Nodaway Healthcare

Inspectors wroteBased on interview and record review, the facility failed to treat one sampled resident, Resident #1 with dignity and respect when a staff member transferred the resident from a chair to bed without securing the assistance of another staff member or use a gait belt, as directed in the residents plan of care, and put the resident to bed when the resident was not ready to go to bed. This affected one of four sampled residents (Resident #1). The facility census was 20. On 4/21/2026, the Administrator was notified of the past noncompliance which occurred on 4/5/26. On 04/05/2026, facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented to include a facility wide in-service that included abuse, resident rights, compliance and ethics policy, elder abuse hotline Number, gait belts, and call lights. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This had the potential to affect all residents. The facility census was 30. The facility did not provide a policy for RN coverage. Review of the facility's Payroll Based Journal data (PBJ - a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2025 (January 1 - March 31) showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29 and 3/ 30. Review of staffing schedule for February 2025 showed no RN on the day: 2/23. Review of the staffing schedules for March 2025 showed no RN on the following days: 3/2, 3/16, 3/29 and 3/30. During an interview on 8/5/25 at 9:52 A.M., the Regional Nurse said she knew something was not right with the PBJ and did not think it had been filled out correctly. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to complete Tuberculosis (TB) skin testing for three out of ten employees. The facility additionally failed to establish and maintain an effective water management program to aide in identifying and reducing the risk of Legionella and other waterborne pathogens that can grow and spread and lead to Legionnaires' disease (a type of serious pneumonia caused by a type of bacteria called Legionella.) The facility census was 30. Review of the facility's Employee TB Screening and interpretation of Results Policy, Revised July 2010 showed: All employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test (TST) prior to beginning employment. The need for annual testing shall be determined by the annual TB risk classification or as per State regulations. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two of the 12 sampled residents reviewed for unnecessary medications, (Resident #3 and #33) and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 30. Review of the facility's policy for antipsychotic medication use, revised December 2016, showed: - Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. [...]

Inspectors wroteBased on observation and interview the facility failed to promote an environment respectful of the rights of each resident to make choices, when six out of six residents in a group interview were concerned about specific aspects of their life when staff did not offer a bedtime snack to the residents. This potentially affected all residents who would like a snack. The facility census was 30. Review of facility Resident Nutrition Services Policy, dated November 2015, showed snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. Review of facility Resident Rights Policy, undated policy included federal and state laws guarantee certain basic rights to all residents of this facility. [...]

Inspectors wroteBased on observation and interview, during a group interview six out of six participants said the facility failed to protect resident rights when the facility did not prominently display information on how to file a grievance or how to call or contact the Missouri Adult Abuse & Neglect hotline in the facility for its residents. The facility census was 30. Review of facility policy, Resident and Family Concerns and Grievances Policy and Procedure, dated 2020, showed the facility will notify residents, individually or through posting in prominent locations throughout the facility, of the right to file a grievance. The notification must include the following information: Contact information for the relevant state agency or Ombudsman program for filing a complaint. Review of facility policy, Resident Rights, not dated, showed; [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to maintain the privacy of three of the 12 sampled residents (Resident #15, #2 and #30), when staff failed to post signage at the front door, and outside each sampled residents room to indicate 24 hour camera surveillance was in progress and failed to obtain consents from (#15) and (#30)'s responsible party. The facility census was 30. The facility failed to provide a policy for video surveillance with or without audio. Interview, observation and record review of resident #15, on 08/05/25 at 1:45 P.M. showed: Resident is alert and orientated to self and place, uses a walker with ambulation and wants to be as independent as possible. Resident is his/her own person and able to make his/her own decisions. Resident has diagnosis of: [...]

