Odessa Health Care Center

Inspectors wroteBased on observation and interview the facility failed to ensure the kitchen equipment was kept clean for storage and cooking of food. This deficient practice potentially affected everyone who ate out of the kitchen. The facility census was 60 residents. 1. Observation on 1/28/226 at 8:59 A.M. of the kitchen showed:-The convection oven had grease build up on the inside windows and lip below the food racks.-The floor of the oven had raised burnt food debris at the base. -There was a greasy film on the outside of the oven.-The stove had a greasy film and debris on the knobs, front panel, oven handle and platform (on top of the stove).-Refrigerator #1 had a sticky, dried, orange spill on the floor of the refrigerator with food spillage and crumbs.-Refrigerator #3 had fruits and vegetables inside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure handwashing was completed to prevent cross contamination during tracheostomy (a surgical procedure that creates an opening, or stoma, through the neck into the trachea (windpipe) care and failed to use enhanced barrier precautions (EBP- an infection control intervention in nursing homes and skilled nursing facilities that mandate the use of gowns and gloves during high-contact resident care activities) when providing care for one sampled resident (Resident #4), out of 15 sampled residents; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident's dignity and privacy during resident care (Resident #4) by providing care in a common use area; and failed to ensure residents were treated with dignity during the lunch meal by failing to serve the lunch meal timely and failing to provide beverages to residents who were in the dining room waiting for their meals to be served. This failure potentially affected 22 residents who ate in the dining room. The facility sample was 15 residents. The facility census was 60 residents. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the inside of the restroom ceiling vents in the following shared restrooms of the following pairs of resident rooms: 2 and 4; 1 and 3; 5 and 7; 10 and 12; 9 and 11; 13 and 15; 35 and 33; 36 and 34; 31 and 29; 32 and 30; 26 and 28; 27 and 25; 23 and 21; and room [ROOM NUMBER], a room without a shared restroom; failed to ensure that numerous pieces of paper debris was removed from the floor of Resident room [ROOM NUMBER] on 1/28/26 and 1/30/26; failed to maintain the tabletop fan free from a buildup of dust in Resident #49's room; and failed to maintain the ceiling fans in the Main Dining Room (MDR) free from a dust buildup on the blades of those fans. This practice potentially affected 56 residents who resided in those shared rooms. The facility census was 60 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory equipment such as nasal cannulas (a lightweight, flexible medical device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help), face masks (a medical device designed to deliver supplemental oxygen from a storage source (tank or concentrator) to a patient's nose and mouth to improve breathing and oxygen saturation) were kept covered to prevent cross contamination when not in use for three sampled residents (Resident #6, #1, and #50), who were at risk for respiratory infections, out of 15 sampled residents. The facility census was 60 residents. Review of the facility's Oxygen policy and procedure dated 5/18/24, showed:-Oxygen is administered under orders of a physician, except in the case of an emergency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staffing to meet the needs of two sampled residents (Resident #5 and #54) out of 15 sampled residents. The facility census was 60 residents. Review of the facility's Sufficient Staff Policy dated 5/18/24 showed:-It was the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Certified Nursing Assistants (CNAs) and licensed nursing staff had the appropriate competencies and skills check off training to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being was completed annually and as needed. This had the potential to affect any resident care provided by the nursing staff. The facility census was 60 residents. Review of the facility's Sufficient Staff Policy dated 5/18/24 showed:-It is the policy of this facility to provide sufficient staff with appropriate competencies and skills sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's response related to the pharmacist's Gradual Dose Reduction (GDR) recommendation and pharmacy monthly Medication/Drug Regimen Review( MRR or DRR) for as needed antipsychotic medication (used to manage psychosis symptoms, including hallucinations, delusions, paranoia, and severely disordered thinking) for one sampled resident (Resident #51) out of 15 sampled residents. Facility census was 60 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage, with an ongoing monitoring system and accountability for narcotic medication (is technically known as opioids or opioid analgesics, are powerful, prescription-only drugs used to manage moderate-to-severe pain that is not relieved by other, safer pain medications) that included Morphine (used to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and when other pain medicines did not work well) and Lorazepam (Ativan antianxiety, involve more than occasional worry or fear) for three sampled residents (Resident #51, #10, and #35); [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide a pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) vaccine for one sampled resident (Resident #46) out of five residents sampled for immunizations. The facility census was 60 residents. Review of the facility's Influenza and Pneumococcal immunizations policy dated 5/14/24 showed:-As a part of the admission process , the resident and/or the resident's legal representative will be provided education on the benefits and potential side effects of both the Influenza and Pneumococcal Immunization.