Meadow View Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to ensure utensils, beverage dispensers, and food preparation items/equipment were kept in a sanitary condition; failed to maintain plastic and/or rubber cutting boards, plate covers, room trays, and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs, 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 87 residents with a licensed capacity for 120 residents at the time of the survey. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate medication and medical equipment storage in two out of five medication carts and in one out of two medication storage rooms. The facility census was 87 residents. Review of the facility's undated policy titled Storage pf Medications showed:-Drugs and biologicals were stored in the packaging, containers or other dispensing systems in which they are received. -Only the issuing pharmacy was authorized to transfer medications between containers.-Drug containers that had missing, incomplete, improper, or incorrect labels were returned to the pharmacy for proper labeling before storage. -Discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure orders were in place for self-administration of medication for one sampled resident (Resident #81) and one supplemental resident (Resident #47); and failed to ensure an assessment for self-administration of medication was in place for one supplemental resident (Resident #47) out of 18 sampled residents and seven supplemental residents. The facility census was 87 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store a Bilevel Positive Airway Pressure (BiPAP a machine that helps you breathe) mask and a nasal cannula (NC a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose) in a plastic bag for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 87 residents. A policy was requested on BiPAP mask storage and NC storage and was not received by the time of exit. 1. Review of Resident #25's admission Record showed he/she was admitted to the facility with the following diagnosis: [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled residents (Resident #59) 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), and one sampled resident (Resident #66) who had a positive finding on the trauma/abuse/neglect screening out of 18 sampled residents. The facility census was 87 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident shower rooms were kept clean, maintained and free from build-up of black mold like/grime on the lower corner of the shower wall and shower floor tile located on 200 hallway; failed to ensure shower room was maintained and showed missing base board shower tiles and missing tile on memory care floor of the shower room and missing tile in the shower itself. This practice potentially affected all resident residents who used those shower rooms. The facility census was 82 residents. Review of the facility's undated Daily Cleaning of Guidelines showed: -The facility were complete regular inspect the shower room for signs of mold (often appearing as black, brown, or green stains), mildew and clogs. -If mold or mildew return after cleaning report to maintenance immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) with limited range of motion (ROM) received restorative therapy services to prevent further decrease in his/her ROM out of 10 sampled residents. The facility census was 91 residents. Review of the facility's policy titled Restorative Nursing Services dated July 2017 showed: -Residents would receive restorative nursing care as needed to promote optimal safety and independence. -Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services. -Residents may be stared on restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. -A restorative goal may have included maintaining his/her dignity and self-esteem. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staffing numbers to consistently provide timely Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) assistance for two sampled residents (Resident #77 and Resident #69) out of 18 sampled residents and ADL-dependent residents on the [NAME] Side of the building and to ensure adequate weekend staffing as reflected on the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the fourth quarter of 2023 (July 1 - September 30, 2023) and first quarter of 2024 (October 1 - December 31, 2023) which had the potential to affect all residents. The census was 88 residents. Review of the facility's Staffing policy, revised October, 2017 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floor under the refrigerator in the storage room, free of heavy dust buildup; failed maintain the sprinkler heads over the handwashing sink and the food preparation, free of dust buildup on the sprinkler heads; failed to remove a buildup of grime from under the deep fat fryer; failed to maintain the gaskets (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects) of the walk-in freezer and the reach-in refrigerator across from the food preparation table in good repair; failed to maintain the ceiling vents in the kitchen free of a heavy buildup of dust; failed to maintain the handles of the food spatula in good repair; failed to maintain the nozzle of the upper spray wand of the dishwasher; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the floors free from a heavy buildup of dust and debris in the following resident rooms 208, 207, 302, 300, 601, 510, 500 Hall shower room, 607, 405, 410, 409, 407, 401; failed to maintain the fans free of a heavy buildup of dust in the following resident rooms 302, 301; and failed to maintain ceiling vents free of a heavy buildup of dust in the following resident rooms 405 and the 500 Hall shower room . This practice potentially affected at least 30 residents who resided in or used those areas. The facility census was 88 residents. 