Parkway Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #6) was free from abuse when on 5/28/26 Resident #6 was hit by Resident #7 causing a skin tear to Resident #6's right eyebrow area out of 13 sampled residents. The facility census was 60 residents. On 6/29/26, the Administrator was notified of past non-compliance which occurred on 5/28/26. Immediate interventions were put into place for both Resident #6 and Resident #7. All staff received education prior to their next working shift. The deficiency was corrected on 5/29/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and secure storage for narcotics for two sampled residents (Resident #10 and #11), when the nursing staff did not conduct a shift-to-shift count of the narcotics which resulted in missing narcotics out of 11 sampled residents. The facility census was 68 residents. On [DATE] the Administrator and the Director of Nursing (DON) were notified of the failure, and the facility took immediate action and began an investigation, in-services and education for the nurses and Certified Medication Technicians (CMT). The facility purchased a new locking box for narcotics, relocated liquid and as needed (PRN) narcotics to the nurse cart and restricted access. All changes and training were completed on [DATE]. Additional training for count on shift change and documentation was completed on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) out of five sampled residents, with known diagnoses of dementia, impulsive disorder, bi-polar disorder, anxiety disorder, cognitive impairment, and who was a known elopement risk received adequate supervision to prevent accidents. On 02/28/26, the magnetic door locks and alarm failed on the secured unit. Staff assigned to supervise the resident, to ensure safety, left the resident unsupervised. The resident went out the door, located off a busy street and major highway, between 7:15 P.M. and 7:20 P.M. The resident remained unaccounted for until 03/01/26 at 2:00 P.M., when he/she was found on the public transit system in a major metropolitan area. The facility census was 69 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six sampled residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #7 and Resident #11) received medications as prescribed by the physician out of 13 sampled residents. The facility census was 49 residents. Review of the facility's Medication Administration Policy dated 4/6/17 and revised on 6/26/24 showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -It was the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines. -Sign Medication Administration Record (MAR) after administering medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. The facility assigned one nurse to be on a locked memory care unit and the Transitional Unit at the same time to pass medications, monitor resident behaviors and document such behaviors, leaving one other staff member on each unit, as a result medications were not given to the residents. The facility census was 49 residents. Review of the facility's Sufficient Staff Policy dated 5/18/24 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized service care plan that identified resident triggers and de-escalation needs to maintain the resident's highest physical, mental and psychosocial well being for one sampled resident (Resident #3) out of 13 sampled residents. The facility census was 49 residents. Review of the facility Behavioral Contracts Policy dated 4/30/24 showed: -Residents who exhibit behaviors which could endanger themselves, other residents, or staff may benefit from a behavioral contract to ensure they are receiving appropriate services and interventions to meet their needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly complete an assessment for capacity to consent per the facility policy for one sampled resident (Resident #2) including coordination and participation with all health professionals out of 13 sampled residents who were known to engage in sexual activity. The facility census was 49 residents. Review of the facility Sexual Activity Abuse and Neglect Policy, dated 5/14/24, showed: -Residents that are wishing to engage in sexual activity will be allowed to participate in these activities as long as both parties consent and have the ability to consent. Nonconsensual acts and acts of impact negatively on the resident community such as public displays shall not be allowed. -If the resident has a guardian or cognitive impairment an assessment should be completed to determine the resident's ability to consent. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a broken window on a locked behavioral and mental health unit from 3/22/25 to 4/16/25 was replaced and cleaned up. Broken glass shards were left on the unit and accessible to all residents on the unit. All resident on the unit had the potential for harm with broken glass left unattended. The facility census was 49 residents. Review of the facility Incidents and Accidents Policy dated 5/18/24 showed: -It is the policy of this facility for staff to utilize Point Click Care Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. -Accident refer to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' personal possessions were maintained and failed to ensure the residents' dignity when having to wear clothes that didn't fit or were not in good repair for five sampled residents (Residents #5, #41, #42, #43, and #10) and three supplemental residents (Residents #16, #21, and #50) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's policy, Dignity and Respect, dated 6/29/23 showed: -Every resident has a right to be treated with dignity and respect. -All the residents' possessions, regardless of their apparent value to others, must be treated with respect. -Residents have the right to retain and use personal possessions to assist each resident in maintaining their independence. 1. Review of Supplemental Resident #16's care plan dated 5/30/23 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete the residents' Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for six sampled residents (Residents #10, #43, #45, #51, #9, and #41) and one supplemental resident (Resident #16) out of 13 sampled residents. The facility census was 50 residents. Review of the facility policy titled MDS 3.0 Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed: -The purpose of the MDS policy was to ensure that the MDS 3.0 sections were completed accurately and in a timely manner by the responsible parties. -Section F was to be completed by the activity director. -Section F allowed the resident to determine his/her own preferences for daily activities. -Section L was to be completed by the nursing staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or the resident's representative of meetings for care plan (a document that specified health care and supported needs and outlined how the facility met resident requirements) development, review, and revision, for seven sampled residents (Resident #47, #41, #17, #46, #33, #10, and #51) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's policy titled Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 3.0 Care Assessment Summary and Individualized Care Plans dated 11/6/23 showed it did not include any instructions related to inviting the resident and/or their responsible party to participate in care plan meetings. Review of the facility's Comprehensive Care Plans policy, dated 6/26/24 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to hire an adequate number of dietary staff to safely carry out all of the functions of the food and nutrition services, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service and safety. This deficient practice potentially affected all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 50 residents with a licensed capacity for 97 residents at the time of the survey. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. showed the Dietary Manager (DM) was the only staff in the kitchen at that time. During an interview on 10/15/24 between 2:04 P.M. and 2:52 P.M. the DM said the following: -The dietary staff consisted of 1 morning cook and aide and 1 afternoon cook and aide. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional adequacy needs of residents; failed to have basic food items in stock that were called for in their main menus; and failed to have a comparable always available or alternate foods menu posted that was nutritionally equal to the main dishes, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service. This deficient practice potentially affected all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 50 residents with a licensed capacity for 97 residents at the time of the survey. Review of the 7-page Dietary Resident Rights Policy, last reviewed 11/6/23 and provided by the Administrator, showed under Section XIII. [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the kitchen and Dry Storage (DS) room floors clean; failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to maintain plastic and/or rubber cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; and failed to store foodstuffs within recommended temperature parameters, 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 50 residents with a licensed capacity for 97 residents at the time of the survey. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a well-known, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors, to ensure the food's safe and sanitary handling, storage, and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 50 residents with a licensed capacity of 97 residents. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed there was a reach-in refrigerator in a hallway outside the kitchen and a reach-in freezer in the Dry Storage room. Review of the Dietary Resident Rights Policy, last reviewed 11/6/23 and provided by the Administrator, under Section XIII. [...]