-The resident or their legal representative will be informed that the Pneumococcal immunization will be offered upon admission per CDC guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to ensure five sampled residents (Residents #2, #10, #35, #46, and #51) were offered and had documentation of refusal of COVID-19 (a new disease caused by a novel (new) coronavirus) education provided out of 5 residents sampled for immunization review. The facility census was 60 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the commode safety rails (adjustable, sturdy, metal frames with handles that fit around or bolt onto a toilet to provide stable support for a person who was going from a siting to standing position or from a standing to sitting position) in the restrooms were sturdy in the shared restroom of resident rooms [ROOM NUMBERS], in the shared restroom of resident rooms [ROOM NUMBERS], in the shared restroom of resident rooms [ROOM NUMBERS], in the shared restrooms of resident rooms [ROOM NUMBERS], and resident room [ROOM NUMBER]. This potentially affected 15 residents who resided in those rooms. The facility census was 60 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain written authorization from the guardian of two sampled residents (Resident #21 and #9) to allow the facility to make withdrawals from their Resident Trust accounts for specific HealthCare (clinics which were funded through supplemental insurance paid by residents and are established on-site and treatment is provided using advanced equipment specifically selected for residents of senior care communities in the areas of optometry, podiatry, dental and audiology services) out of four residents sampled for resident funds review. The facility census was 60 residents. Review of the Facility's Policy titled Resident Trust, revised on 9/21/25, showed:-Personal funds of the resident shall be used exclusively for the resident, which must be authorized in writing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the mood and behaviors section of the care plan was up to date for one sampled resident (Resident #43) out of 15 sampled residents. The facility census was 60 residents. Review of the facility's policy Comprehensive Care Plans dated 10/31/24 showed:-It was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing was completed twice weekly by nursing staff in addition to bathing that was completed by hospice (end of life) staff for one sampled resident (Resident #10) out of 15 sampled residents. This deficient practice potentially affected all residents on hospice services. The facility census was 60 residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to obtain and transcribe a physician order for the use of a Low Air Loss Mattress (LAL mattress a specialized medical mattress technology designed for pressure ulcer prevention and treatment) with soft side bolsters (create a gentle raised edge that gives resident sensory awareness when near the mattress edge) to include the required settings and monitoring of the LAL mattress for proper inflation and function for one sampled resident (Resident #51) who was at risk for skin changes; and failed to ensure the smoking assessment accurately reflected the current safety status of one sampled resident (Resident #4) who required supervision when smoking due to adverse smoking behaviors, and failed to monitor the smoking behaviors out of 15 sampled residents. The facility census 60 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and transcribe a physician's order for use of an Indwelling Catheter (is a flexible, indwelling tube inserted through the urethra into the bladder to drain urine, held in place by a small, water-filled balloon) to include the type of catheter used, the French size of the tube (Fr, a measure of the outer diameter of a catheter) and tip, [NAME] size and daily monitoring and care of the catheter; failed to prevent cross contamination during catheter care by not using enhanced barrier precautions (EBP- an infection control intervention in nursing homes and skilled nursing facilities that mandate the use of gowns and gloves during high-contact resident care activities) when providing care for one sampled resident (Resident #35) who was at risk for bladder infections, out of 15 sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's meal intake was being monitored when one sampled (Resident #12) was having gradual weight loss out of 15 sampled residents. The census was 60 residents. Review of the facility policy titled Weight Monitoring Policy revised dated 5/7/2024 showed: -Based on the resident's comprehensive assessment, the facility would ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that this was not possible or resident preferences indicate otherwise.-A weight monitoring schedule would be developed upon admission for all residents:--Weights should be recorded at the time obtained. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a thermometer in the refrigerator and the temperature was monitored and logged for one sampled resident (Resident #26) out of 15 sampled residents. The census was 60 residents Review of the facility policy titled Resident Food: Storage and Sharing revised dated 9/16/24 showed:The purpose of this policy was to ensure that residents food storage was safe with sanitary storage, handling and consumption.-Resident personal refrigerators and facility snack refrigerators would be monitored on a daily basis by facility staff.