Nathan Richard Health Care Center

Inspectors wroteBased on interview and record review, facility staff failed to ensure each resident received necessary behavioral health care and services to attain or maintain highest practicable mental and psychosocial well-being when the facility failed to have process in place to monitor repetitive behavior, failed to document new interventions to address repetitive behaviors, and failed to document behavioral services offered to address behaviors of one resident (Resident #1) who had continued behaviors of inappropriate language directed at or around staff and residents. The facility had a census of 62. Review of the facility policy titled, Behavioral Health Services Policy, revised 10/31/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe when the facility failed to report a verbal altercation/threat involving two residents (Resident #1 and Resident #2 ). Four residents were sampled. The facility census was 60. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received care per standards of practice when staff failed to address one resident's (Resident #45) change in condition timely. The resident's baseline was alert and oriented and cognitively intact. He/she experienced a change which resulted in the resident being unable to respond to questions, unable to feed him/herself, unable to lift his his/her own feet, and unable to express his/her own desires/wishes. The staff failed to send the resident out emergently, failed to follow-up with the physician when the physician did not return an office message, and failed to reach out to the medical director regarding the change of condition on the day the changes were observed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care of pressure ulcers per standards of practice, when staff failed to have processes in place to ensure consistent, accurate, and thorough wound assessments were completed upon discovery and weekly; to complete weekly wound tracking; to complete accurate and timely entries of wound treatments; and to complete wound treatments as ordered for one resident (Resident #22) who had a facility acquired wound that required wound care specialist treatment and was considered for foot amputation. The facility census was 59. Review of the facility's policy titled Wound Treatment Management Policy, reviewed 05/18/24, showed the following: -Policy purpose was to promote wound healing of various types of wounds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours to allow the DON to complete the duties of DON when the DON frequently had to work as the charge nurse. The facility census was 59. Review of the facility's job description titled Director of Nursing, undated, showed the following: -The DON provides leadership and direction for overall medical care to provide quality patient care in accordance with all laws, regulations, and the management company; -DON duties were to oversee the nursing staff and overall nursing operations of the healthcare facility; -Duties included evaluating and directing all nursing employees, establishing goals for the nursing department, and creating and enforcing compliant healthcare policies; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner to protect food from possible contamination, when staff failed to use effective hair restraints; failed to consistently label and date food; failed to wash hands and equipment appropriately during food prep; failed to ensure food kept in mini refrigerators in resident rooms was not expired or spoiled; and when staff failed to ensure non-food contact surfaces in the kitchen were clean and maintained in good repair. The facility census was 59. 1. Review of the facility's policy titled, Dietary - Receiving and Storing Food and Supplies, revised 06/30/23, showed the following: -Food items will be received and handled in accordance with good sanitary practice; -Food items will be stored, thawed, and prepared in accordance with good sanitary practice; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that a written transfer agreement with a hospital was in effect to ensure residents timely admission to the hospital when medically appropriate and that information would be exchanged between providers. The facility census was 59. Review showed the facility did not provide a policy pertaining to written transfer agreements with a hospital or a written transfer agreement with a community hospital. During an interview on 02/27/25, at 3:30 P.M., the Administrator said he/she had not been able to locate a written transfer agreement. When the facility changed to new ownership in 2020, the facility applied at two local hospitals with no response. The facility had transfer agreements with other nursing homes and churches for emergency evacuation.