1. Review of the undated Housekeeping Route sheet (a sheet which showed the steps to clean the resident rooms), showed: 7-Step room cleaning: 1. Pull Trash. 2. Dust horizontal surfaces. 3. Sanitize high traffic areas. 4. Spot clean walls. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a system in place for monitoring shower/bathing related to Activities of Daily Living (ADL's- grooming, bathing, hygiene), and to ensure baths or showers were provided at as scheduled for five sampled residents (Resident #6, #32, #58, #76, and #85) out of 18 sampled residents. The facility census was 88 residents. Review of undated facility policy entitled Bath, Shower/tub showed: -The purpose was to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. -Complete bathing per residence preference (shower or bath). -Document the time the shower/tub bath was performed. -Document the name and title of the individual(s) who assisted the resident with shower/tub bath. -Document all assessment data. -Document how the resident tolerated the shower /tub bath. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to cook broccoli florets so they would not be mushy; failed to follow the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) broccoli, so the broccoli would be palatable; and failed to maintain room trays at the 600 Hall and the 300 Hall at or close to 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least 13 residents. The facility census was 88 residents. 1. Review of the recipe for pureed broccoli florets, dated 9/1/15, showed: - Steam broccoli 15-25 minutes until tender. - Drain broccoli, in large mixing bowl, and toss broccoli with margarine and season with salt and pepper. - Transfer to service pans and hold at a temperature of 135 ºF or greater. - Puree step: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of the following resident rooms: 106, 102, 210, 209, 206/204, 205, 311/309, and 302/304. This practice potentially affected at least 20 residents who resided in those rooms. The facility census was 88 residents. **Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn up then negative air flow was present; if the paper was not drawn to the ceiling vent, then negative airflow was absent. 1. Observations with the Maintenance Director and the Regional Maintenance Person on 5/21/24, showed: -At 9:52 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER]. -At 9:57 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for the setting of the low air loss mattress (LAL - a mattress designed to distribute weight over a broad surface and help prevent skin breakdown. It has continuous air flow through tiny holes on the mattress surface) for one sampled resident (Resident #77) who had developed a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) out of 18 sampled residents. The facility resident census was 88 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation of refusal of enteral feeding via feeding tube called Percutaneous endoscopic gastrostomy (is a surgery to place a feeding tube also called a PEG or G-tube) and physician order for total amount caloric formula to be given in a 24 hour period, for one sampled resident (Resident #4) who's at risk for weight loss due to decline health, refusal of treatment and cares out of 18 sampled residents. The facility resident census of 88 residents. Review of the facility Policy for Medication Orders revised on 11/2014 showed: -Enteral feedings orders: when recording orders for enteral tube feedings, specify the type of feeding, amount, frequencies of the feeding and rationale if as needed. -The order should always specify the amount of flushing following the feeding. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to puree (to make food into a paste or a thick liquid suspension which is made from finely ground cooked food) turkey into a smooth texture that was not stringy. This practice potentially affected three residents with pureed diets. The facility census was 88 residents. 1. Review of the recipe for pureed turkey showed: - Place turkey roasts in oven at a temperature of 375 ºF (degrees Fahrenheit) and roast for 3-4 hours. [NAME] until an internal temperature of 165 ºF was reached. - Remove from oven and allow turkey breast to rest for 15 minutes prior to carving. - Hold at 135 ºF or greater, for service. - For pureed step do the following: Remove the desired number of servings and add nutritive liquid such as milk, broth etc. Blend until desired consistency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free from accident hazards by not assessing for safe smoking practices for one sampled resident (Resident #340) out of 19 sampled residents. The facility census was 95 residents. Record review of facility's undated policy titled Smoking Policy and Acknowledgement showed: -All residents must be supervised by a facility staff member or personal family member at the designated location. -Smoke breaks were outside in a designated area. -Facility staff member would only supervise smoke breaks at the designated times. -The policy did not include a safe smoking assessment was to be performed for the resident who smoked or be assessed for any special equipment the resident needed while he/she smoked. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #81) was free from abusive acts when one sampled resident (Resident #25) who had a known history of aggression, anger issues, yelling, hitting and kicking other residents struck the resident in his/her face causing reddened areas to his/her left cheek, nose and the left side of his/her upper lip with a small amount of blood noted out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring policy revised 3/2019 showed: -The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, assess, monitor and treat non-pressure wounds to the right great toe, the right little toe, the right ankle, the right Achilles tendon (fibrous tissue that connects the calf muscles to the heel bone)) and multiple scabbed areas over the resident's bilateral shins resulting in the non-pressure wounds worsening over the 42 day delay before treatment started for one sampled resident (Resident #14); to ensure the charge nurse reviewed and followed up with lab results for a resident suspected of having Clostridium Difficile (C. Diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately assess, monitor, document and provide treatment that includes ongoing appropriate interventions related to the resident's behaviors; to ensure monthly psychiatric visits were in the medical record and reviewed by the staff; to ensure supportive services were in place and to have an individualized care plan based on the resident's behaviors of two sampled residents (Resident #14 and #25) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring policy revised 3/2019 showed: -The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and self-worth for three sampled residents (Resident #14, #44 and #81) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility Resident rights policy revised 12/2016 showed the resident had the right to be treated with kindness, respect, and dignity. 1. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of residents needs and preferences to create a home-like environment by serving meals on Styrofoam plates or container and serving beverages in Styrofoam cups for six sampled residents (Resident #3, #340, #14, #44, #84 and #72) out of 19 sampled residents. The facility census was 95 residents. Record review of facility policy entitled Homelike Environment revised February 2021 showed: -Residents were provided with a safe, clean, comfortable and homelike environment. -Staff provided person-centered care that emphasized the residents' comfort, independence and personal needs and preferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote the right to self-determination and choices by not providing access to food when hungry and/or reasonable access to beverages for seven sampled residents (Residents #12, #21, #87, #14, #44, #3, and #4); and to assist with getting out of bed, getting dressed, and taken to the dining room when requested for one sampled resident (Resident #14) out of 19 sampled residents. This potentially effected all facility residents who were able to consume beverages and food provided by the facility kitchen. The facility census was 95 residents. Record review of the facility Resident Rights policy revised December 2016 showed the following rights: -A dignified existence. -Be treated with respect, kindness and dignity. -Self-determination. Record review of the facility Dignity policy revised February 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry checks were completed to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) in accordance with the state and federal regulation prior to hire on four out of ten employees sampled. The facility census was 95 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Comprehensive Care Plan meetings were held on admission and quarterly and to the extent practicable, the participation of the resident and the resident's representative(s), and an explanation was not included in the residents medical record why the participation of the resident and residents representative was determined to impractical for the development of the resident's care plan for three sampled residents (Resident #3, #68, and #84) out of 19 sampled residents. This potentially effected all facility residents who could participate in care plan meetings. The facility census was 95 residents. Record review of facility policy titled Care Planning-Interdisciplinary Team revised September 2013 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Acetaminophen (an over the counter pain medication) orders were clarified to include parameters (a numerical or other measurable factor) for maximum dose per day for four sampled residents (Resident #68, #37, #72 and #84); and to ensure the pain medication order was confirmed and continued upon admission to the facility for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility Acute Condition Changes - Clinical Protocol policy, revised March 2018 showed: -The physician and nursing staff would review the details of any recent hospitalization. -The physician would help identify medications and medication combinations that were associated with adverse consequences that could cause significant changes in condition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staffing levels were adequate to meet the needs of the residents based on their acuity; and to ensure staffing levels were adequate to get residents dressed, out of bed, and to meals for two sampled resident (Resident #14 and #81) out of 19 sampled residents. This deficient practice potentially affected all residents who needed assistance with Activities of Daily Living(ADL's-dressing, transfers eating, mobility). The facility census was 95 