-Refrigerators would be kept clean and within the regulation temperature guidelines of 32-40 degrees. If the temperature falls beyond the regulated guidelines the food would be discarded. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure communication was established and completed between the facility and the hospice nursing staff; and failed to ensure change of condition hospice orders were in place for one sampled resident (Resident #59) out of 15 sampled residents. The facility census was 60 residents. Review of the Coordination of Hospice Services Policy, revised dated [DATE] showed: -When a resident chooses to receive hospice care and services, the facility would coordinate and provide care and cooperation with hospice staff in order to promote the residents highest practicable physical, mental, and psychosocial well-being.--The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staffing on a 24-hour basis to care for resident's basic needs and to ensure resident safety for three sampled residents (Resident # 1, #3 and #4) out of three sampled residents. This practice had the potential to affect all residents. The facility census was 56 residents. Review of the facility Sufficient Staff Policy updated 5/18/24, showed: -It was the policy of the facility to provide sufficient staff with appropriate competencies and skills sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. -The facility census, acuity and diagnosis of the resident population will be considered based on the facility assessment. Review of the Facility Assessment Tool revised 4/25, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week and to designated a Director of Nursing (DON) . The facility census was 56 residents. 1. Review of the facility policy titled Registered Nurse (RN), revised 4/30/24, showed: -It was the intent of the facility to comply with Registered Nurse staffing requirements. -The facility would utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days a week. -The facility would designate a Registered Nurse to serve as the Director of Nursing (DON) on a full-time basis Review of the Facility Assessment Tool, revised 4/1/25, showed: -The facility needed one Administrator, one DON, and one RN to provide support and care for the residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was administered in a manner that allowed residents to attain or maintain their highest practicable physical well-being by not having administrative oversight to the residents on a full time basis and by not having a Registered Nurse (RN) or a Director Of Nursing (DON) physically present in the facility for a minimum of 8 hours within a 24 hour period. This had the potential to affect all residents of the facility. The facility census was 56. Review of the facility policy titled Registered Nurse (RN), revised 4/30/24, showed: -It was the intent of the facility to comply with Registered Nurse staffing requirements. -The facility would utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days a week. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to carry out activities of daily living (ADL) to maintain grooming and personal hygiene for three sampled residents (Resident #1, #3, and #4) out of three sampled residents. The facility census was 56. Review of the facility's ADL Policy revised 5/18/24, showed: -The facility would based on the resident's comprehensive assessment and consistent with the residents needs and choices, ensure a residents abilities in ADL's did not deteriorate unless unavoidable. -Care and services would be provided for bathing, dressing, grooming and oral care. -A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming, and personal and oral hygiene. Review of the facility's Resident Showers Policy revised 6/26/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided food that was at a safe and appetizing temperature for three sampled residents (Residents #1, #3, and #4) out of 4 sampled residents. The facility census was 56. A facility's Food Temperature policy was requested and not provided. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/23/25 showed he/she was cognitively intact. During an interview on 6/17/25 at 11:47 A.M., the resident said: -He/She often received food that was cold in temperature and not appetizing. -He/She often received food trays in his/her room. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure certified/trained personal provided Activities of Daily Living (ADL- a set of basic tasks that individuals need to perform to maintain their daily life and independence. These tasks typically include bathing, dressing, eating, toileting, and mobility) care to the resident. The facility census was 56 residents. Review of Facility assessment dated [DATE] showed: -Staff competencies for resident population included: --Resident rights and dignity. --Confidentiality. --Infection control and standard precautions. --Emergency procedures and disaster preparedness. --Fall prevention and safety protocols. --Abuse, neglect, and exploitation prevention. --Dementia care, including trauma informed practices. --De-escalation techniques and behavioral support. --Documentation procedures and electronic health record usage. [...]

