Pillars of North County Health & Rehab Center, the

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures for one resident (Resident #6) when staff failed to re-admit the resident from the hospital following an immediate discharge order dismissal. The sample size was six. The census was 58. Review of the facility's Immediate Discharge Policy & Procedure Manual, revised November 2017, showed:-Residents would not be transferred or discharged unless permitted by federal and Missouri regulations. An immediate discharge occurred when the safety or health of the resident or others was endangered, when the facility could not meet the resident's needs, or when the resident's behavior presented an immediate threat;-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for the Abuse Prevention Program to ensure one resident's safety when staff failed to report an abuse allegation immediately to administration for one of four sampled residents (Resident #2). The census was 64. Review of facility policy and procedure for Abuse Prevention Program dated 9/29/22, showed: -Internal reporting requirements and identification of allegations;-Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services that meet professional standards when the facility failed to follow physician orders for one of four sampled residents (Resident #1). The facility did not provide adequate enteral gastrostomy tube (g-tube, a feeding tube inserted into the stomach for resident nutrition, fluids and medications) management, which led to resident weight loss. The census was 64Review of the facility's Enteral Nutrition Policy and Procedure, dated 3/28/25, showed: [...]

Inspectors wroteBased on observation, record review, interviews, and facility recipe review, the facility Dietary [NAME] (DC) failed to ensure the puree chicken lunch entrée was proper texture for four of four residents (Resident (R) 6, R13, R39, and R262) reviewed for pureed diet of 22 sample residents. This failure had the potential to make the entrée unpalatable and difficult to swallow for the residents who required a puree meal.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to maintain the walk-in refrigerator at 41 degrees Fahrenheit (F) or below during two of two observations in one of one kitchen of 55 of 71 census residents which could have caused food spoilage and failed to distribute and maintain clean water pitchers for three of three residents (Resident (R) 47, R61, and R38) observed for cleanliness. This failure had the potential to affect resident safety.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to maintain clean and bug-free bathroom vents, store urinals and plungers in a sanitary manner, and maintain fixtures/equipment in a safe and functional manner for 11 of 26 residents (Resident (R) 27, R24, R43, R111, R14, R9, R112, R56, R11, R26, and R30) observed for the environment. These failures had the potential cause avoidable allergies or spread of infection and injury from broken fixtures/ equipment.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure the call light was within reach for two of 22 sample residents (Resident (R) 163 and R34) reviewed for accommodation of needs and preferences. This failure had the potential to cause R163 and R34 to have unmet care needs.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure one of ten residents (Resident (R) 55) reviewed for bathing had his preference of bathing type of 22 sample residents. The failure affected R55's right to make choices and honor preferences.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse to the Administrator and to the State Survey Agency (SSA) for one of three residents (Resident (R) 24) reviewed for abuse of 22 sample residents. These failures placed residents at risk of continued verbal abuse, which could cause depression, fear, or mental anguish.

Inspectors wroteBased on record review and interviews, the facility failed to obtain a level two pre-admission screening and resident review (PASARR) assessment for one of one residents (Resident (R) 19) reviewed for PASARR of 22 sample residents. This failure could affect R19 from receiving services to assist in the treatment of psychiatric diagnoses.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a comprehensive Care Plan was developed for two of 25 sampled residents (Resident (R) 111 and R27) to address R111's pain and R27's dependence on staff for activities of daily living (ADLs). These failures had the potential to contribute to inadequate or inappropriate pain intervention for R111 and lack of provision of ADL care for R27.