residents. Record review of the facility's staffing policy dated 10/2017 showed: -The facility provided sufficient numbers of staff with the skills and competency necessary to provide care an services for all residents in accordance with resident care plans and facility assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were not subjected to unnecessary psychotropic medications (drugs which affect psychic function, behavior, or experience); to ensure pro re nata (PRN, as needed or indicated) antipsychotic medications (a group of drugs affecting mental functioning such as mood, behavior, or thinking processes, commonly used to treat psychosis) were not prescribed for more than 14 days; to ensure an oral medication was ordered to try a lower dose of medication for behaviors; and to ensure non-pharmacologic interventions were implemented prior to administering PRN Intramuscular (IM) antipsychotic medication for two sampled residents (Resident #25 and #14); and to ensure documentation showed monitoring of behaviors and response to medications for one sampled resident (Resident #68) out of 19 sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had sufficient alternate food choices at breakfast including one sampled resident (Resident #3) out of 19 sampled residents. This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 95 residents. Record review of the facility's Frequency of Meals policy revised 7/2017 showed alternate meals would be offered to residents who choose to eat non-traditional or outside of scheduled meal times. 1. Record review of the facility's undated Spring/Summer Menu Cycle showed: -The breakfast meal was outlined daily with food and beverages. -There was no alternate meal listed for breakfast. Record review of the facility's untitled, undated, alternate menu showed: -The alternate meal choices were lunch and dinner items. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's wishes for advanced directives related to a Do not Resuscitate (DNR a directive indicating that, in case of respiratory or cardiac failure, the resident or legal representative had directed that no cardiopulmonary resuscitation (CPR - a lifesaving technique involving hard, fast chest compressions and/or rescue breaths/oxygen supplementation used when someone's breathing or heartbeat has stopped) code statuses were communicated to direct care staff and the physician and were reflected on the Physician Order Sheet (POS) and Care Plan for one sampled resident (Resident #42) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Advanced Directives policy, revised 12-16-22 showed: [...]

Inspectors wroteBased on interview and record review, the facility to failed to notify the resident's physician when there was a missed medication and when blood sugars continued to be elevated for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 residents. Record review of facility policy titled Change in a Resident's Condition or Status revised February 2021 showed: -The facility would promptly notify the resident, his/her attending physician, and the resident representative of a change in the resident's medical/mental condition and/or status. -The nurse would notify the resident's attending physician when that had been: -A need to alter resident's medical treatment significantly. -Significant change in the resident's physical condition. -A significant change of condition is major decline in the resident's status that: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations of resident abuse were reported to the State immediately or no later than two hours after the allegation was made for an incident of abuse involving two out of 25 sampled residents. Resident #25 was witnessed punching Resident #81, resulting in a bloody nose requiring an emergency room (ER) visit. The facility census was 99 residents. Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed staff are required to immediately report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, and misappropriation of resident property, mistreatment or a crime against a resident. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate allegations of resident abuse by not conducting interviews and/or obtaining statements from all witnesses and by not reviewing pertinent information from nursing notes and incident reports and using the information to determine if abuse occurred. This deficient practice affected two residents (Resident #81 and #11) out of 25 sampled residents. The facility census was 99 residents. Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed: -The Administrator will ensure any further potential abuse is prevented. -The individual conducting the investigation will, at minimum: --Review completed documentation. --Review the resident's medical record to determine events leading to incidents. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a discharge including the reason for the transfer for one sampled resident (Resident #90) out of three sampled closed records. The facility census was 95 residents. 1. Record review of Resident #90's admission Record showed the resident: -Was admitted to the facility on [DATE] with a diagnosis of lung cancer. -Was at the facility for a rehabilitation stay. Record review of the resident's Discharge Instructions for Care form dated 8/1/22 showed the resident was being discharged to home. Record review of the resident's Progress Notes on 9/19/22 showed no information regarding a discharge transfer notice being given to the resident. During an interview on 9/20/22 at 9:24 A.M. Registered Nurse (RN) B said: [...]