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staffing on a 24-hour basis to care for resident's needs and to ensure resident safety by not having adequate staff in the building for night shifts and failed to meet the minimum staffing requirements for fire safety. This practice had the potential to affect all residents. The facility census was 54 residents. Review of the facility Minimum Staffing Requirements for Fire Safety policy revised 3/13/25 showed: -11:00 P.M. to 7:00 A.M. (night shift) one personnel for every 3-20 residents. -The flow chart showed staffing requirements per census required staff for night shift (11:00 P.M. to 7:00 A.M.) with a census range of 41-60 residents would require 3 staff members assigned for the shift. 1. Review of the facility staff daily time punches dated 4/7/25 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week and failed to ensure a Director of Nursing (DON) or interim DON was onsite full -time 8 hours a day for a minimum of 40 hours a per week. The facility census was 54 residents. The facility staffing policy for the DON and Registered Nurses requirement was requested and not provided. 1. Review of the Facility Assessment revised on 4/1/25 showed one DON full time day shift and one RN where available. Review of facility's staffing sheet from 4/7/24 to 4/9/24 showed no time recorded for the facility RN or DON. Observation on 4/9/25 at 5:00 A.M. the facility had one Licensed Practical Purse (LPN) and two Certified Nursing Aides (CNA) in the building. There was no RN in the building. Observation on 4/9/25 at 5:25 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post staffing information in a location that was easily accessible to residents on the Long Term Care (LTC) of the facility and to ensure staffing data was posted for visitors including the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 54 residents. he facility staffing posting policy was requested and not provided. 1. Observation on 4/9/25 at 5:00 A.M. the facility had one LPN and two CNAs with a census of 54 residents. There was no RN in the building. Observation on 4/9/25 at 5:25 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation for one sampled resident (Resident #3) when Certified Nursing Assistant (CNA) A cultivated a relationship with the resident and borrowed $150.00 to pay court costs out of five sampled residents. The facility census was 53 residents. On 2/20/25 the Administrator and Assistant Director of Nursing (ADON) were notified of past non-compliance which occurred on 2/19/25. On 2/19/25 the facility Administrator was notified of the incident and the investigation was started. CNA A was terminated on 2/17/25 for no call no show to work. No employees were allowed to work prior to reeducation completed on 2/19/25. The deficiency was corrected on 2/19/25. Review of the facility's Abuse and Neglect Policy dated 11/28/16 and revised on 6/12/24 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's responsible party after staff performed the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage) on one sampled resident (Resident #3) who had choked on food and the physician had made some medication changes and ordered tests that were not relayed to the responsible party out of three sampled residents. The facility census was 54 residents. On 1/2/25 the Administrator was notified of the past noncompliance which occurred on 12/19/24. On 12/26/24 the facility administration was notified of the change of condition and notification not being completed. Facility staff were educated on change of condition and notification of responsible party. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week. This had the potential to affect all residents of the facility. The facility census was 49 residents. An undated policy titled Nursing Services and Sufficient Staff showed the facility must use the services of a RN for at least eight consecutive hours a day, seven days a week. 1. Review of the facility's daily staffing schedules from 3/1/24 to 5/24/24 showed a lack of a RN on: -Saturdays: 3/2/24, 3/9/24, 3/30/24, 4/6/24, 4/13/24, 4/20/24, 4/27/24, 5/4/24, 5/11/24, and 5/18/24. -Sundays: 3/3/24, 3/10/24, 3/17/24, 3/24/24, 3/31/24, 4/7/24, 4/14/24, 4/21/24, 4/28/24, 5/5/24, 5/12/24, and 5/19/24. [...]

Inspectors wroteBased on observation and interview, the facility failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to ensure food preparation items were kept in a sanitary condition; and failed to maintain plastic plate covers in good order to avoid food safety hazards (cross-contamination), in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 49 residents with a licensed capacity for 60 residents at the time of the survey. 1. Observation on 5/22/24 between 9:25 A.M. and 10:06 A.M. during the initial kitchen inspection, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility administration failed to pay debts to vendors, including the utility company and fire sprinkler service, resulting in a failure to ensure its resources were used effectively and efficiently in order to promote the wellbeing of each resident and provide necessary goods and services. This had the potential to affect all residents and staff at the facility. The facility census was 49 residents. The facility had not provided any policies regarding payment of vendors at the time of exit. The facility did not have a policy for the Administrator's duties. Review of the facility's Job Description for the Administrator dated 2022 showed: [...]

Inspectors wrote2. Review of Resident #10's entry tracking record showed the resident admitted to the facility on [DATE]. Review of the resident's immunization tab showed: -The resident's first-step TST was administered on 4/12/24 and there was no read date. -The resident's second-step TST was administered on 4/24/24 and there was no read date. Review of the resident's Medication Administration Record (MAR) dated April 2024 showed no administration or reading of any TSTs. Review of the resident's Treatment Administration Record (TAR) dated April 2024 showed: -A physician's order dated with a start date of 4/5/24 to administer a TST. -4/5/24 to 4/8/24 were left blank for TST administration. -The TST was documented as not completed and referred to a nurse's note on 4/9/24. -A physician's order dated with a start date of 4/10/24 to administer the first TST. [...]