Inspectors wroteBased on the interview and record review, the facility staff failed to check the Certified Nurses Assistant (CNA) Registry for nine of 10 sampled staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). this affected 10 of 10 sampled staff (Licensed Practical Nurse(LPN) B, Certified Medication Technician (CMT) A, Social Service Designee (SSD), Nursing A, Nursing B, and Nursing C, [NAME] A, Nursing Assistant (NA) A, Care Partner (CP)A, and Administrator 2. The facility also failed to have a criminal record check on file prior to employee's first date working for two of 10 sampled staff: CMT A and Nurse A. The facility census was 30. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the bed hold policy, a discharge summary regarding Resident #8, and the reason for discharge to the resident's representative in writing, including the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in long-term care facilities) for (Resident #1, #4, #6 and #12) and failed to notify the Ombudsman of the discharge. This affected five of 12 residents sampled. The facility census was 30. Review of facility policy Transfer or Discharge Notice, revised 12/2016, showed:- The facility shall provide a resident and/or resident's representative with a thirty-day written notice of an impending transfer or discharge;- A notice will be given for the following reasons: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff developed and implement a person-centered comprehensive care plan to meet preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for three of 12 sampled residents when the facility failed to update a (Resident #3) care plan after a significant change, and when the facility failed to include the use of oxygen therapy in the care plans for (Resident #30 and Resident #31). The facility census was 30. Review of the facilities Comprehensive Person-Centered Care Plans policy showed: -The Interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; [...]

Inspectors wroteBase on observation, interview, and record review the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good, grooming, personal hygiene, when the facility failed to provide proper peri care for four of the 12 sampled residents, (Resident #3, #12 and #28), and when the facility failed to provide proper catheter care for resident #16. The facility census was 30. Review of facility Perineal Care policy, dated February 2018, showed: -For a female resident wash perineal area, wiping from front to back, separate labia and wash area downward from front to back; -If the resident has an indwelling catheter, gently was the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed provide proper respiratory care when staff failed to date the oxygen tubing for two residents (Resident #7 and #30), failed to clean the oxygen concentrator filters for one resident (Resident #7), failed to have an oxygen filter installed for one resident (Resident #5), and failed to obtain an order for oxygen prior to administering to a resident (Resident #30). This affected three of 12 sampled residents. The facility census was 30. Review of the facility's Oxygen Administration policy, revised October 2010, showed:- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration;- Review the resident's care plan to assess for any special needs of the resident;- Equipment and supplies: [...]

Inspectors wroteBased on observations, interviews and record review, the failed to ensure staff discarded expired medications and biologicals stored in the medication room and in the nurse's medication cart. The facility census was 30. Review of the facility's undated policy for Storage of Medications, showed:- The facility shall store all drugs and biologicals in a safe, secure, and orderly manner;- Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers;- Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing;- The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to maintain proper standards of cleanliness and storage in the kitchen area, and failed to use proper handwashing hygiene in the kitchen. This affected all residents by putting them at risk for a food borne illness. The facility census was 30. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit the Payroll Based Journal (PBJ) data (a mandatory submission by nursing facilities to the Centers for Medicare & Medicaid Services detailing facility staffing levels, including staff identification, hours worked, and job titles, on a quarterly basis correctly for Quarter 2 2025 (January 1 to March 31). The facility census was 30 The facility did not provide a policy for PBJ. Review of the facility's Payroll Based Journal data (PBJ - a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2025 (January 1 - March 31) showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29, and 3/ 30 and no licensed nurse on 1/25, 2/11, 3/13 and 3/29. Review of staffing schedule for February 2025 showed no RN on the day: 2/23. [...]