Inspectors wrote2. Review of the facility's Infection Prevention and Control Program policy dated 6/26/24 showed: -A system of surveillance was utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. -The Infection Preventionist (IP) served as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility. Review of the facility's Infection Control Surveillance log book for the previous 12 months showed: -No documentation of infection tracking for October 2023, November 2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals, qualified by completing specialized training in infection prevention and control, as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The facility had a census of 50 residents. A policy for Infection Preventionist was requested but not received at the time of exit. 1. Review of the facility Infection Control Surveillance log book showed the Director of Nursing (DON) completed the infection control training modules 1 - 15 on 10/19/24. The final test showed he/she did not pass the IP test. During an interview on 10/21/24 at 2:07 P.M., the DON said: -He/She was the IP for the facility. -He/She was not IP certified. -He/She had been in classes for the IP program since 10/1/24 and finished the last module on 10/17/24. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain essential kitchen cooking, cleaning, and/or storage equipment in a proper and safe operating condition to ensure the ability to meet the residents' nutritional needs in an uncontaminated and timely manner. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility census was 50 residents with a licensed capacity for 97 residents at the time of the survey. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed various kitchen appliances and equipment including, but not limited to, a chemical dishwasher, a stove with a flat-top grilling surface, and a convection oven. During an interview on 10/15/24 between 2:04 P.M. and 2:52 P.M. the DM said the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment for residents in the resident rooms and shared bathrooms. Specifically, resident rooms on the locked dementia unit #104, #105, #102, #106, #103, #101 and #207 had no toilet paper, paper towels, or soap for the residents to utilize after toileting, resident rooms on the locked dementia unit #104, #102, #106, and #105 had broken toilet paper holders, broken or missing baseboards, broken drywall, broken or dirty door vents, missing molding, and resident rooms #104 and #207 were dirty with feces and a dark brown/blackish mold-like substance on the floors and walls. The facility census was 50 residents. Review of the facility's Safe and Homelike Environment policy dated 6/5/24 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing for three sampled residents (Residents #14, #60, and #10) out of 13 sampled residents. The facility census was 50 residents. Review of the Facility's Notification of Changes Policy dated 5/14/2024 showed: -The purpose of the policy was to ensure that the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his/her authority, the resident's representative when there was a change requiring notifications. -The facility must have informed the resident, consulted with the resident's physician, and/or notified the resident's family member or legal representative when there was a change that required such notification. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notification to a resident or resident representative upon transfer or discharge for three sampled residents (Resident #14, #60, and #10) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Bed Hold Policy, date 11/6/23, showed: -When a resident was admitted to the facility, they received a copy of the bed hold policy from the admission Packet. -When a resident was discharged to the hospital or went on therapeutic leave, the facility provided a copy of the Bed Hold Policy to the resident or resident representative. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for three sampled residents (Residents #14, #9, and #41) out of 13 sampled residents. The facility census was 50 residents. Review of the facility policy titled Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) 3.0 Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed there were twenty (20) areas that could become triggered areas for concern and must be addressed with individualized interventions on the plan of care for the resident. Review of the facility's policy titled Comprehensive Care Plans dated as revised on 6/26/24 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure three sampled residents (Resident #5, #41, and #43) had assistance by the staff for oral cares, out of 13 sampled residents. The facility census was 50 residents. Review of the facility's policy, Activies of Daily Living, dated 5/18/24 showed: -Care and services would have been provided for the following activities of daily living; -Bathing, dressing, grooming, and oral care. -A resident who was unable to carry out activities of daily living would have received the necessary services to maintain good oral hygiene. 1. Review of Resident #5's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 7/14/24 showed: -He/She was severely cognitively impaired. -He/She had Dementia (a group of thinking and social symptoms that interferes with daily functioning). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the interests as well as the physical, mental, and psychosocial well-being for four sampled residents (Residents #8, #14, #9, and #41) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Activities policy, dated 7/19/23, showed: -The purpose of the policy was to ensure that all residents were provided an ongoing program of activities designed to meet their interests and their physical, mental, and psychosocial well-being. -The activities calendar was posted on each unit and included activities that were appropriate for the general population that met the specific needs, interests, and supported the quality of life. -The activities director documented each resident's activity within the facility daily. [...]