Inspectors wroteBased on interview and record review, the facility failed to have in their policy to check the Nurses' Aide (NA) Registry to ensure the applicants did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) for all employees prior to hire and failed to complete a check of the NA Registry for four sampled employees (Employees B, C, F and J) out of ten sampled new employees. The facility census was 49 residents. Review of the facility's policy titled Background Investigations revised February 2023 showed: -The Human Resources department was responsible for conducting all applicable background investigations. -A NA registry check would be completed for all applicants applying for a position as a Certified Nursing Assistant (CNA). 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain oxygen equipment in a sanitary condition for three sampled residents, (Resident #9, #41, and #5) out of 13 sampled residents. The facility census was 49 residents. The facility did not provide an Oxygen Policy by the end of the survey. 1. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Stroke (damage to the brain from an interruption of its blood supply). Review of the resident's five day Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 5/19/24 showed: -He/She was cognitively intact. -He/She had a stroke. -He/She was on continuous oxygen therapy. Review of the resident's care plan dated 5/20/24 did not address oxygen use. Observation on 5/20/24 at 8:43 A.M. showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to the pharmacist's monthly medication regimen review (MRR) for two sampled residents (Resident #38, #8, and #18) out of five residents sampled for medication review and failed to follow a physician's order to have been evaluated and medication management for one sampled resident (Resident #18). The facility census was 49 residents. Review of the facility's undated policy titled Pharmacy Services showed it did not address the response to the pharmacist's monthly medication regimen review. 1. Review of Resident #38's tracking forms showed the resident admitted to the facility on [DATE]. Review of the resident's care plan dated 4/3/23 showed: -Some of the resident's diagnoses included: --Diabetes (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 observe the resident take his/her medications for one supplemental resident (Resident #37), who had not been assessed for self-administration of medications and did not have a physician's order for self-administration of medications, failed to ensure two medications carts were locked when staff was not using them. The facility census was 49 residents. Review of the facility's policy titled Resident self-administration of medication dated February 2023 showed: -The interdisciplinary team should determine if self-administration is clinically appropriate for the resident and consider the following: --The medications were appropriate and safe for self-administration. --The resident's physical capacity to swallow without difficulty. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for two sampled residents (Resident #10 and #4) out of 13 sampled residents. The facility census was 49 residents. Review of the facility's policy titled Conducting an Accurate Resident Assessment dated 2023 showed: -Qualified staff who were knowledgeable about the resident would conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. -The assessment would be documented in the medical record. -The appropriate, qualified health professional would correctly document the resident's overall status. -Information provided by the initial comprehensive assessment established baseline data for the ongoing assessment of resident progress. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure completion, submission and retention of a Level I Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid (program that helps with medical costs for some people with limited income and resources) certified beds in a nursing facility regardless of the source of payment. The screening assures appropriate placement of persons known or suspected of having a mental impairment(s) and that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment) for one supplemental resident (Resident #38). The facility census was 49 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's responsible party with a baseline care plan for two sampled residents (Residents #43 and #44) out of 13 sampled residents. The facility census was 49 residents. Review of the facility's undated policy titled F655 Baseline Care Plans showed: -A baseline care plan would be developed within 48 hours of the resident's admission. -Within 48 hours, the summary of the baseline care plan should be presented to the resident and/or their representative in writing. 1. Review of Resident #43's tracking log showed the resident admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one sampled resident (Resident #14) of 13 sampled residents. The facility census was 49 residents. A policy on comprehensive care planning was requested but not provided. 1. Review of Resident #14's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 5/8/24 showed: -An admission date of 5/1/24. -The resident was on hospice (end of life care). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to hold medications according to physician's orders for one supplemental resident (Resident #38) out of five residents sampled for medication review and failed to obtain physician's orders for the care of a colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) for one supplemental resident (Resident #43). The facility census was 49 residents. Review of the facility's undated policy titled Physician Medication Orders did not address holding medications. 1. Review of Resident #38's dashboard tab showed the resident admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one closed record sampled resident, (Resident #53) had a continuing care provider (the entity or person who will assume responsibility for the resident's care after discharge); a recapitulation of stay (concise summary of the resident's stay and course of treatment in the facility); and reconciliation of medications (process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) when he/she was discharged from the facility. The facility census was 49 residents. The facility did not provide a policy for discharges at the time of exit. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and intervene in a decline in a resident's condition related to chronic venous hypertension (a disease that causes improper functioning of the vein valves in the leg, resulting in swelling) and congestive heart failure (CHF) for one sampled resident (Resident #12) of 13 sampled residents. The facility census was 49 residents. 1. Review of Resident #12's care plan dated 7/25/23 showed: -The resident needed staff assistance with lower body dressing due to lymphedema. -The resident had CHF and was at risk of the disease process worsening. An intervention included monitoring, documenting and reporting signs and symptoms of CHF including edema. -The care plan lacked information related to the resident's venous hypertension or lymphedema. Review of the resident's physician visit progress notes showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide addiction recovery program or psychological services for one supplemental resident (Resident #31) who needed to participate in a recovery program for six months as one of the requirements to be placed on a transplant list for a new liver. The facility census was 49 residents. The facility did not have a policy regarding support groups. 