Inspectors wroteBased on interview, record review, the facility failed to ensure the follow through of the Pre-admission Screening and Resident Review (PASARR) recommendations and integrate the recommendations into the care plan for one sampled resident (Resident #90) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Behavioral Assessment, Intervention and Monitoring policy revised 2019 showed the Level II PASARR report would be used when conducting the resident assessment and developing the care plan. 1. Record review of Resident #90's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or his/her representative with a copy of the baseline care plan for one sampled resident (Resident #341) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility policy Care Plans-Baseline revised December 2016 showed: -A baseline care plan to meet the resident's immediate needs would be developed for each resident within 48 hours of admission. -The interdisciplinary team would review the health practitioner's orders and implement a base line care plan that met the resident's immediate care needs. -The baseline care plan would be used until staff conducted the comprehensive assessment and developed an interdisciplinary person-centered care plan. -The resident and his/her representative would be provided a summary of the baseline care plan. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a recapitulation of stay was completed; to have a clear discharge plan after a rehabilitations stay, and to document the disposition of belongings upon discharge for one sampled resident (Resident #90) out of three sampled closed records. The facility census was 95 residents. Record review of the facility's policy Discharge Summary and Plan revised 12/2016 showed: -When the facility anticipated a resident discharge to a private residence, a discharge summary and post-discharge plan would be developed. -The discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status upon discharge. 1. Record review of Resident #90's admission Record showed the resident: -Was admitted to the facility on [DATE] with a diagnosis of lung cancer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing resident-centered activities program that provided daily meaningful involvement in activities of choice and included opportunities for individual expression, creativity, enjoyment, success and a sense of belonging and enhanced the physical, cognitive, and emotional well-being for two sampled residents (Residents #81 and #25) who could benefit from daily 1:1 and/or small group activities out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Activity Evaluation policy, revised June, 2018 showed: -An activity evaluation is conducted as part of the resident's comprehensive assessment that reflects the choices and interests of the resident and is used to develop an individual activities care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed for pressure-reducing boots for one sampled resident (Resident #81) who had a Pressure Injury (PI - localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) out of 19 sampled residents. The facility census was 95 residents. Record review of the National Pressure Injury Advisory Panel (NPIAP) definition of a Deep Tissue Injury showed: -A Deep Tissue Injury (DTI) was defined as intact or non-intact skin with localized area of persistent non-blanchable (skin that does not turn white when pressed) deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys were not able to filter the blood) receives ongoing assessments of the dialysis site, accurate description of resident's the dialysis site, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one sampled resident (Resident #341) out of 19 sampled residents. The facility census was 95 residents. Record review of facility policy Hemodialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) Access Care policy revised September 2010 showed: -Central dialysis catheters (type of access used for Hemodialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 25 observed medication opportunities, two errors occurred during insulin (Insulin is a hormone that lowers the level of glucose (a type of sugar) in the blood) administration resulting in an error rate of 8%. The facility census was 95 residents. Record review of the facility Insulin Administration policy revised September 2014 showed: -Onset of action is the characteristic of how quickly a type of insulin reaches the bloodstream and begins to lower blood glucose (sugar). -Rapid-acting insulin has an onset of 10 to 15 minutes. Record review of the facility Administering Medications policy revised April 2019 showed: -Medication administration times are determined by resident need and benefit, not staff convenience. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were free of significant medication errors by ensuring Intravenous (IV) medications were administered as ordered for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 resident's Record review of policy titled Administering Medications revised April 2019 showed: -The Director of Nursing (DON) supervised and directed all personnel who administered medications and/or related functions. -Medications were administered in accordance with the prescriber's orders, and included any required time frames. -Medication errors were documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) team. Record review of facility policy titled Administered Medications by IV push revised March 2022 showed: [...]