Inspectors wroteBased on interview and record review, the facility failed to provide continued training for certified nursing aides (CNAs) that included competency evaluation as part of the required minimum 12 hours of in-service education per year. The facility census was 59. Review showed the facility did not provide a policy related to in-service training. 1. Review of the facility's In-Service Training Records, on 02/27/25, showed no CNA competency evaluations. During an interview on 02/28/25, at 9:35 A.M., CNA L said he/she had attended in-services and training with the Administrator and Director of Nursing (DON). They will often demonstrate during the training, but he/she was not aware of being observed for proper care of residents. During an interview on 02/27/25, at 2:50 P.M., the DON said in-services and training included in-person and online training that was assigned to each staff member. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse and neglect prevention policies, when they failed to complete criminal background checks (CBC) for five sampled staff (Maintenance J, Registered Nurse (RN) E, RN F, Dietary Aide (DA) H, and Housekeeper I). The facility also failed to complete employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) checks for three sampled staff (RN E, RN F, and DA H) and failed to complete the Nurse Aide (NA) Registry check for two sampled staff (RN E and RN F) to ensure the staff did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to establish and maintain an effective infection control program, when nursing staff failed to practice proper hand hygiene and infection practices while performing wound care for three residents (Residents #22, #31, and #13) and during catheter (a tube inserted in the bladder allowing your urine to drain freely) care for one resident (Resident #45) and when staff failed to gown as required for four residents (Residents #22, #31, #13, #45 ) who had enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO-microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and complete antibiotic stewardship program, when staff failed to track residents on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections including three residents (Residents #13, #31, and #45) identified as currently or recently on an antibiotic. The facility census was 59. Review of the facility policy Antibiotic Stewardship Program, revised 06/29/23, showed the following: -Purpose was to optimize antibiotic use in the nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach; -At minimum, the antibiotic stewardship program (ASP) will be comprised of the Director of Nursing (DON), a nurse with administrative duties, and a charge nurse; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received care per professional standards of practice, when staff failed to have processes in place to obtain ordered blood tests in a timely fashion for one resident (Resident #17) out of a total sample of 17 residents. The facility census was 59 . Review of the facility's policy titled, Diagnostic Testing Services Policy, dated 06/26/24, showed the following: -The facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain overall health of its residents and in accordance with State and Federal guidelines; -The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when staff failed to obtain and administer medications as ordered for one resident (Resident #41). The facility census was 59. Review showed the facility did not provide a policy regarding pharmacy services or obtaining medications for administration. Review of Resident #41's face sheet showed the following: -admission date of 03/1/24; -Diagnoses included chronic kidney disease stage 5 (damage to kidneys and less likely to filter waste and fluid out of the blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/8/24, showed the following: -Cognition intact; -Renal (kidney) failure; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded in a timely manner to pharmacist recommendations during the monthly pharmacist review, when the physician did not address the pharmacist recommendation to discontinue one medication not recommended for use in the elderly due to its anticholinergic side effects (causing falls and confusion) for one resident (Resident #12) in a timely manner. The facility census was 59. Review showed the facility did not provide a policy regarding the pharmacy medication review and recommendation process. Review of Resident #12's face sheet showed the following: -admission date of 08/15/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate not greater than 5%, when facility staff crushed extended release tablets for one resident (Resident #23) and when staff did not administer a medication for one resident (Resident #41). This resulted in two errors out of 36 opportunities and medication error rate of 5.56%. The facility census was 59. Review of the facility policy Medication Administration Policy, revised 6/26/24, showed medications that typically should not be crushed included sustained-release or extended-release medications. 1. Review of the Drugs.com warnings for Potassium Chloride, updated 02/29/24, showed the following: -Do not crush, chew, break, or suck on an extended-release tablet or capsule. Swallow the pill whole. -Breaking or crushing the pill may cause too much of the drug to be released at one time. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete medical record for all residents, when staff failed to document in the medical record a change in condition and transfer to the hospital for one resident (Resident #1). The facility census was 59. Review of the facility's policy titled, Resident Transfer, Discharge, Immediate Discharge and Therapeutic Leave Policy, dated 05/14/24, showed with the exception of ceasing to operate, the resident's medical record must be documented with the reason(s) for any facility-initiated transfer or discharge. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 02/05/25; -Diagnoses included essential hypertension (high blood pressure), edema (swelling caused by fluid building up in body tissues, and presence of cardiac pacemaker. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies to assure all residents were given the opportunity to receive pneumococcal vaccinations (pneumonia vaccines) when staff did not document offering the vaccine to two residents (Residents #11 and #31). The facility census was 59. Review of the Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccine, dated 10/26/24, showed the following: -There are two types of vaccines recommended to help prevent pneumococcal disease in adults; -One type of vaccine is the pneumococcal conjugate vaccines (PCVs): PCV15,PCV20,and PCV21; -One type of vaccine is the pneumococcal polysaccharide vaccine (PPSV23); -For older adults who received PCV13 and PPSV23, they have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. [...]