1. Review of Resident #31's dashboard tab showed: -The resident admitted to the facility around two years ago. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure antipsychotic drugs (drugs that can be used to treat severe mental illness) were appropriately monitored and as needed (PRN) psychotropic drug (a drug that can affect emotions and behavior, used to treat psychiatric diseases) orders did not extend beyond 14 days without physician rationale for one sampled resident (Resident #8) of 5 residents reviewed for unnecessary medications. The facility census was 49 residents. An undated facility policy titled Behavior Assessment and Monitoring showed: -If a resident was being treated for problematic behavior or mood, the staff were to obtain and document ongoing reassessments of changes in the individual's behavior, mood and function. A policy regarding antipsychotic/psychotropic medication administration was requested on 5/24/24 but was not provided at the time of exit. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to hold insulin per physician's orders for one supplemental resident (Resident #38) out of five residents sampled for medication review. The facility census was 49 residents. The facility did not have a policy regarding this citation. 1. Review of Resident #38's care plan dated 4/3/23 showed: -The resident had a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Instructions to administer medication for diabetes as ordered. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 3/22/24 showed the following assessment of the resident: -Had a diagnosis of diabetes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing sheets were posted daily. The facility census was 27 residents. 1. Observation on 9/14/22 at 11:20 A.M. showed no staffing sheets were posted visibly in the front entrance, nurse's station, or dining room for residents and visitors to see. Observation on 9/15/22 at 8:12 A.M. showed no staffing sheets were posted visibly in the front entrance, nurse's station, or dining room for residents and visitors to see. Record review on 9/15/22 at 11:35 A.M. showed: -A white binder with staffing information tucked in with all other binders behind the nurse's station. -The daily staffing sheets only showed care staff assignments and not the daily staffing care staff numbers. During an interview on 9/15/22 at 11:51 A.M. the Administrator said: -He/she posted the daily staffing numbers at the end of the day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the buildup of food debris and dust on the floor in the dry goods storage room and under the three reach-in refrigerators; to ensure the filters of the two ceiling vents located in the kitchen at the entrance from North Hall corridor, were free of a heavy dust buildup; and to to ensure a 5 pound (lb) container of sour cream was discarded after its expiration date. This practice potentially affected 27 residents who ate food from the kitchen. The facility census was 27 residents 1. Observations on 9/12/22 from 9:25 A.M. through 12:40 P.M., showed: - Two moon pies of the chocolate cream and the flavor and the oatmeal cream pie flavor were found on the floor of the dry goods storage room. - Two filters in the ceiling vents over entrance way from the North Service Hall with heavy buildup of dust. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep a lid on a trash container in the kitchen during the lunch meal. The facility census was 27 residents. 1. Observation on 9/12/22 on 10:39 A.M., 10:53 A.M., 11:48 A.M., 12:19 P.M., and 1:17 P.M., showed one trash container next to dishwasher was left open without a lid. During an interview on 9/12/22 at 1:17 P.M. Dietary Aide (DA) A said he/she did not know where the lid for that trash container, next to the dishwasher, was located. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Chapter 5-501.113 entitled Covering Receptacles, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure handwashing was completed to prevent cross contamination during incontinence care for one sampled resident (Resident #6), wound care for two sampled residents (Resident #21 and Resident #274); failed to ensure infection control monitoring, tracking, and trending was completed; failed to ensure TB (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, and abnormal lung tissue and function) screening was obtained, completed and documented correctly for three sampled residents (Resident #16, Resident #224 and Resident #4); failed to ensure appropriate infection control practices were used during blood sugar checks for one supplemental resident (Resident #75) out of five resident's sampled for TB and out of 14 sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic stewardship program was being conducted and reviewed during the last 12 months that included antibiotic usage, infection monitoring, laboratory results, and an overall system for the provision of feedback reports was being done facility wide. The facility census was 27 residents. Record review of the facility's undated Infection Prevention and Control Program showed: -Facility wide surveillance will be performed to identify opportunities to prevent and/or reduce the rate of infection in our residents, employees, and visitors. -Data will be trended internally for historical comparison and reported to the infection prevention committee no less than quarterly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an Infection Preventionist was designated and certified in infection prevention and control. The facility census was 27 residents. Record review of the facility's undated Infection Prevention and Control Program policy showed: -The Infection Preventionist was qualified to conduct infection prevention. -He/she would complete the Centers for Disease Control and Prevention (CDC) Long Term Care Infection Preventionist module. 1. During an interview on 9/14/22 at 12:50 P.M. the Minimum Data Set (MDS-a federally mandate assessment tool completed by facility staff for care planning) Coordinator said: -He/she was the designated Infection Preventionist as of 9/12/22. -He/she was not a certified Infection Preventionist. -He/she thought the Director of Nursing (DON) was in charge of infection control prior to Monday, 9/12/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a monthly group was organized for facility residents and family members that allowed them the opportunity to voice grievances and concerns, this deficient practice had the potential to effect all residents residing in the facility. The facility census was 27 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) memo dated 4/7/22 showed: - CMS will end the specified waivers in two groups, 60 days from issuance of this memorandum and 30 days from issuance of this memorandum. -While the waivers of regulatory requirements have provided flexibility in how nursing homes may operate, they have also removed the minimum standards for quality that help ensure residents' health and safety are protected. [...]