Inspectors wroteBased on interviews and record review, the facility failed to follow care plan directions for maintaining and using hearing aids for one resident of 12 sampled (Resident #30). The facility census was 30. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide an environment free from accident hazards when staff did not implement new interventions to prevent falls for one of the 12 sampled residents, (Resident #3), who was at risk for falls and who had experienced multiple falls and failed to update the resident's fall risk assessment with each new fall. The facility census was 30. 1. Review of Resident #3's medical record showed the resident was admitted on [DATE] at 12:15 P.M. Review of the resident's progress notes showed:- 5/24/25 at 12:30 P.M., the resident was found on the right side of the bed on the floor. No injury noted;- 5/25/25 at 1:15 P.m., the resident had an unwitnessed fall. The resident was found on the floor, no injury noted. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure pain management was provided for one resident, (Resident #1) when staff failed to obtain any medications for the resident for the first 48 hrs after admission from an acute hospital stay following a vehicle accident. The facility census was 39. Review of facility policy, protocol for pain management and as needed medication, undated, showed: -Pain management must be provided to a resident who requires such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences; -Nurses will complete a pain evaluation on each resident for pain upon admission to the facility every week for four weeks, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nebulizer tubing and a nebulizer mouthpiece were cleaned after use and stored in a manner to prevent potential contamination between uses for 1 (Resident #22) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected two of five sampled residents (Resident #1 and #2) Facility census was 38. Review of facility policy, Conveyance upon discharge, eviction, or death policy, dated 2019, showed: -Upon discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident's funds and final accounting of those funds, to the resident, his or her legal representative, or in the case of death, the individual, or probate jurisdiction administering the resident's estate, in accordance with state law. 1. Review of the facility's interim aging report, dated 8/21/24, showed the following residents had money in the facility's operating account: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they used the services of a registered nurse (RN) for at least eight consecutive hours a day on the day shift, seven days a week. This had the potential to affect all residents who resided in the facility. The facility's census was 30. Review of the facility's undated policy regarding RN coverage showed the requirements for long term care facilities require that a skilled nursing facility provide 24-hour nursing services, an RN for eight consecutive hours a day, seven days a week (more than 40 hours a week), and that there be an RN designated as Director of Nursing (DON) on a full time basis. Review of the facility's December 2021 schedule sheets, which showed all nursing staff scheduled for the entire month of December, showed: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they provided each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs when staff failed to ensure they covered foods when transporting them from the kitchen to resident rooms and prepared the meals too far in advance. This affected all residents who received their meals from the facility's kitchen. The facility census was 30. The facility did not provide any dietary policies regarding covering foods during transport of when to prepare the meals. 1. Observation and interview on 3/16/22 at 10:26 A.M., the dietary manager (DM) said she already had to noon meal prepared and on the steam table. The evening cook would be starting his/her meal prepare around 3:00 P.M. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they stored, prepared, and distributed foods in accordance with professional standards of food service safety when staff did not date foods when opened, did not change gloves and wash their hands when moving from one task to another, and failed to keep all surfaces clean, all of which affected all residents who received food from the facility's kitchen. The census was 30. The facility did not provide any cleaning schedules. The facility did not provide a policy on hand washing and glove changes in the kitchen. The facility did not provide a policy to address dating foods when opened. 1. Observation on 3/14/22 at 10:20 A.M., during the initial tour of the kitchen showed: - The walking refrigerator: [...]