Inspectors wroteBased on observation and interview, and record review, the facility failed to maintain a safe, functional, and comfortable environment by allowing tripping hazards to be created in at least four locations throughout the facility. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. Additionally the facility failed to supervise residents in the dining room, failed to safely transfer the resident off the floor and failed to have an appropriate wheelchair for one sampled resident (Resident #45) out of 13 sampled residents. The facility had a census of 50 residents with a licensed capacity of 97 residents at the time of the survey. 1. Observation on 10/18/24 between 12:59 P.M. and 1:41 P.M. showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift where residents and visitors could easily see it. The facility census was 50 residents. The facility staffing policy was requested and not received at the time of exit. 1. Review of the Facility assessment dated [DATE] showed the required daily nursing services was: -1 Registered Nurse (RN). -1 Licensed Practical Nurse (LPN). -4 Certified Medication Technician (CMT)'s. -13 Certified Nursing Assistant (CNA)'s. Observation on 10/15/24 at 8:30 A.M., showed: -No posted staffing sheet at the entrance reception desk and glass case near the door to the [NAME] hall. -No posted staffing sheet on the [NAME] or Cherry halls. Observation on 10/16/24 at 11:18 A.M., showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oncoming and off going nursing staff counted the narcotics at the same time, failed to ensure the nursing staff did not pre-sign the narcotic count sheets, failed to ensure the count was correct by totaling the narcotic cards daily, failed to ensure all nursing staff was counting the narcotics, and failed to ensure the narcotic count sheets were accurate for three sampled residents (Resident #24, #2, and #11) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Controlled Substance Administration and Accountability policy dated 5/14/24 showed: -The facility will have safeguards in place in order to prevent loss or diversion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a gradual dose reduction (GDR-tapering of a medication dose) of a psychotropic (a medication that affected mental activity, behavior, or perception) medication was attempted for two sampled residents (Residents #41 and #51) and failed to ensure labs were drawn as ordered to provide adequate monitoring for one sampled resident (Resident #14) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy, dated 5/14/24, showed: -Residents who used psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated. -Dose reductions and behavioral interventions were part of the medication management. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were locked when nursing staff was not in direct observation of the medication cart, failed to ensure there were no extra objects in with the residents prescribed medications, and failed to ensure there were no loose pills in the drawers of the medication cart, The facility census was 50 residents. Review of the facility's policy, Medication Storage Policy, dated 5/18/24 showed: -All drugs and biologicals would have been stored in locked compartments. -During a medication pass, medications must have been under the direct observation of the person administering medications or locked in the medication storage area/cart. -Disinfectants were to have been stored separately from internal medications. 1. Observation on 10/16/24 from 9:42 A.M. to 9:48 A.M., showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a facility-wide infection prevention and control program that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic usage. Five sampled residents included in the antibiotic stewardship review out of 13 sampled residents. The facility census was 50 residents. Review of the facility Antibiotic Stewardship Program policy dated 6/29/23 showed: -The facility will track and monitor antibiotic prescribing practices and resistance patterns among its residents. -At the end of each month, the Facility Antibiotic Steward will print the Monthly Infection Log and place the report in the Antibiotic Stewardship Program binder. -All antibiotics will be entered into the Physician Orders in the electronic medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided education to accept or decline the influenza and/or pneumococcal vaccine for four sampled residents (Residents #43, #46, #41, and #33) out of 13 sampled residents. The facility census was 50 residents. Review of the facility Influenza and Pneumococcal Immunization policy dated 5/14/24 showed: -This policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable diseases. -As 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. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure provision and documentation of education regarding the benefits, risks and potential side effects associated with the COVID-19 (a new disease caused by a novel (new) coronavirus) vaccine for residents upon admission to the facility for one sampled resident (Resident #33) out of 13 sampled residents and for two out of seven sampled staff (Employees C and E). The facility census was 50 residents. A policy for COVID vaccination for residents and staff was requested and not received at the time of exit. 1. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical record showed no documentation of education, administration, and/or declination of the COVID vaccine since admission to the facility. 2. Review of Employee C's employment record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNA). The facility census was 50 residents. Policies were requested for staffing and 12-hour education/in-service and were not received at the time of exit. 1. Review of the Facility assessment dated [DATE] showed: -Facility assessment would be used to ensure there were a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. -The facility was licensed for 97 beds. -The average number of occupied beds during the previous quarter was 48. -Staffing as described (in the assessment) was adequate as evidenced by: --License. --In-Services. --Performance evaluations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #41) who was identified as a person with limited English proficiency was provided with a means of translating into his/her language so the resident could have been fully evaluated and participated in activities on his/her unit out of 12 sampled residents. The facility census was 50 residents. 1. Review of Resident #41's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a group of thinking and social symptoms that interferes with daily functioning). -Cognitive communication deficit ( a communication impairment that was caused by an underlying cognitive deficit, rather than a speech or language deficit). -Need for assistance with personal care. -The resident had a guardian. -The resident resided on a locked Memory Care unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Residents #2 and #19) out of two sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 50 residents. Review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an alleged allegation of abuse was reported to the state agency within the required time frame of no later than two hours after the allegation was made for one sampled resident (Resident #23) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed: -The facility reported all allegation of abuse/neglect/exploitation or mistreatment were reported immediately to the Administrator of the facility and other appropriate agencies in accordance with current state and federal regulations. -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. -Instances of abuse that caused physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff for care planning) was accurate for one sampled resident (Resident #46) out of 13 sampled residents. The facility census was 50 residents. 1. Review of Resident #46's Annual MDS, dated [DATE] showed: -His/Her Brief Interview for Mental Status (BIMS) should have been assessed. -The BIMS summary score for level of cognition was not scored. -He/She had the following diagnoses: --Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change comprehensive assessment within 14 days after the resident was placed on hospice (end of life care) for one sampled resident (Resident #45) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's policy titled Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 3.0 Care Assessment Summary and Individualized Care Plans dated 11/6/23 showed it did not include any instructions related to a significant change. 1. Review of Resident #45's MDS showed a quarterly MDS was completed on 1/24/24. Review of the resident's current physician's order sheet showed the resident admitted to hospice on 2/16/24. Review of the resident's care plan dated 3/8/24 showed: -The resident had a terminal prognosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a mental disorder and individuals with intellectual disabilities had a DA-124 level I screen (used to evaluate for the presence of psychiatric conditions to determine if a Preadmission Screening/Resident Review ((PASRR-a federal program implemented in 1987 to: Prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care)) level II screen is required) and failed to ensure the follow-through of the PASRR recommendations and failed to integrate the recommendations into the care plan for two sampled residents (Resident #9 and #41) out of 13 sampled residents. The facility census was 50 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow-up regarding the resident's responsible party's request for monitoring after chemotherapy and radiation treatment for cancer and failed to clarify the resident's related diagnoses for one sampled resident (Resident #10) out of 13 sampled residents. The facility census was 50 residents. The facility did not have a policy related to this care area. 1. Review of Resident #10's census showed he/she admitted to the facility in January 2023. Review of the hospital emergency department provider note dated 1/16/24 showed the resident had a past medical history of liver cancer. Review of the resident's nurse's note dated 9/12/24 written by Licensed Practical Nurse (LPN) A showed the resident's responsible party had questions about an oncologist visit and prostate (a small gland in men that helps make semen) exam. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two sampled residents (Resident #51 and #33) received a vision exam and glasses out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Hearing and vision policy last revised on 6/26/24 showed: -Ensure all residents have access to vision services and receive adaptive equipment as indicated. -The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision abilities to provide person-centered care. -Employees should refer any identified need for vision services/appliances to the social worker/social service designee. -Once vision services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging transportation. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) completed by the pharmacist was reviewed and responded to by the facility physician(s) and failed to monitor for side effects of anti-psychotic (the main class of drugs used to treat people with schizophrenia) medications for two sampled residents (Resident #47 and #51) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's Medication Regimen Review Policy, dated 6/26/24, showed: -Each resident was reviewed at least once a month by a licensed pharmacist. -The MRR was a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine and emergency dental services to meet the needs of residents were offered for two sampled residents, (Resident #9 and #17) out of 13 sampled residents. The facility census was 50 residents. Review of the facility policy titled Dental Services, updated on 6/26/24, showed: -It is the policy of the facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. -Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that requires immediate attention by a dentist. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to notify the next of kin timely of one sampled resident's (Resident #1) significant change of condition out of five sampled residents. The facility census was 89 residents. Review of the facility policy for Notification of Changes revised [DATE] showed: -The purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician, and notified, consistent with his/her authority, the resident's representative when there was a change in the resident's condition. -Significant changes in the resident's physical, mental or psychosocial condition such as a deterioration in the resident's health, mental or psychosocial status. -Changes in the resident's condition could have been life-threatening conditions, or clinical complications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety when one sampled resident (Resident #1) out of nine sampled residents, drank an unknown liquid substance from an unmarked spray bottle. The facility census was 89 residents. The Administrator was notified on 8/2/24 of Past Non-Compliance which occurred on 7/31/24. The facility had done a safety sweep, put locks on cabinents on the unit for storage and in-serviced all nursing and housekeeping staff before the start of their next shift. The facility had corrected their deficiency 8/1/24. Review of the facility's Accidents and Supervision Policy, revised 5/18/24, showed: -The resident environment was free of accident hazards as much as possible. -Each resident received adequate supervision to prevent hazards, including: --Identify hazards and risks. --Evaluate and analyze hazards and risks. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one sampled resident (Resident #1) from financial exploitation when Housekeeper A received $50 from the resident for personal use out of 10 sampled residents. The facility census was 92 residents. Review of State Statute RSMo 570.145 showed: -Financial exploitation of a person with a disability - penalties - certain defense prohibited, additional violation, restitution. -A person commits the offense of financial exploitation of a person with a disability if such person knowingly obtains control over the property of the person with a disability with the intent to permanently deprive the person of the use, benefit or possession of his or her property thereby benefiting the offender or detrimentally affecting the person with a disability by: (1) Deceit; (2) Coercion; [...]

Inspectors wroteBased on interview and record review, the facility failed to report to local law enforcement agency when one sampled resident (Resident #1) was financially exploited out of 10 sampled residents. The facility census was 92 residents. Review of State Statute RSMo 570.145 showed: -Financial exploitation of a person with a disability - penalties - certain defense prohibited, additional violation, restitution. -A person commits the offense of financial exploitation of a person with a disability if such person knowingly obtains control over the property of the person with a disability with the intent to permanently deprive the person of the use, benefit or possession of his or her property thereby benefiting the offender or detrimentally affecting the person with a disability by: (1) Deceit; (2) Coercion; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when a staff member threw a plastic meal tray at the resident, hitting the resident on his/her upper lip and causing the resident to go to the hospital and receiving eight stiches to the space between his/her lip and nose. Facility staff failed to protect three residents (Resident #2, #3, and #10) out of 10 sampled residents, from abuse by another resident. On 5/22/24, Resident #2 self-propelled him/herself towards Resident #10 unprovoked and struck him/her in the face causing his/her nose to bleed. On 5/28/24, Resident #2 called Resident #3 a racial slur and struck the resident. In response, Resident #3 struck Resident #2 multiple times, causing two skin tears and a knot on the resident's head. The facility census was 92. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent one sampled resident (Resident #1) out of three sampled residents from leaving his/her locked unit, going through the locked outer door and exiting the facility on 4/30/24. The facility census was 86 residents. On 5/7/24, the Administrator was notified of the past noncompliance which occurred on 4/30/24. The facility administration was notified on the same day of the incident and the investigation was started. The facility implemented immediate safeguards to prevent any further elopement from the locked unit. The residents' Care Plans were updated. All staff were in-serviced and visitors notices were placed. The deficiency was corrected on 5/1/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #2) was free from abuse when on 2/19/24 Resident #1 punched Resident #2 in his/her face resulting in facial hematoma (solid swelling of clotted blood within the tissues) out of five sampled residents. The facility census was 91 residents. A policy was requested from the facility on abuse and this was not received. On 3/1/24, the Administrator was notified of the past noncompliance which occurred on 2/19/24. The facility administration was notified on the same day of the incidents and the investigation was started. Facility staff were educated on abuse and neglect policy, resident intervention and behaviors including de-escalation before the start of the next shift. New rules were given for the smoking porch. The residents' Care Plans were updated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility doors were secure on the locked unit for one sampled resident (Resident #2) out of three sampled residents. The facility census was 87 residents. On 2/1/24, the facility Administration was notified of the past noncompliance which occurred on 1/23/24. Facility staff were educated on 1/23/24 and maintenance to the door was completed on 1/23/24. The deficiency was corrected on 1/23/24. Review of the facility policy titled, Elopement Protocol, dated 1/19/22 showed: -An elopement will be defined as any time a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown. -The first person aware of an elopement will call a Code White to the area of the believed elopement, if known. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep one sampled resident (Resident #1) free from physical abuse when on 9/29/23, Certified Nursing Assistant (CNA) A grabbed Resident #1 by the neck and left shoulder, forcing him/her to sit down in a chair with enough force to cause the chair to tip back and then CNA B placed his/her hands on the resident's shoulders in attempt to keep the resident seated in the chair, out of eleven sampled residents. The facility census was 84 residents. On 10/12/23, the Administrator was notified of the past noncompliance which occurred 9/29/23. The facility administration observed the incident while viewing the facility's locked dementia unit camera on 10/1/23 and immediately began the investigation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication pass and to accurately document medication administration for two out 17 sampled residents and nine out 19 supplemental sampled residents who were administrated double doses of evening medication or failed to document medication given. The facility resident census was 92 residents. Record review of the facility's Medication Administration and Monitoring Policy revised on 9/17/22 showed: -It is imperative that all medications are given using the seven rights to medication administration. --The right Resident, the right medication, the right dose, the right route, the right time the right documentation and the right dosage form. -Ensure that documentation was correct in the resident Medication Administration Record (MAR). [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the faucet of the three-compartment sink in good repair; to maintain the floor at the side and under the six burner stove free of food debris; to maintain areas of kitchen free from standing water; to maintain the ceiling and ceiling fixtures in the kitchen free of a heavy dust buildup; to ensure the salad greens in the kitchen refrigerator, were fresh; to ensure there were paper towels available at the hand washing sink; to have test strips for the sanitizing water at the three compartment sink; to ensure the thermometer was calibrated ((correlate the readings of (an instrument) with those of a standard in order to check the instrument's accuracy); to ensure utensils were stored free from food debris in the utensil drawer; to ensure two employees had their hair completely covered within a hair restraint or hair net; [...]