Inspectors wroteBased on interview and record review, the facility failed to print and distribute quarterly statements for the residents who allowed the facility to manage their resident funds. This practice affected three residents (Resident's #75, #10 and #11) out of 12 sampled residents who allowed the facility to manage their resident funds. This deficient practice had the potential to affect all residents with funds in the facility's resident trust. The facility census was 27 residents. 1. Record review of the financial records of the three sampled resident's showed the absence of quarterly statements. During an interview on 9/14/22 at 11:54 A.M., the Corporate Financial Consultant said: - The records of the previous quarterly statements for the months of January 2022 through March 2022, were not available. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policies and procedures for checking the employee disqualification listing (EDL) and completing criminal background checks (CBC) and checking the Nurse Aide Registry in accordance with state requirements for two employees sampled for the CBC screening, one employee sampled for the EDL screening and four employees sampled for the Nurse Aide Registry screening out of 10 employees sampled. This deficient practice potentially affected all residents in the facility. The facility census was 27 residents. Record review of the facility Abuse and Neglect Policy updated 11/2017, showed: -Policies and procedures should be consistent with regulatory requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was completed and submitted when a resident was admitted to Hospice services (end of life care) for three sampled residents (Resident's #224, #325, and #16) out of 12 sampled residents. The facility census was 27 residents. 1. Record review of Resident #325's Physician's Order Sheet (POS) showed he/she was admitted to Hospice services on 8/11/22. Record review of the resident's Center for Medicare and Medicaid Services (CMS) MDS database submissions showed the last assessment was an Entry MDS assessment with an ARD of 6/30/22. Record review of the resident's facility Electronic Medical Record (EMR) showed a Significant Change MDS assessment with an ARD of 8/24/22 in process. [...]

Inspectors wroteBased on interview and record review, the facility failed to transmit required Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessments for four sampled residents (Resident's #325, #224, #15, and #16) and one supplemental resident (Resident #2) out of 12 sampled residents and four supplemental residents. The facility census was 27 residents. Record review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17 showed: -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 plus (+) 14 days). -All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) certified the Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning) completion date (Z0500B) was no later than 14 days after the Assessment Reference Date (ARD - A2300) for five sampled residents (Resident's #325, #19, #224, #16, #15) and two supplemental residents (Resident #2, and #3) out of 14 sampled residents and four supplemental residents. The facility census was 27 residents. Record review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, showed the following: -Z0500B description: MDS Completion Date - date of the RN assessment coordinator's signature, indicating that the MDS is complete; [...]

Inspectors wrote3. Record review of Resident #224's admission Face Sheet showed the resident was admitted to the facility on [DATE] with diagnosis of Malignant Neoplasm (is a cancerous tumor) of unspecified part of right bronchus (is a passage or airway in the lower respiratory tract that conducts air into the lungs) or lung. Record review of the resident's submitted MDS's showed he/she did not have documentation of a current MDS or a significant change MDS for change of condition complete, showing the resident admission to Hospice services. Record review of the resident's Comprehensive Care Plan showed the resident did not have a Hospice Care Plan initiated or implemented after a his/her admission to Hospice services. Record review of the resident's Physician order dated 8/22/22, showed the resident had an order to be admitted into Hospice services of his/her choice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to storage oxygen (O2) nasal cannulas (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help), O2 tubing and breathing treatment masks when not in use, for five sampled residents (Resident #6, #21, #15, #13 and #276) out of 14 sampled residents. The facility census was 27 residents. Record review of the facility's undated Oxygen Cleaning policy and procedure did not show how the oxygen tubing, facemasks and nasal cannulas should be stored. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the recommendations from the Pharmacist's Drug Regimen Review were obtained and to determine if there were any recommendations that needed a response for follow up for four sampled resident's (Resident #6, Resident #21, Resident #13, and Resident #16). The facility census was 27 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the recipe for the fried chicken was palatable and to have a mechanism via the resident council process, for residents to state any concerns regarding the palatability of the food. This practice potentially affected at least 25 residents who ate a regular diet from the kitchen. The facility census was 27 residents. 1. Record review of the recipe for 25 servings of fried chicken showed: - 9 pounds of cut up boneless chicken that was thawed. - 2 cups flour. - 1 tablespoon (Tbsp.) +1/4 teaspoon (tsp.) salt. - 1 and 5/8 tsp. paprika. - 1 and 5/8 tsp. black pepper. - Directions: mix the seasonings and flour. Dredge the chicken in seasoned flour. - ¼ cup and 3 Tbsp. whole liquid eggs. - ½ cup + tsp. 2% milk. - Directions: dip the chicken in the egg/milk mixture. - 6 and ¼ ounces bread crumbs. - Directions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was completed and submitted timely for two sampled residents (Resident #325 and #224) out of 14 sampled residents. The facility census was 27 residents. 