Inspectors wroteBased on interview and record review the facility failed to follow their set Antibiotic Stewardship Program (ASP) when they failed to maintain appropriate antibiotic tracking and use of the standard assessment and communication tool-SBAR for 3 residents (Resident #22, #24 and #27) out of 17 sampled residents. This had the potential to effect all residents. Facility census was 30. Review of facility policy Antibiotic Stewardship Program dated September 2017 showed in part: -The facility will use a standard assessment and communication tool for residents suspected of having an infection-SBAR. -Monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of changes. -The Infection Preventionist will be responsible for the ASP in the faciltiy i.e.: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they did not hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents sampled for resident trust fund (RTF) review (Residents #30, #31, #32, #33, #34 and #80). The facility's census was 30. Review of the Personal Funds Agreement, dated 2016, showed: - The facility offers the service of holding and managing residents' personal funds. Residents are not required, however to deposit their personal funds with us. They may manage their own funds or have a family member or other person do so. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility's census was 30. Review of the facility's approved surety bond, approved 7/29/20, showed an approved amount of $15,000.00. Review of the RTF worksheet, completed with the Business Office Manager, on 3/21/22, showed: - The average monthly balance for the facility's interest bearing account and petty cash account of $12,580.84; - The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $18, 871.50; $3871.50 more than the approved amount. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they developed person-centered, complete, accurate and individualized care plans based on residents' comprehensive care plans to address the specific needs of the residents which affected for five of 12 sampled residents (Residents #1, #4, #13, #22, and #27). The census was 30. The facility did not provide a policy for developing, implementing or updating residents' plans of care. 1. Review of Resident #13's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/21, showed: - A Brief Interview for Mental Status (BIMS) score of 6, indicating moderate cognitive impairment; - Scored a 1 on the mood interview, meaning the resident is not at risk for depression; - Independent with bed mobility, moving on the nursing unit, eating; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for three of 12 sampled residents. (Resident #27, #4, #22). The facility census was 30. Review of facility policy for Providing Activities, dated January 2019, showed: -It is the policy of the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental and psycho-social well-being of the residents. -The facility identifies each resident's interests and needs and involves the resident in an ongoing program of activities that is designed to appeal to his or her interests, and to enhance the resident's highest practicable level of physical, mental and psycho-social well-being. 1. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they conducted assessments for risk of entrapment from bed rails prior to installation and failed to review the risks and benefits of bed rails with the resident and their representative and obtain informed consent prior to installation. This had the potential to affected all facility residents, and affected one of 12 sampled residents (Resident #25). The facility census was 30. The facility did not provide a policy on bed rails. 1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, date 2/4/22, showed: - A Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment; - Independent with bed mobility, transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a dementia care plan was developed for four sampled residents (Residents #14, #4, #22, and #27) with dementia diagnosis out of 12 sampled residents. The facility census was 30. The facility did not provide a policy to address behaviors or handling residents with dementia.1. Record review of Resident #14's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Dementia with behavioral disturbances. Record review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by the facility staff for care planning dated 12/31/21 showed : -His/her BIMS (brief interview for mental status) score of 0 ( indicating morbid cognitive impairment) -Had an active diagnosis of Dementia; -He/she exhibited no behaviors; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they provided a notice before transfer and/or discharge for one of 12 sampled residents (Resident #2) when they transferred the resident to the hospital. The facility census was 30. Review of the undated Facility Initiated Transfer or Discharge of Resident policy, showed on occasion, residents may be transferred or discharged for various reasons and these transfers and discharges may be initiated by the facility. The facility may initiate transfer or discharge for the following reasons including the transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility. The procedure included: - Should the facility determine that transfer/discharge is necessary, the facility shall complete the following: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they provided a notice of their bed-hold policy before transferring for one of 12 sampled residents (Resident #2) when they transferred the resident to the hospital. The facility census was 30. Review of the facility's September 2017 Bed Hold/readmission Policy showed to comply with Federal rules, this facility is giving the letter to you and/or your resident representative at this time to inform you of the policy on bed holds and readmission to our facility. Residents and the resident representative will be sent a letter each time one of the following events take place: - Resident is transferred to the hospital; - Resident goes on a therapeutic visit; [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they completed an accurate comprehensive assessment which reflected residents' status for one of 12 sampled residents (Resident #25). The facility census was 30. The facility did not provide a policy on completing the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for residents. Review of Resident #25's annual MDS, dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of 5, indicating moderate cognitive impairment; - No behaviors, such as physical or verbal behavioral symptoms directed towards others, did not reject care, and no change in current behavior status. - Independent with all activities of daily living (ADLs); - Always continent of bowel and bladder; - No falls since prior assessment.; - No ulcers, wounds and skin problems. [...]