Inspectors wroteBased on observation, interview, and record review, failed to maintain proper infection control practices during a blood sugar check for one supplemental resident (Resident #34); failed to ensure work surface was cleaned and disinfected and maintain proper hand hygiene during medication pass for four supplemental residents (Resident #25, #76, #22 and #11); and failed to maintain the proper documentation of Tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing records for one sampled resident (Resident #24) out of 17 sampled residents and 17 supplemental residents and for 6 out of 10 sampled employees. The facility census was 92 residents. Record review of CDC.gov's article titled Medication Preparation Questions, dated 6/20/19, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain resident rooms [ROOM NUMBERS] free from a strong urine odor; to maintain the ceiling fans in the Memory Unit dining Room free of a buildup of dust; to ensure all light fixtures in the Memory Unit and [NAME] Dining rooms worked so they could provide illumination; to prevent a damaged sheet from being used in resident room [ROOM NUMBER]; to ensure the floors in resident rooms 33, 34 37, 105, 106, 207, 204, 310, 303, 305, 412, 411, 410, 405 and 406 were maintained clean and in good repair; to maintain the mattresses in resident rooms 34, 102 and 209 in good repair and easily cleanable; to maintain the commode seat in resident room [ROOM NUMBER] in an easily cleanable manner; to maintain the ceiling of resident room [ROOM NUMBER], free from cobwebs; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of the comprehensive care plans for one sampled resident (Resident #76) and to create a comprehensive care plan after an admission or readmission for two sampled residents (Resident #82 and #24) out of 17 sampled residents. The facility census was 92 residents. Record review of the facility's policy titled Comprehensive Care Plans and Baseline Care Plans dated 1/19/22 showed: -The interdisciplinary team was to work together to ensure the accuracy of the information gathered. -The comprehensive care plan was to be completed within 14 days of admission. -The care plan will be oriented toward managing risk factors, evaluating treatment and outcomes of care, and using current standards of practice in the care planning process. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure hot foods (pancakes and sausage) were served at or close to a temperature at 120 ºF (degrees Fahrenheit) at the time of service to the residents in the [NAME] dining room. This practice potentially affected at least 15 residents who ate breakfast in the [NAME] dining room. The facility census was 92 residents. 1. Observation of the breakfast food service in [NAME] Dining Room on 12/5/22 from 9:58 A.M., through 10:40 A.M., showed: - At 9:59 A.M., the temperature of pancakes was 114 ºF on the steam table. - At 10:01 A.M., the temperature of the sausage patties was 105 ºF on the steam table. - At 10:11 A.M., the temperature of the sausage patties was 101.3 ºF on the steam table. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the steam tables on Cherry Lane and the Memory Unit in good repair. This practice potentially affected 59 residents who resided in those areas. The facility census was 92 residents. 1. Observation on 12/5/22 at 1:29 P.M., showed the steam table on Cherry Lane had two bent legs, which caused the steam table to be unsteady if it were moved. During an interview on 12/5/22 1:36 P.M., Dietary Aide (DA) A said he/she had been here for four years and the steam table has had those bent legs. During an interview on 12/5/22 at 2:57 P.M., the Dietary Manager (DM) said the steam table had been in that condition since he/she started which was around March 2022. During an interview on 12/6/22 at 9:29 A.M., the Administrator said no one told him/her about the damage to the steam table until 12/5/22. During an interview on 12/6/22 at 9: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system operated properly in resident rooms 33, 32, 37, 38, 39, 30, 40, 102, 106, 207, 209, 401, and the Memory Unit shower room; and to record that call lights were not operating properly in the maintenance logs at each nurse's station. This practice potentially affected 35 residents who resided in those rooms or used that shower room. The facility census was 92 residents. 1. Observations with the Housekeeping Supervisor and the Maintenance Director on the Memory Unit on 12/8/22, showed: -At 10:09 A.M., the call light cords were absent in resident room [ROOM NUMBER]. -At 10:16 A.M., the call light signal did not illuminate the signaling light outside the door, when the call light button was pressed at resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation and interview, the facility failed maintain the ceiling in the dry goods storage room in good repair; to ensure the drainage in the janitor's closet across from resident room [ROOM NUMBER] operated properly; to ensure the area under the vending machines next to the elevator from the Memory Unit was free from pieces of candy and grime; to ensure the elevator well next to the kitchen, was free of spilled food;to ensure the shower rooms were free of a mildew like substance; and to repair a broken vent edging which had a sharp edge in in resident room [ROOM NUMBER]. This practice affected three non-resident use areas and two residents in resident room [ROOM NUMBER]. The facility census was 92 residents. 1. Observation with the Dietary Manager (DM) on 12/5/22 at 2:32 P.M., showed two damaged areas in the ceiling above the dry-good storage room. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was adequate ventilation in the Memory Unit Shower room and the shower room across from resident room [ROOM NUMBER], to remove excess moisture from those shower rooms. This practice potentially affected 59 residents who used the showers in those areas of Memory Unit and Cherry Lane. The facility census was 92 residents. Note: Exhaust air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was sucked up then negative air flow was present; if the paper fell and was not drawn up towards the vent, then negative airflow was absent. 1. Observation with the Housekeeping Supervisor and the Maintenance Director on 12/8/22 at 10:34 A.M., showed the lack of negative airflow ventilation. [...]