Inspectors wroteBased on observations and interviews, the facility failed to ensure nail care was provided for one of 22 sample residents (Resident (R) 34) reviewed for activities of daily living (ADL). This failure had the potential to cause R34 to have unmet care needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one of 22 sample residents (Resident (R) 55) reviewed for appointments had scheduled physician's appointments. The failure increased R55's risk of delayed medical care.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of three residents (Resident (R) 32) reviewed for dialysis received as-needed medication as ordered and her physician was notified when a dialysis appointment was missed of 22 sample residents. These failures had the potential to cause significant risks, including increased mortality, hospitalization, and cardiovascular complications, due to the buildup of toxins and fluids in the body.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one resident (Resident (R) 14) reviewed for dental was provided with a visit to the dentist as ordered by the physician to address a mouth infection of 22 sample residents. This failure had the potential to lead to spread of infection, increased pain, and difficulty eating for R14.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure three of 22 sample residents (Resident (R) 2, R32, and R7) had accurate physician's orders. These failures had the potential to affect provision of hospice services for R2, provision of dialysis and communication with the dialysis center for R32, and provision of restorative services for R7.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure staff donned (put on) appropriate personal protective equipment (PPE) for three of five residents (Resident (R) 43, R61, and R262) reviewed for use of Enhanced Barrier Precautions of 22 sample residents. These failures had the potential to cause the spread of infection from staff to other residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure two of five residents (Resident (R) 164 and R61) reviewed for vaccinations, who consented to receive vaccinations, were administered the vaccines of 22 sample residents. These failures had the potential to cause avoidable spread of pneumonia or influenza.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their pressure ulcer and wound care policies/procedures by failing to ensure Resident #3's wound care Physician's orders were initiated when ordered, and Registered Dietician's (RD) recommendations were promptly followed. The facility also failed to promptly identify, assess, document and notify the resident's Physician regarding the resident's pressure ulcers located on both feet/heels. In addition, the facility failed to ensure Resident #2, who was admitted on [DATE], with a pressure ulcer on the coccyx (the tailbone), had a treatment order in place until 7/1/24, failed to ensure a nurse contacted the physician for a treatment order prior to administering a treatment to the coccyx, failed to ensure the wound care Physician's orders were initiated and the RD's recommendations were promptly followed. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a full code resident who was diagnosed with COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), in accordance with their policy (Resident #1). The facility did not document assessments of symptoms, vital signs, oxygen saturation levels and respiratory symptoms. The sample was four. The census was 57. Review of the facility's Change in Condition Policy, dated February 2012, showed the following: -Policy: It is the policy of the facility that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner; -Definition: -Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that affects less than two areas of activities of daily living; [...]

Inspectors wroteSee Event ID 8DC412. Based on observation, interview and record review, facility staff failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were within reach for four sampled residents (Residents #204, #18, 406 and #405) with mobility limitations, and by failing to ensure a call light was installed at the bedside for one resident (Resident #407). The census was 58. Review of the facility's Answering the Call Light policy, revised July 2014, showed: -Policy: The purpose of this procedure is to respond to the resident's requests and needs; -General guidelines, included: --Be sure that the call light is plugged in at all times; --When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders to hold one resident's (Resident #400) Eliquis (a blood thinner) three days prior to his/her surgical procedure. This resulted in the resident's urological procedure being canceled and rescheduled for two weeks later. The facility also failed to ensure a specialist's recommendation for nothing by mouth (NPO) was communicated to the physician and followed for one resident with a swallowing disorder (Resident #204). The sample was 11. The census was 58. Review of the facility's Obtaining and Following Physician Orders policy, revised 2014, showed: Policy: It is the policy that physician orders will be obtained by licensed personnel and followed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure general accounting principles were followed for an accurate accounting of all monies, by failing to research outstanding checks and failing to reconcile the resident petty cash. The facility also failed to obtain documentation one resident or his/her responsible party were notified before using his/her funds to purchase personal items for the resident (Resident #4). In addition, the facility also failed to ensure the resident personal resident trust fund (RTF) account was not overdrawn (Resident #25). This affected residents whose funds were managed by the facility. The census was 55. Review of the facility's Resident Rights packet, undated, showed: -The resident has the right to manage his or her financial affairs. [...]