Inspectors wroteBased on interview and closed record review , the facility failed to ensure staff completed a comprehensive discharge summary for one of the two sampled closed records (Resident #9) to include appropriate information about the resident's diagnosis, course of illness/treatment or therapy, a post discharge plan of care to assist the resident to adjust to his/her new living environment when applicable. The facility census was 30. Review of facility policy titled Discharge Planning Policy, undated, showed the following: -To complete discharge planning on any resident where discharge is anticipated to home, another skilled nurse facility/nursing facility or other type post acute setting. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow safety standards and policy for one of 12 sampled residents (Resident #1) who had no smoking assessment. Facility census was 30. Review of facility policy Smoking Policy dated October 2017 showed in part: -Any resident who smokes shall be assessed for their ability to smoke safely unsupervised. Assessments shall be conducted upon admission, quarterly and with changes in condition. -The assessment shall include cognition, communication/vision/hearing, physical abilities, safety risk history, and observations of smoking history. 1. Review of Resident #1 quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 3/8/22 showed: -Brief Interview of Mental Status (BIMS) of 5. (this indicates moderate to severe cognitive impairment). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents remained free from unnecessary drugs when staff failed to discontinue the use of as needed (PRN) opioids after 14 days or have the physician reassess the appropriateness of the continued use of the medication for one of 12 sampled residents (Resident #2). The facility census was 30. The facility did not provide a policy to address the use of unnecessary drugs and discontinuing PRN opioids after 14 days. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21 , showed: - Long and short-term memory problems; - Extensive staff assistance with bed mobility, transferring from one surface to another, dressing, toilet use and personal hygiene; - Diagnoses included: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents remained free from unnecessary drugs when staff failed to discontinue the use of as needed (PRN) psychotropic medications after 14 days or have the physician reassess the appropriateness of the continued use of the medication and failed to ensure they attempted an gradual dose reduction (GDR) in an effort to discontinue psychotropic drug use, unless clinically contraindicated for one of 12 sampled residents (Resident #2). The facility census was 30. The facility did not provide a policy to address the use of unnecessary drugs, gradual dose reductions and discontinuing PRN opioids after 14 days. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21 , showed: - Long and short-term memory problems; [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. This affected two of 12 sampled residents. (Resident #2 and #22). The facility census was 30. Review of the undated Comparison of Facility/Hospice Responsibilities, part of the facility's contracted agreement with hospice providers showed: - Hospice plan of care (HPOC) must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have ben agreed upon and included in the HPOC. - HPOC reflects participation by the hospice, facility, patient and patient's family. - Discussions of changes to the HPOC with the facility or patient; - Approval by Hospice of any changes to the HPOC prior to implementation. 1. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff who are not up-to-date with COVID-19 vaccination were routinely tested for COVID-19 according to their policy and county transmission rate. This affected four staff members and had the potential to affect all residents. The facility census was 28. 1. Review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the following: - Purpose- In accordance with the facility's duty to provide and maintain a workplace that is free of known hazards, the facility was adopting the policy to safeguard the health of the employees and their families, customers and visitors and the community at large from the COVID-19 virus, that may be reduced by vaccinations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to fully develop and implement their staff vaccination policy for COVID-19 when they did not ensure all required components were included in the policy and failed to implement a process for tracking and documenting the COVID-19 vaccination status for all staff. Facility census was 30. 1. Review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the following: - Purpose- In accordance with the facility's duty to provide and maintain a workplace that is free of known hazards, the facility was adopting the policy to safeguard the health of the employees and their families, customers and visitors and the community at large from the COVID-19 virus, that may be reduced by vaccinations. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the corridor was equipped with firmly secured handrails and handrails are in good repair on one side of the hall. The facility census was 30. Observations on 3/14/22 at 2:20 P.M. showed: - On the 200 hall, first handrail at central bath was loose. - The handrail by the soiled utility room is loose and cracked with jagged edges. During an interview on 3/21/22 at 2:05 P.M. the Maintenance Director said: - He/she does not do rounds and check handrails. - He/she was unaware some needed repaired; - Handrails should not be jagged or loose since the residents use those to stabilize when walking down the halls During an interview on 3/21/22 at 4:19 P.M., the Administrator said handrails should be checked and maintained in good condition.