Inspectors wroteBased on interview and record review, the facility failed to invite two sampled residents (Resident #45 and #58) to their quarterly care plan meetings out of 17 sampled residents. The facility census was 92 residents. Record review of the facility's policy titled Comprehensive Care Plans and Baseline Care Plans dated 1/19/22 showed no policy for invitation to care plan meetings. 1. Record review of Resident #45's undated face sheet showed he/she admitted with the following diagnoses: -Type 2 Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Chronic Pain (persistent pain last several weeks or years). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one employee, Certified Medication Technician (CMT) A, provided meal service to one sampled resident (Resident #8) out of 17 sampled residents in a dignified manner. The facility census was 92 residents. Record review of the facility's policy entitled Dignity and Respect, last reviewed on 7/9/21, showed: -Every resident had the right to be treated with dignity and respect. -All staff should speak to and treat all residents with dignity and respect. -All of the residents' possessions, regardless of their apparent value to others, must be treated with respect. 1. Observation during lunch meal service on 12/5/22 at 1:52 P.M., showed the following: -Resident #8 made a statement about wanting a second serving of the lunch meal. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL) form to Missouri (MO) HealthNet within 30 days of the death of two sampled residents (Residents #96 and #97) out of six sampled residents for resident funds review. The facility census was 92 residents. 1. Record review of the Admission/Discharge to/from Report dated 12/6/22 showed: -Resident #96 passed away on 8/8/22. -Resident #97 passed away on 8/19/22. During an interview on 12/6/22 at 1:06 P.M., the Business Office Manager (BOM) said: -Resident #97 had $6.00 in his/her account when he/she passed away and he/she submitted a form entitled a Report of Change to the Social Security Administration (SSA) to notify the SSA that Resident #97 was not a resident at the facility anymore and he/she did not fill out a TPL form. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy was maintained for one sampled resident (Resident #24) out of 17 sampled residents. The facility census was 92 residents. Record review of the facility's policy titled Resident's Rights dated 4/29/21 showed personal privacy includes accommodations, medical treatment, and personal care. 1. Record review of Resident #24's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Personal History of Traumatic Brain Injury (TBI- external force to the brain that causes temporary or permanent brain damage). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff for care planning) for one sampled resident (Resident #82) out of 17 sampled residents. The facility census was 92 residents. Record review of the facility's policy titled Comprehensive Care Plans and Baseline Care Plans dated 1/19/22 showed: -Each discipline was to gather information that covered the observation period. -The interdisciplinary team (IDT) was to work together to verify for accuracy. 1. Record review of Resident #82's Face Sheet showed he/she was re-admitted on [DATE] with the following diagnoses: -Obesity. -Hypertension (high blood pressure). Record review of the resident's admission MDS, dated [DATE], showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing home or long term care) Level I was completed for one sampled resident (Resident #24) out of 17 sampled residents. The facility census was 92 residents. 1. Record review of Resident #24's undated face sheet showed the resident admitted to the facility with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Personal History of Traumatic Brain Injury (TBI- external force to the brain that causes temporary or permanent brain damage). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one sampled resident (Resident #58) with proper Activities of Daily Living (ADL) care necessary to maintain grooming needs out of 17 sampled residents. The facility census was 92 residents. A policy of the facility's ADL care standards was requested and not received at the time of exit. 1. Record review of Resident #58's undated face sheet showed he/she was admitted with the following diagnoses: -Chronic Kidney Disease (CKD- a gradual loss of kidney function). -Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). [...]

Inspectors wroteBased on observation, interview and record review, showed the facility failed complete a comprehensive fall investigation to include the root cause for one sampled resident (Resident #74) who was at risk for falls out of 17 sampled residents. The facility resident census was 92 residents. 1. Record review of Resident #74's admission face sheet showed he/she was admitted to facility with diagnose of Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait) and Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Record review of the resident's Facility un-witnessed incident report dated 10/12/22 at 9:30 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow physician order for a specialized cup and to transcribe and obtain new physician's order recommended diet changes, for speech therapy for one sampled resident (Resident #60) out 17 sampled residents. The facility had resident census of 92 residents. 1. Record review of Resident # 60's admission face sheet showed he/she had diagnoses of a foreign body in respiratory tract, part causing asphyxiation (choking on food or drinks that became lodged in the airway or lungs of an adult patient) and a had history of a stroke that affected the resident's left side. Record review of the resident's physician communication note dated 9/29/22 at 11:38 A.M. showed: -The resident had diagnosis of Aspiration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for a Continuous Positive Airway Pressure machine (CPAP-a device that ensures your breathing is not obstructed through the night by continuously applying air pressure through your nose and or mouth) was transcribed onto the physician's order sheet to include the air pressure setting of the machine, the frequency of use, document maintenance of the tubing and face mask; to ensure the face mask for the CPAP remained covered when not in use to prevent cross contamination, for one sampled resident (Resident #57); and to ensure a nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) was covered when not in use for one sampled resident (Resident #76) out of 19 sampled residents. The facility census was 92 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure orders were present for dialysis cares and to maintain records of dialysis communications for one sampled resident (Resident #76) out of 17 sampled residents. The facility census was 92 residents. Record review of the facility's policy titled Dialysis dated 3/8/22 showed: -The facility was to assess the resident and monitor for complications before and after dialysis treatments. -The facility was to have ongoing communication and collaboration with the dialysis clinic. -Nurses were to monitor the bruit (a rumbling or swooshing sound caused by the high-pressure flow of blood through the fistula (a surgically created connection between an artery and vein) every shift and document on the Treatment Administration Record (TAR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent for three supplemental residents (Resident #34, #22, and #11) out of 19 supplemental residents. The medication error rate was 9.8%. The facility census was 92 residents. Record review of the facility's policy titled Blood Glucose Monitoring and Insulin Administration dated 7/9/21 showed there was no policy for insulin (a hormone produced in the pancreas that regulates the amount of glucose in the blood) pen administration. A policy of the facility's inhaler administration and medication pass policy was requested and not received at the time of exit. 1. [...]