Inspectors wroteBased on observation, interview, document and policy review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to protect 21 residents (R46, R8, R2, R5, R16, R31, R30, R22, R17, R14, R19, R35, R36, R52, R26, R43, R211, R57, R7, R38, and R10) who required blood glucose monitoring from potential blood-borne pathogens (serious infections caused by exposure to infectious organisms) by failing to disinfect the glucometers between the blood glucose testing of the 20 residents. On 06/15/23 at 2:50 PM, the Administrator and Director of Nurses (DON) were notified that the failure to ensure glucometers shared among multiple residents were disinfected with an appropriate cleaning agent that ensured the removal of blood borne pathogens and viruses constituted Immediate Jeopardy at F880: Infection Control. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the light covers above the steam table and food preparation table clean; failed to seal opened bags of food; failed to discard dented cans of food; and failed to ensure food storage containers were clean. These failures had the potential to affect 57 residents who consumed food prepared from the facility's kitchen. The facility census was 58.

Inspectors wroteBased on observations, interviews, record review, and tasting of foods on a requested test tray, the facility failed to provide food that was palatable and at an appetizing temperature for five (Resident (R) 26, R48, R50, R52, and R17) out of a total of 37 residents. This failure had the potential to affect residents on one of two halls who were served room trays. The facility census was 58.

Inspectors wroteBased on record review and staff interviews, the facility failed to update the electronic medical record (EMR) and Nurse Aide (NA) reference book for one of one resident (Resident (R) 46) reviewed for Advance Directives to reflect the resident's choice to change from a full code(life saving measures including cardiopulmonary resuscitation (CPR) to a do not resuscitate(DNR) status out of a total sample of 37 residents. The failure to update the EMR and NA reference book increased the risk that R46's end of life wishes would not be honored and unwanted care and services would be provided. The facility census was 58.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide a notice of bed hold to two (Resident (R) 46 and R29) of two sampled residents reviewed who were transferred to the hospital. The facility census was 58.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive care plan for three of fifteen sampled residents (Resident (R) R9, R10, and R36) for oxygen usage, communication, and behavior management out of a total sample of 37 residents These failures created the potential for medical and psychosocial needs to be unmet. The facility census was 58.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that a care plan for falls was updated for one of one resident (Resident (R) 38) reviewed for falls. After a fall there were no updates or interventions added to R38's care plan. The facility census was 58.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure an incident report and investigation was completed following a fall for one of one resident (Resident (R)38) reviewed for falls. This failure placed the resident at greater risk of more falls and not know the reason for the falls. The facility census was 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measure for the storage and changing of oxygen tubing for two of two (Residents (R) 9 and R52) residents reviewed for respiratory care. Oxygen tubing was stored without being placed in a bag and was not changed weekly. The facility census was 58.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure pharmacist recommendations were acted upon for two of five residents (Residents (R)38 and R41) reviewed for unnecessary medications. The pharmacist made recommendations to discontinue medication and to add some direction to another for R38 and R41. This deficient practice had the potential to allow residents to continue medications may have adverse consequences. The facility census was 58.

Inspectors wroteBased on observation, record review, document review, and policy review, the facility failed to ensure the medication error rate was less than 5% due to two medication errors (Resident (R) 46 and R31) out of 27 medications observed delivered to residents. The facility's medication error rate was 7.4%. The facility's failure to follow the manufacturer's instructions to prime the insulin pens resulted in incorrect insulin dosing and failure to follow physician orders. The facility census was 58.