Inspectors wroteBased on interview and record review, the facility imposed a charge for a service for which payment was made under Medicaid for two residents (Resident #36 and #4) out of a sample of 3. The facility census was 55. Record review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed the following: -13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services include, but are not limited to, the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to determine the presence of a federal indicator with the Nurse Aide Registry (NA) check for three of 10 sampled employees hired since the last survey. The facility hired at least 290 new employees since the last survey. The census was 55. Review of the facility's Abuse Prevention Program policy, revised 9/29/22, showed: -Procedures for Prevention; -Pre-employment Screening of Potential Employees; -The facility will not knowingly employ any individual convicted of resident abuse, neglect or misappropriation of property. The facility will not knowingly employ any direct care staff with findings of abuse listed on the Health Care Worker Registry. Prior to a new employee starting a working schedule, the facility will: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure side rails were accurately assessed as a necessary device prior to installation and use. The facility also failed to obtain physician's orders for the use of side rails and failed to document usage in the resident's care plan for four (Residents #10, #47, #41 and #17) of 14 sampled residents. The census was 55. Review of the facility's Bed Rail Maintenance and Installation and Entrapment Prevention policy, revised December 2016, showed: -Purpose: To diminish the potential for and severity of adverse events related to bed rail usage and compatibility of bed rails, mattresses and bed frames; -Procedure; -Center will follow manufacturer's recommendations and specifications for installing and maintaining bed rails; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained when they failed to perform quality control checks of the blood glucose (sugar) test machines to ensure accurate results. The census was 55. Review of the Evencare G3 Blood Glucose Monitoring System User's Guide, Copyright 2016, showed the purpose of the control solution testing is to validate that the EVENCARE G3 Meter is working properly with the test strips. Control solutions are not included in the kit; -You should perform a control solution test when: -Using the meter for the first time; -Using a new package of EVENCARE G3 Blood Glucose Test Strips; -At least once per week to verify that the meter and test strips are working properly together; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow recipes to ensure adequate nutritive value, taste and texture for pureed foods (a very smooth blended food like applesauce or mashed potatoes) for three out of four observations. This deficient practice affected the four residents who ate pureed meals at the facility. The census was 55. Review of the facility's breakfast menu, dated 10/27/23, showed breakfast consisted of choice of cereal, eggs and sausage strata, wheat toast, margarine, juice, milk, coffee or tea. Observation on 10/27/23 at 7:33 A.M., showed [NAME] I prepared puree sausage for three residents. He/She added 6 sausage patties to the blender and one and one half cups of tap water to the blender and blended the mixture for approximately one minute and a half. He/She poured the mixture into a pan for serving. [...]

Inspectors wroteBased on observation and interview, the facility failed to label, date and properly store opened food items and failed to maintain cleanliness in the freezer and refrigerator for four of five days of observations. In addition, the facility failed to discard expired food items and properly store dry foods. This deficient practice had the potential to affect all residents who ate at the facility. The census was 55. 1. Observations of the walk-in freezer on 10/25/23 at 9:38 A.M., 10/26/23 at 10:13 A.M., 10/27/23 at 6:25 A.M. and 10/30/23 at 7:19 A.M., showed: -An opened bag of frozen hamburger patties in a box. The box was opened and the bag was also opened, with the meat patties exposed; -Three unidentified brown patties in a bag, not labeled or dated; -A bag of what appeared to be carrots, not labeled or dated. The bag was opened and the contents were exposed; [...]