Inspectors wroteBased on observation, interview and record review, the dietary staff failed to follow the recipe for pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) chicken and to follow the recipe to make gravy for mechanical (a type of texture-modified diet in which the food was chopped for people who have difficulty chewing and swallowing to make eating safer) chicken. This practice potentially affected two residents with pureed diets and five residents with mechanical soft diets. The facility census was 92 residents. 1. Record review of the undated recipe for five servings of pureed baked chicken showed: - 5 servings of prepared chicken. - 1/2 teaspoon (tsp) chicken base. - 5 ounces (oz.) of water. - 1 ¼ tablespoon commercial thickener. Directions: - Measure number of pureed portions required from the regular recipe. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the outdoor dumpster lids were closed on 12/5/22 and 12/6/22, and failed to ensure the kitchen trash container was maintained closed when it was not being actively used by dietary staff. This practice affected one outdoor area and the kitchen area. The facility census was 92 residents. 1. Observations on 12/5/22 at 8:31 A.M., 10:44 A.M., 12:15 P.M. and 4:11 P.M., and on 12/6/22 at 7:55 A.M. and 10:31 A.M., showed the lid of the outdoor dumpster was not closed. During an interview on 12/6/22 at 10:33 A.M., the Dietary Manager (DM) said he/she would have to remind facility staff to close the dumpster lids when they threw trash into it. 2. Observations on 12/5/22 at 9:34 A.M., 10:43 A.M., 11:22 A.M., and 2:40 P.M., showed one trash container in kitchen with an open lid. [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent the presence of gnats (small flies) under the automated dishwasher area in the kitchen, an unlabeled room in the Memory Unit and in resident room [ROOM NUMBER]. This practice potentially affected two non-resident use areas and three residents in resident room [ROOM NUMBER]. The facility census was 92 residents. 1. Observation on 12/5/22 at 10:51 A.M., showed numerous gnats under dishwasher flying around and crawling around standing water that was present under the automated dishwasher. During an interview on 12/6/22 at 9:31 A.M., the Corporate Dietary Person said the drainage box for the automated dishwasher was pushed in too far and caused the water to overflow on to the ground. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer and provide residents appropriate, alternative food substitutes that were nutritionally consistent with the usual and/or ordinary food items provided by the facility and to ensure one sampled resident (Resident #84) was provided an alternate meal consistent with his/her dietary Physician's orders. The facility census was 92 residents at the time of the survey. 1. Record review of Resident #84''s Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Care Plan dated 3/02/19 showed he/she was independent with eating and able to feed himself/herself without issues. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated tool required to be completed by the facility staff for care planning) dated 10/11/19 showed he/she: -Was cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to determine refrigerated food storage temperatures; to store opened food in a sanitary manner; to determine whether sanitary conditions were met for food and non-food contact surface areas before, during and after food preparation; to maintain a sanitary manual can opener blade; to maintain refrigerated units in a sanitary condition; to store kitchen equipment in a sanitary manner and to adhere to hygienic practices. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen trash was emptied in a timely fashion to prevent the potential harborage and feeding of pests. The facility census was 92 residents. 1. Observation on 1/21/20 at 9:07 A.M., and at 11:05 A.M., showed the kitchen trash container's lid was open with trash overflowing the trash container and could not be closed due to the amount of trash in the container. During an interview on 1/21/20 at 9:13 A.M., the Dietary [NAME] said that this was a common occurrence every morning, where the dietary staff did not empty the trash container from the night before. 2. Observation on 1/27/20 on 5:09 A.M., showed the kitchen trash container's lid was open and could not be closed due to the amount of trash in the container. Record review of the 2013 edition of the U.S. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a nebulizer and mouth piece was stored in a manner to prevent contamination for one sampled resident (Resident #78) and to ensure an annual review of the facility's infection prevention and control program (IPCP) out of 19 sampled residents . The facility census was 92 residents. Record review of the facility Infection Control Program policy dated 11/28/16 showed: -The purpose of the policy is to ensure the facility's infection control program provides written standards including policies and procedures that identifies, prevents and monitors possible communicable diseases or infections before they can spread to other persons in the facility. -The facility Infection Control Program includes the following policies, but not limited to: --Handwashing Policy. --Gloving Policy. --Pericare Policy. --Linen Policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote the right to self-determination and choices by failing to provide access to beverages throughout the day for three sampled residents (Resident's #55, #84 and #74); to honor resident requests for fresh fruit; to ensure one sampled resident (Resident #41) receives more to eat after communicating he/she is still hungry and to provide requested juice to one sampled resident (Resident#79). This potentially effected all residents who come to the common dining areas for beverages and meals. The facility census was 92 residents. Record review of the facility's admission Agreement revised 10/13/11 showed: -The resident had the right of free choice. -The resident shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL) and Criminal Background Check (CBC) were completed in accordance with the state regulation and facility policy on three out of seven employees sampled. The facility census was 92 residents. Record review of the facility policy titled Screening-Applicant, Employee, Volunteer and Vendor (Missouri), effective 01/01/2016 showed Human Resource staff were required to complete identified screens, prior to hire. The required screens included a request for criminal records check, Family Care Safety Registry, Employee Disqualification List, and Certified Nurse's Aide registry verification. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) was accurate, completed timely, and was the correct type of assessment for six sampled residents (Resident's #6, #58, #65, #87, #46 and #78) out of 19 sampled resident's. The facility census was 92 residents. 1. Record review of Resident #6's face sheet dated 1/21/19 showed he/she admitted to the facility on [DATE] with the following diagnoses: -Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) was accurate, completed timely, and was the correct type of assessment for eight sampled residents (Resident's #2, #35, #1, #87, #65, #46, #58 and #78) out of 19 sampled resident's. The facility census was 92 residents. 