Inspectors wroteBased on interview and review of the Facility Assessment and facility policy, the facility failed to ensure the Facility Assessment was reviewed and updated. This deficient practice could allow the facility to use resources and provide the needed services for residents. The facility census was 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to ensure the air gap for two ice machines in the facility had the required two inch gap between the drain in the floor and the tubing from the ice machine. The facility had a census of 38 residents. 1. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. Observation on 11/03/2020, at 12:23 P.M., showed the ice machine in the kitchen had the following: -Ice machine located near the kitchen door had two drain pipes below the floor level; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a risk assessment to include alternative interventions attempted prior to the use of side rails, obtain informed consent for the use of side rails, and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Resident #1, #2, #5 and #36) out of a sample of 16 residents. The facility census was 38. Record review of the facility's policy entitled, Bed Siderails (last revised 11/2017) showed the policy included the following information: -Purpose: To ensure all bed side rails in use have been evaluated for safety; -All residents using any size siderail device on their beds will have a Restraint/Entrapment Assessment completed to determine the restraining, enabling, or hazard effect of the device. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made four errors out of 25 opportunities resulting in an error rate of 16% when staff failed to prime the insulin pens for three residents (Resident #9, #14, and #25). The facility census was 38. Record review of the Novolog Flexpen (name brand for insulin aspart [rDNA origin] injection) manufacturer's website, dated May 2016, showed the product is a man-made insulin used to control high blood sugar in adults and children with diabetes. Instruction for use included the following: -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle, pull of the paper tab, push and twist the needle on until it is tight. Pull off both needle caps; -Prime the pen - Turn the dose selector to select two units. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for three residents (Resident #9, #14, and #25) during random medication pass observations. The facility had a census of 38. Record review of the Novolog Flexpen (name brand for insulin aspart [rDNA origin] injection) manufacturer's website, dated May 2016, showed the following information: -This product is a man-made insulin used to control high blood glucose levels (sugar) in adults and children with diabetes mellitus; -Instruction for use include; -Pull off the pen cap and wipe the rubber stopper with an alcohol swab; -Attach a new needle. Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps; -Prime the pen. Turn the dose selector to select 2 units. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications according to professional standards and manufacturer's guidelines when staff failed to note when a vial of insulin was opened for three residents (Resident #11, #25, and #26 ) and failed to discard expired or discontinued insulin for one resident (Resident #11). The facility census was 38. Record review of the facility's policy titled, Administering Medications, dated [DATE], showed the policy included the following information: -Medication must be administered per physicians' orders. All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants, when staff failed to use appropriate hand hygiene during incontinence care for two residents (Resident #2 and #40), failed to perform hand hygiene when assisting multiple residents and failed to wear facemasks appropriately with meal trays and meal assistance, including seven residents (Resident #1, #4, #12, #14, #16, #18, and #34) in the dining room, failed to use appropriate hand hygiene during blood glucose testing and/or failed to properly disinfect glucometers (small hand-held devices that check blood glucose levels in residents) between resident use for eight residents (Resident #9, #11, #14, #15, #21, #24, #25, and #40) and failed to complete appropriate hand hygiene [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect when they did not provide a dignity bag for one resident (Resident #5) with an indwelling urinary catheter (tubing placed internally to drain the bladder). A sample of 12 residents was selected for review; the facility census was 38. Record review of the facility's (undated) policy titled, Nursing Urinary Catheter Care, showed the following information: -Resident with indwelling catheters will receive catheter care every shift or as ordered by the physician; -Catheter bags are to be placed in privacy bags to promote the resident's dignity. 1. Record review of Resident #5's face sheet (general information at a quick glance) showed the following information: -admission date of 10/19/2015; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for two residents (Resident #31 and #36). A sample of 16 residents was selected for review out of a facility with a census of 38. Record review of the facility's policy entitled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy (last revised 5/2018), showed the following information: -Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected; -Before any resident is transferred or discharged under a Facility-Initiated Transfer or Discharge, the facility must: [...]

Inspectors wroteBased on record review and interview, the facility failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Resident #31 and #36). A sample of 16 residents was selected for review out of a facility with a census of 38. Record review of the facility's policy entitled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy (last revised 5/2018), showed the following information: -When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy. This notice must be given at the time of transfer, or within 24 hours of emergency transfers; [...]