1. Record review of Resident #325's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Physician's Order Sheet (POS) showed he/she was admitted to hospice services (end of life care) on 8/11/22. Record review of the resident's CMS MDS database submissions showed: -An Entry MDS assessment with an Assessment Reference Date (ARD) of 6/15/22. -A Discharge MDS assessment with an ARD of 6/28/22. -The last assessment was an Entry MDS assessment with an ARD of 6/30/22. --NOTE: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a base line care plan consistent with the resident's specific conditions, needs, and risks, to provide effective person centered care that met professional standards of quality of care within 24 hours of admission to the facility for two sampled residents (Resident's #274 and #276) out of 14 sampled residents. The facility census was 27 residents. Record review of the facility's undated policy titled Care Plan-Temporary showed: -Staff were to ensure the resident's immediate care needs were met and maintained by creating a temporary care plan within 24 hours of admission. -Staff were to use the temporary care plan until a comprehensive assessment had been completed. 1. Record review of Resident #274's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Unspecified injury of head. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were developed to show the health care needs of the residents and interventions to address care needs for two sampled residents (Resident's #15 and #325) out of 14 sampled residents. The facility census was 27 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review,the facility failed to ensure that an ongoing activities program was being completed that met the residents' physical, mental, and psycho-social needs for one sampled resident (Resident #4) out of 14 sampled residents. The facility census was 27 residents. An Activities Policy was requested and not received from the facility at the time of exit. 1. Record review of Resident #4's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Lymphedema (swelling of body tissue due to a build-up of fluid). -Cellulitis (an infection of deep skin tissue) of left lower limb. -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Chronic Pain (pain that lasts over three months). During an interview on 9/12/22 at 1:24 P.M. the resident said: -Activities do not normally happen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's who admitted to the facility with pressure sores (injuries to skin and underlying tissue resulting from prolonged pressure) had an admission skin assessment, had a description of the wounds, had wound measurements, had the appropriate type and stage of wound documented, had treatment orders for all wounds within four hours of admission, and documentation of the physician being notified of the wounds for one sampled resident (Resident #274) who admitted to the facility on [DATE] with a pressure sores to his/her left buttock, right buttock, and left heel; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize equipment correctly to prevent harm by not locking the mechanical lift or the wheelchair when transferring one sampled resident (Resident #274) out of 14 sampled residents. The facility census was 27 residents. Record review of the facility's undated policy titled Hydraulic Lift (Hoyer Lift) showed: -Staff were to set the brake on the Hoyer lift before lifting a resident. -Staff were to lock the brakes on the resident's wheelchair before lifting the resident out of, or placing a resident in, a wheelchair. 1. Record review of Resident #274's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Unspecified injury of head. -Contusion (bruise) of scalp. -Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Fever. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to change a Peripherally Inserted Central Catheter (PICC line- a thin, soft, long catheter (tube) that is inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws) dressing and to create a baseline care plan for the PICC line for one sampled resident (Resident #276) out of 14 sampled residents. The facility census was 27 residents. Record review of IV-therapy.net's undated article titled Policy and Procedure for PICC Line or Midline Catheter Dressing Change showed: -The dressing for a PICC line or midline catheter was required to be changed every seven days and as needed when the dressing was loose, damp, or soiled. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician orders; to complete a safety assessment for the use of one-half bed side rail (is a adjustable metal or ridge plastic bar placed on the bed); to update the care plan for the use of side rails; and to have documentation of ongoing monitoring during the use of the bed side rail and for the safety of one sampled resident (Resident #13) out of 14 sampled residents. The facility resident census of 27 residents. Requested the facility's Side Rail-Restraint policy and was not provided at the time of exit. 1. Record review of Resident #13 admission Face-Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of: -Muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a manner appropriate for one sampled resident (Resident #16) out of 14 sampled residents. The facility census was 27 residents. Record review of the International Dysphagia Diet Standardization Initiative (IDDSI) article Complete IDDSI Framework Detailed Definitions dated July 2019 showed a soft diet: -Could not contain any regular dry bread, sandwiches, or toast of any kind. -Could not contain food with a floppy textures as it would be a choking risk; if they are not chewed into small pieces they become thin and wet and can form a covering over the opening of the airway, stopping air from flowing. Record review of the facility's policy titled Soft Diet dated 7/14/21 showed this type of diet excluded toast. [...]