema (swelling) in the resident's legs, failed to ensure weekly licensed nurse skin assessments and completion of and licensed nurse review of Certified Nurse (CNA) shower sheets, failed to notify the resident's physician of the resident's left heel skin breakdown to his/her legs, and failed to ensure the resident's emergency room physician's instruction for the resident's anticoagulant medication to be held for two doses and then resumed was reviewed by a licensed nurse and written [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure weekly pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) assessments were completed, ensure hand hygiene (washing/sanitizing hands) during wound treatment and correct application of a wound product for one sampled resident (Resident #1), out of four sampled residents. The facility census was 49 residents. Review of the facility Prevention of Pressure Injuries policy revised April 2020 showed: -Assess the resident on admission (within eight hours) for existing pressure injury risk factors. -Repeat the risk assessment weekly and upon any changes in condition. -Use standardized pressure injury screening tool to determine and document risk factors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure correct catheter (a hollow, partially flexible tube inserted into the bladder to drain urine) care for one sampled resident (Resident #1) out of four sampled residents. The facility census was 49 residents. Review of the facility Catheter Care, Urinary revised August 2022 showed: -Wash and dry hands thoroughly. -Put on gloves. -With non-dominant hand separate the labia (the folds of skin around the vaginal opening) of the female resident or retract the foreskin (skin that covers the head of the penis) of the uncircumcised (having intact foreskin) male resident; maintain the position of this hand throughout the procedure. -For a male resident: --Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus (the opening where urine leaves the body). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure side rails (also known as bed rails - devices, usually metal attached to the bed frame and extending along the side of the mattress and extend upward above the level of the mattress) were not used unless the resident's assessment indicated side rails were safe for the resident, out of four sampled residents. The facility census was 49 residents. A side rail policy was requested and not received. Review of U.S. Food and Drug Administration Safety Concerns About Adult Portable Bed Rails dated 2/27/23 showed: -Deaths and serious injuries can happen when using bed. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food products were sealed, labeled, and dated to prevent contamination, failed to ensure spills in the refrigerator were cleaned up, and failed to ensure spoiled food was discarded. This deficient practice potentially affected all residents who ate meals from the kitchen. The facility census was 44 residents. Observation and interview on 12/19/22 at 8:59 A.M., showed the following: -The kitchen had been cleaned and there was no one actively working in the kitchen or cooking. -On the countertop by the sink there were two packages labeled tea that were sealed, but there was a dried brown, liquid substance on the top and sides of the packages. -The backsplash of the stove had debris running down the backsplash. -The tabletop can opener tip was dirty with dried on food debris. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure temperatures on the North Unit were maintained between 71 degrees Fahrenheit (ºF) and 81 ºF when the outside temperatures on 12/21/22 through 12/23/22, fell to -6 ºF; and to follow its policy which pertained to the monitoring of temperatures on the unit affecting 20 residents residing on the unit. The facility census was 44 residents. Record review of the facility's undated policy entitled Internal Climate Change showed: -Purpose: To ensure residents and staff are kept as comfortable as possible during in the event there is loss of power to the facility and/or the air conditioner/heater is not functioning, causing the temperature in the facility to remain above 81 ºF or below 71 ºF. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for behavioral monitoring including target behaviors for two sampled residents (Resident's #16 and #45) and meaningful activities that address resident routines, interests, preferences and choices for five sampled residents (Resident's #16, #33, #34, #38, and #45); and to develop a comprehensive person-centered care plan that met three sampled resident's (Resident's #7, #16, and #45) medical, nursing, mental, and psychological needs out of 14 sampled residents. The facility census was 44 residents. Record review of facility Activity Program Policy, dated 6/2018, showed activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities for the residents on the locked dementia unit for three sampled residents (Resident #16, #45, and #33) out of 14 sampled residents. The facility census was 44 residents. Record review of facility Activity Program Policy, dated June 2018, showed activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 1. Record review of activity calendar on the dementia unit designated unit for residents who have Alzheimer's (disorder marked by memory disorders, personality changes, and impaired reasoning) and other types of dementia and need special care) showed: -12/19/22 at 10:30 A.M. the activity was fancy nails. -12/19/22 at 2:30 P.M. the activity was movie time. -12/20/22 at 10:30 A.M. the activity was bingo. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the area of the toilet tank (the upper portion of the toilet that holds water that flushes the toilet) where the tank lever (the handle used to flush the toilet) was located, free from a sharp edge caused by a broken area around the tank lever. The facility also failed to ensure there was a handle on the cold side of the faucet in resident room [ROOM NUMBER]. This practice potentially affected three residents who resided in those rooms. The facility census was 44 residents. 1. Observations on 12/19/22 at 9:14 A.M., and 12/21/22 at 9:59 A.M., of the toilet tank in resident room [ROOM NUMBER] showed a 2.5 inch (in.) missing area around the tank lever, which created a sharp edge. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL) form to the Missouri (MO) HealthNet within 30 days of the death of two sampled residents (Residents #97 and #98) out of six sampled residents for resident funds review. The facility census was 44 residents. 1. Record review of the Open Balance Report, printed on 12/20/22, showed Resident #97 passed away on 7/26/22 and Resident #98 passed away on 10/7/22. During an interview on 12/20/22 at 12:50 P.M., the Business Office Manager (BOM) said: - Resident #97 had $2,744.27 in his/her account on the day he/she passed away. - A check was made out for the resident's cremation on 7/27/22 for the amount of $1,209.00 - After that payment for the cremation $1,515.47 was the balance. [...]

Inspectors wroteBased on interview and record review, the facility failed to serve a Notice of Medicare Non-Coverage (NOMNC-form CMS 10123) to one supplemental resident (Resident #28) out of 14 sampled residents and four supplemental residents. The facility census was 44 residents. Record review of the facility's policy titled Medicare Advanced Beneficiary Notice, dated April 2021, showed staff were required to issue the NOMNC form to a resident at least two calendar days before his/her Medicare covered services ended. Record review of CMS.gov undated article titled Form Instructions for the NOMNC showed: -The NOMNC was to be delivered at least two calendar days before Medicare coverage ended or the second to last day of service if care was not provided daily. -The beneficiary or the representative was required to fill in the date that he/she signed the document. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for the use of a wheelchair seatbelt (are designed to maintain the pelvis in as neutral alignment as possible, to provide stability and to prevent the client from slipping), gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move). for positron of feet while in wheelchair and a half bedrail (metal rail that normally hangs on the side of the patient's bed. They are used in nursing facilities for a variety of reasons including fall preventative and positioning the resident); and to assess and document ongoing evaluation and care plan for the use bed side rails and wheelchair seat belt at least quarterly for one sampled resident (Resident #23) out of 14 sampled residents. The facility census of 44 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility, failed to update the care plans to accurately reflect the resident's current positioning needs for one sampled resident (Resident #16) out of 14 sampled residents. The facility census was 44 residents. 1. Record review of Resident #16's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Alzheimer's Disease (progressive disease involving parts of the brain that controls thought, memory, and language). -Cardiomyopathy (chronic disease of the heart muscle). -Essential hypertension (high blood pressure). -Spinal Stenosis (narrowing of the spinal canal). -Diabetes (high blood sugar). -Dementia with behavioral disturbances. -Hospice (end of life care). -Senile degeneration of brain (mental deterioration, loss of intellectual ability). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and manufacturer's instructions for insulin administration timing for one supplemental resident (Resident #27) out of 14 sampled residents and 4 supplemental residents. The facility census was 44 residents. Record review of the facility's policy titled Insulin Administration, dated September 2014, showed rapid-acting insulin had an onset of ten to fifteen minutes. Record review of Prescriber's Digital Reference's undated article Insulin Aspart rDNA origin-Drug Summary showed: -Novolog was a rapid-acting insulin. -For the treatment of adults with Type II Diabetes Mellitus, when given subcutaneously (beneath the skin), rapid-acting insulin was to be given five to ten minutes before a meal. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately track and document wounds, failed to document weekly detailed comprehensive skin assessments, and failed to obtain outside wound clinic notes that provided the monitoring of a new skin issue for one sampled resident (Resident# 23), out of 14 sampled residents. The facility resident census of 44 residents. Record review of the facility's Wound Care Policy, revised on October 2010, showed: -Verify physician orders for the resident wound care. -The following information should be recorded in the resident's medical record. --Any changes in the resident wound and how the resident tolerated the wound care. --Document all wound assessment obtained when inspecting the resident's wound to include but not limited to, wound bed color, size of the wound (measurement) and any drainage, or changes to the wound, etc. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound clinic notes that provided the monitoring of a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (a dry scab) may be present on some parts of the wound bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the overlay bolster on a low air loss mattress was monitored and fall prevention measures were in place to prevent injuries for one sampled resident (Resident #24), who was a risk for falls; failed to accurately complete and update a Safe Smoking Evaluation Assessment for two sampled residents (Resident #1 and #18); and failed to ensure resident smoking materials were stored safely for one sampled resident (Resident #18) out of 14 sampled residents. The facility census was 44 residents. Record review of the facility Fall Risk Evaluation Assessment Policy, revised 3/18, showed facility staff will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food consumption was monitored and documented for one sampled resident who was at risk for weight loss and had continued weight loss that was not significant; to provide set up assistance and encouragement to eat and drink physician ordered supplements during meals, to document the resident's meal preferences to show food items the resident would be more likely to eat as weight loss interventions; for one sampled resident (Resident #25) out of 14 sampled residents. The facility census was 44 residents. Record review of the facility's Weight Loss policy and procedure, dated March 2022, showed: -Unless notified of significant weight change, the Registered Dietician will review weight units monthly to follow individual weight trends over time. -If weight change is desired, this will be documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders for oxygen were transcribed onto the resident's physician's order sheet to include the amount and frequency of oxygen that should be provided, and to ensure the oxygen nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose) and tubing were kept covered when not in use for one sampled resident (Resident #20) out of 14 sampled residents. The facility census was 44 residents. Record review of the facility's Oxygen policy and procedure, dated October 2010, showed: -Verify that there is a physician's order for this procedure. Review the physician's orders or protocol for oxygen administration. -Review the resident's care plan to assess for any special needs of the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts and treatment carts were kept locked to prevent tampering, theft, and to ensure resident safety. This potentially affected 19 residents residing on the west unit. The facility census was 44 residents. Record review of the facility's Medication Administration policy, dated April 2019, showed: -During medication administration the medication cart is kept closed and locked when out of sight of the medication nurse or aide. -The (medication) cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 1. Observation on 12/20/22 at 8:21 A.M., showed Licensed Practical Nurse (LPN) B was on the dementia unit, at the medication cart, preparing medications for a resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food was prepared to conserve the nutritional value of the pureed chicken and rice by adding water to thin the puree rather than broth and to ensure the thickening agent was used according to the instructions to thicken pureed chicken. The facility census was 44 residents . 1. Record review of Instant Thickener product showed instructions for thickening showed to add 1 1/2 tablespoons and stir for 10 to 20 seconds (at a time) until thickened to the desired consistency. Observation on 12/19/22 at 11:11 A.M., showed [NAME] A preparing the lunch meal. The lunch meal was chicken teriyaki, rice, and steamed vegetables. There was pre-cooked chicken (chopped), rice, and steamed vegetables on the stove continuing to cook. At 11:25 A.M., the following occurred: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordination of care with hospice (end of life care) services by failing to ensure the hospice orders were transcribed to the physician's order sheet (POS) for four sampled residents (Resident #34, #38, #24, and #1) and to ensure hospice care plans were included on the resident's comprehensive care plans for two sampled residents (Resident #34 and #38) out of 14 sampled residents. The facility census was 44 residents. The facility did not provide a Hospice policy. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper hand hygiene during wound care for one sampled resident (Resident #7), failed to maintain proper hand hygiene during personal care and failed to ensure proper catheter drainage bag (is a flexible tube used to empty the bladder and connect to drainage bag to collect urine) placement (below the bladder) during care for one sampled resident (Resident #23), who was at risk for infection out of 14 sampled residents. The facility census was 44 residents out of 14 sampled residents. The facility census was 44 residents. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated August 2019, showed: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. [...]