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to four out of five residents sampled for immunizations review (Residents #41, #23, #10 and #47). The census was 55. Review of the facility's Infection Prevention and Control Program Policies and Procedures, revision October 10, 2023, showed: -Immunization and vaccination, general statement: The organization receives one time consent from residents/patients for vaccines, as recommended by Center for Disease Control (CDC) and Prevention guidelines: pneumococcal; -These are standing orders for pneumococcal for all residents/patients; -Pneumococcal vaccination are offered to all residents/patients per CDC guideline and applicable regulation. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment, for four of 14 sampled residents (Residents #10, #47, #41 and #17). The census was 55. Review of the facility's Bed Rail Maintenance and Installation and Entrapment Prevention policy, revised December 2016, showed: -Purpose: To diminish the potential for and severity of adverse events related to bed rail usage and compatibility of bed rails, mattresses and bed frames; -Procedure; -Center will follow manufacturer's recommendations and specifications for installing and maintaining bed rails; -The maintenance department will conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders to hold one resident's (Resident #400) Eliquis (a blood thinner) three days prior to his/her surgical procedure. This resulted in the resident's urological procedure being canceled and rescheduled for two weeks later. The facility also failed to ensure a specialist's recommendation for nothing by mouth (NPO) was communicated to the physician and followed for one resident with a swallowing disorder (Resident #204). The sample was 11. The census was 58. Review of the facility's Obtaining and Following Physician Orders policy, revised 2014, showed: Policy: It is the policy that physician orders will be obtained by licensed personnel and followed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who discharged to the community had a recapitulation of stay, final summary of status, reconciliation of all pre and post discharge medications and a post discharge plan of care for one of three residents selected for a closed record review (Resident #53). The census was 55. Review of Resident #53's medical record, showed the resident admitted to the facility on [DATE] and discharged on 8/6/23. Review of the resident's progress notes, showed: -On 8/4/23 at 8:31 A.M., the Director of Social Services (DSS) spoke with the resident's family member to follow up on discharge planning. The family member is still planning on taking the resident home upon discharge. DSS and the family member discussed arranging a home health aide to help the family upon the resident's return to home; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribed one resident's treatment order onto the Medication Administration Record (MAR), which resulted in the treatment not being provided for three days (Resident #204). The sample was 14. The census was 55. Review of the facility's Wound Care Program, dated revision July 2014, showed: - In developing a comprehensive treatment plan for wounds, the clinician should assess not just the wound, but the whole person. The factors affecting the ability of the wound to close and ultimately heal need to be included in the overall treatment plan; -Provide for heel pressure relief by placing a pillow under the calves to completely off weight heels. -Suspected Deep Tissue Injury (DTI): [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure smoking assessments were completed in a timely manner for two of 24 sampled residents (Residents #10 and #40). The census was 55. Review of the facility's Smoking Policy and Procedure, dated 10/21/22, showed: -Purpose: To assure that all residents are safe while smoking; -Procedure; -Any resident that expresses an interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance and supervision that will be needed to ensure the resident's safety. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/25/23, showed: -Cognitively intact; -Current tobacco use: was blank; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #41) who received tube feeding (supplies liquid nutrition) through a gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received the appropriate treatment and services when staff provided care with the resident laying flat while tube feeding formula infused and when staff failed to know how to operate or trouble shoot the tube feeding pump. The sample size was 14. The census was 55. Review of the monitoring Enteral Feeding-Tube policy, revised July 2014, showed: -Policy; -It is the policy of the facility that Enteral Feeding-Tubes will be monitored to ensure that feedings are delivered per physician's orders; -Procedure; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 32 opportunities observed, two errors occurred resulting in a 6.25% error rate (Residents #25 and #39). The census was 55. Review of the facility's Administration Medication policy, dated June 2020, included: -Policy: To administer all medications safely and appropriately to aid residents to overcome illness, relieve, and prevent symptoms, and help in diagnosis; -Procedure: -Wash hands before beginning, whenever you contaminate your hands, and if contact is made with the medication; -Review the resident's Medication Administration Record (MAR). Read each order entirely; -If there is any discrepancy between the MAR and the label, check physician orders before administering