1. Record review of Resident #2's face sheet dated 1/21/19 showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was completed and was an accurate and appropriate plan of care for five sampled residents (Resident #35, #74, #88, #55, and #78) out of 19 sampled residents. The facility census was 92 residents. Record review of the facility's policy titled Comprehensive Care Plans dated 4/6/17 and updated on 10/1/18 showed: -The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. -The comprehensive care plan must be completed within 14 days of admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic stewardship program that utilized protocols for antibiotic use in the facility. The facility census was 92 residents. Record review of the facility Antibiotic Stewardship Program policy dated 11/28/17 showed: -The purpose of the policy was to optimize antibiotic use in the facility and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach. -The Facility Antibiotic Stewardship Program (ASP) will work closely with the Facility Administrator, facility nurses, physicians and prescribing practitioners to ensure the success of the ASP. -The facility ASP will use a systematic evaluation of ongoing treatment which includes, but is not limited to: --The facility will track and monitor antibiotic prescribing practices and resistance patterns among residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a current copy of the residents' Advanced Directive (legal documents that allow individuals to spell out their decisions about end-of-life care ahead of time) was maintained in the resident's medical record for one sampled resident (Resident #88) and to ensure two sampled residents (Resident #84 and #78) were offered the right to formulate advanced directives out of 19 sampled residents. The facility's census was 92 residents. Record review of the facility policy Advanced Directives, effective 11/16/2018 showed: -Individuals have the right to make decisions concerning provided care, which, included the right to accept, or, refuse medical, or, surgical treatment, and the right to input in formulated advance directives, as permitted under state statutory and case law. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) was fully completed or given for two sampled residents (Resident #44 and #55) out of three sampled residents who were discharged from Medicare Part A services and remained in the facility. The facility had five residents who discharged from Medicare Part A services in the last six months. The facility census was 92 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) for two sampled residents (Resident #74 and Resident #78) out of 19 sampled residents. The facility census was 93 residents. Record review of the Resident Assessment Instrument (RAI) Manual, dated May 2013, P-1 showed a physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. 1. Record review of Resident #74's Face Sheet showed he/she was admitted to the facility on [DATE] and had a diagnosis of nicotine dependence, cigarettes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre admission Screen and Resident Review (PASRR) Level I and Level II was completed for one sampled resident (Resident #87) having developmental disability, out of 19 sampled residents. The facility census was 92 residents. Record review of the Missouri Department of Health and Senior Services Division of [NAME] Services and Regulation Level One Nursing Facility Pre-admission Screening for Mental Illness/Mental Retardation (now known as intellectual disability) or Related Condition (DA-124C) guide, dated 9/2017 showed Major Mental Disorder diagnoses included Bipolar Disorder (formerly called manic-depressive illness or manic depression is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for one sampled resident's (Resident #78) antibiotic eye medication had a stop date, out of 19 sampled residents. The facility census was 92 residents. 1. Record review of Resident #78's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Physician's Orders Sheet (POS) dated 1/15/20 showed: -Gentamycin (antibiotic) 3 milligrams (mg)/milliliter (mL) eye drops, instill two drops into right eye twice daily dated 9/27/19. -A notation that there was no stop date for the antibiotic eye drops. -No diagnosis related to why the resident was using the antibiotic eye drops. Record review of the resident's Medication Administration Record (MAR) dated 1/15/20 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an assessment that include attempted alternative interventions prior to the use of side rails and to ensure documented informed consent (permission given in the full knowledge of the possible risks and benefits of an intervention) for the use of side rails, including specific risks of side rail use for four sampled residents (Resident's #41, #84, #88 and #78) out of 19 sampled residents. The facility census was 92 residents. A policy was requested and the facility did not have a policy regarding the use of side rails. 1. Record review of Resident #41's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Muscle weakness. -Abnormal posture. -Lack of coordination. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nurse Assistants (CNA's) directly responsible for resident care per shift and the resident census on three of three resident living areas. The facility census was 92 residents. 1. Observation on the following dates, and times and locations showed posted staffing did not include actual hours worked for RN's, LPN's and CNA's and did not include the resident census: - 1/21/20 at 9:21 A.M. on [NAME] Lane. - 1/21/20 at 12:05 P.M. on Memory Lane. - 1/21/20 at 12:44 P.M. on Cherry Lane. - 1/23/20 at 9:18 P.M. on Cherry Lane. - 1/23/20 at 1:10 P.M. on Memory Lane. - 1/23/20 at 1:27 P.M. on [NAME] Lane. - 1/24/20 at 10:00 A.M. on Memory Lane. - 1/27/20 at 6:28 A.M. on [NAME] Lane. - 1/27/20 at 7:00 A.M. on Memory Lane. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations were reviewed and acted upon by the physician and to ensure the pharmacy requests were completed timely per the facility policy for two sampled residents (Resident #84 and #88) out of 19 sampled residents. The facility census was 92 residents. Record review of the facility policy titled Monthly Drug Regimen Review, effective 11/28/2016 showed: -Drug regimens are reviewed monthly for each resident and are completed by consulting pharmacists, or pharmacy agents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary anti-anxiety Pro Re Nata (PRN-as needed) medications (medications which affect psychic function, behavior, or experience) were limited to 14 days unless evaluated by the resident's physician, and failed to complete non-pharmacological interventions (alternative therapies such as comfort therapy) prior to administering the medications and failed to document the reason the medication was administered and the effect of the medication for two sampled residents (Resident #74 and #78) out of 19 sampled residents. The facility census was 92 residents. Record review of the facility policy titled PRN Antipsychotic Medication and Psychotropic Medications, effective 11/28/2017 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services were provided for one sampled resident (Resident #84) whose dentures were in poor repair out of 19 sampled residents. The facility census was 92 residents. 1. Record review of Resident #84's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Care Plan dated 3/2/19 showed he/she was independent with eating and wore dentures. Record review of the resident's Social Services Quarterly Notes dated 6/28/19 showed: -The resident notified the Social Services Director (SSD) of problems with his/her dentures. -The SSD contacted a dental service related to the concern with the resident's dentures. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper texture of pureed food for one sampled resident (Resident #41) with swallowing issues out of 19 sampled residents. The facility census was 92 residents. Record review of the undated facility policy titled Therapeutic Diets, showed: -Therapeutic diets are prepared and served as prescribed by attending physician. -Resident's with clinically indicated dysphagia pureed diets are to receive foods blended to a pudding like consistency, which, includes bread and bakery products. -Cream of [NAME] is used in place of rice and corn is to be avoided. 1. Record review of Resident #41's Face sheet showed he/she was admitted to the facility on [DATE] and had the following diagnosis of dysphagia (inability or difficulty swallowing). [...]