medication; 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs and biologicals in accordance with State and Federal laws, when controlled medications were not stored in double locked compartments in the medication room refrigerator. In addition, the refrigerator had an undated vial of influenza vaccine that was half empty and a container of applesauce in the refrigerator. The facility did not complete refrigerator temperature checks per facility policy. These deficient practices affected one out of one medications rooms reviewed. The census was 55. Review of the medication storage in the facility policy, dated June 2020, included: -Policy: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy by not communicating the significant weight loss of four sampled residents (Residents #38, #50, #42 and #210) to the physician and registered dietician (RD). Furthermore, the facility failed to follow physician orders to obtain weekly weights and monitor nutrition/fluid intakes and failed to implement RD recommendations for nutritional supplements, fortified foods and additional staff assistance to prevent further weight loss for these four residents, two who developed a wound or experienced a decline in their wound condition (Residents #38 and #50). The sample was 14 and the census was 55. Review of the facility weight management policy, dated July 2014, showed the following: Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the admission policy did not require residents to waive potential facility liability for losses of personal property. This had the potential to affect all residents admitted to the facility. The census was 55. Review of the facility's undated admission agreement contract, showed the following: -The resident acknowledges receipt of the written items identified in the Supplement A: Required Consents and Notifications Index; -All items identified and checked in Supplement A: Required Consents and Notification are incorporated into this contract. The resident will abide by all rules and regulations of the facility and will cooperate in the carrying out of the resident's Plan of Care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staffing to provide consistent resident care for activities of daily living and restorative therapy. The census was 55. During an interview on 9/29/20 at 10:37 A.M., the administrator said the facility utilized agency staff due to a lack of facility staff. The facility has raised their starting salaries to the highest in the area and are hopeful they will be able to hire enough staff where they will no longer need agency staff. During the survey process, the survey team identified problems with residents receiving their showers and restorative therapy services as scheduled due to staffing shortages. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the monthly pharmacist recommendations were being forwarded to physicians for their review and response. Of the 14 sampled residents, eight had pharmacy recommendations that were not forwarded to physicians for review (Residents #37, #44, #52, #57, #15, #32, #50 and #18). In addition, the facility failed to forward any of the pharmacist recommendations for physician review since April 2020. The census was 55. Review of the facility Drug Regimen Review policy, revised on 10/2017, showed: Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed follow proper sanitation practices in order to prevent cross contamination by not ensuring the dishwashing machine sanitized dishware correctly. This deficient practice had the potential to affect all residents who ate at the facility. The census was 55. Review of the facility's Proper Dishwashing policy, revised January 2012, showed: -Proper dishwashing is an important part of a good sanitation program; -Operating instructions, including the correct water pressure (20 pounds per square inch (PSI)), should be posted. If the water pressure is too high or low, the sanitizer will not be effective in sanitizing dishware; -Temperature gauges should be checked before each use. The correct temperature of each cycle should be maintained according to manufacturer specifications; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Quality Assessment and Assurance (QAA) policy and procedures by not holding monthly QAA meetings, and failed to follow federal and state regulations by not holding QAA meetings at least quarterly for the past 12 months. In addition, the facility failed to ensure all required attendees attended their QAA meetings and failed to develop and implement corrective actions for systemic problems within the facility. The lack of consistent and complete QAA meetings and the failure to identify and implement corrective actions had the potential to effect all residents The census was 55. Review of the facility Quality Assurance and Performance Improvement Procedure, revised on 11/2017, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they maintained an adequate bond in the amount of one and one-half times the average monthly balance for the past 12 months. The census was 55. Review of the resident trust account, showed: -From September 2019 to August 2020, the average monthly balance was $40,566.54. This would require a bond in the amount of $61,000; -Review of the Department of Health and Senior Services data base for approved bonds, showed the facility had a bond in the amount of $55,000; -Review of the resident current balance report for September 2020, showed an amount of $62,453.10 in the trust account. During interviews on 9/30/20 at 11:50 A.M. and 10/2/20 at 10:15 A.M., the business office manager was not sure who was responsible to ensure the bond amount was sufficient. She would have to check as the company has homes in different states. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue written emergency transfer/discharge notices to residents and/or residents' representatives when the residents were transferred to a hospital for various medical reasons, and failed to send a copy of the notice to a representative of the State Long-Term Care Ombudsman, for six of six sampled residents (Residents #44, #50, #53, #9, #18 and #32). The sample was 18. The census was 55. Review of the facility's Notice of a Transfer and/or Discharge policy, revised October 2017, showed: -Procedure: -A resident and/or his or her representative will be given notice as soon as practicable before transfer or discharge when: -An immediate transfer or discharge is required by the resident's urgent medical needs; -The written notice to the resident and/or representative will include the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to issue bed reserve notification notices to residents and/or residents' representatives when the residents were transferred to a hospital for various medical reasons, for six of six sampled residents (Residents #44, #50, #53, #9, #18, and #32). The sample was size was 14. The census was 55. Review of the facility bed reserve policy notification, undated, showed: The bed reserve policy will be given to the resident at the time of admission and a copy will be given to the resident each time you are transferred from the facility; -Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received their showers as scheduled for 10 of 14 sampled residents, three expanded sample residents and one closed record. (Residents #53, #18, #9, #42, #3, #50, #30, #32, #36, #37, #14, #57, #29 and #17). The sample size was 14. The census was 55. 1. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/20, showed: -admitted [DATE]; -Cognitively intact; -Always understood; -Rejection of care not exhibited; -Required extensive assistance for transfers, personal hygiene and bathing; -Diagnoses include heart failure, wound infection and diabetes. Review of the facility's shower schedule, showed the resident scheduled for showers during day shift on Mondays and Thursdays. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received Restorative Therapy (RT) as ordered. The facility identified 25 residents receiving RT services. Of those 25, seven were sampled and problems were identified with three. In addition, problems were identified with three of four expanded sample residents. (Residents #15, #42, #55, #3, #52 and #58). The census was 55. Review of the facility Rehabilitative (Restorative) Nursing Care policy, dated 2/2012, showed: Policy: -Rehabilitative nursing care is provided for each resident admitted ; Procedure: General rehabilitative nursing care is that which does not require the use of a Qualified Professional Therapies to render such care. Nursing personnel are trained in rehabilitative nursing care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a thorough, documented assessment after one resident (Resident #38) sustained an injury of unknown origin and another resident (Resident #36) sustained an injury from improper wheelchair positioning. Furthermore, the facility failed to prevent resident access to razors in two of three unlocked shower rooms. This had the potential to affect all residents who were able to move freely around the facility. The sample size was 14. The census was 55. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/20, showed the following: -Severe cognitive impairment; -Extensive assistance required for transfers, bed mobility, dressing and personal hygiene; -Unable to ambulate; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders for the use of side rails for three sampled residents (Residents #52, #42 and #32), and failed to properly assess residents for the use of side rails, to attempt alternative interventions prior to installing side rails, and to update resident care plans regarding the use of side rails for three sampled residents (Residents #44, #57 and #37). The facility identified 30 residents with side rails and six were sampled. The census was 55. Review of the facility's Restraint policy, revised April 2020, showed: -Policy: Restraint usage will always be an interdisciplinary decision, including the resident or responsible party and based on a comprehensive assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the monthly pharmacist recommendations, for gradual dose reductions for psychotropic medications, were being forwarded to physicians for their review for a possible gradual dose reduction. Of the 14 sampled residents, six had pharmacy recommendations for psychotropic medication gradual dose reductions and the facility failed to forward any of those six residents' pharmacy recommendations to their physicians for review for possible gradual dose reductions (Residents #37, #44, #52, #57, #32 and #18). In addition, the facility failed to forward any pharmacy recommendations for possible gradual dose reductions of psychotropic medications since April 2020. The census was 55. Review of the facility Drug Regimen Review policy, revised on 10/2017, showed: Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 35 opportunities for error, 2 errors occurred resulting in a 5.71% medication error rate (Residents #16 and #15). The census was 55. Review of the facility's policy on Medication Administration, updated 5/1/10, showed: -Procedure: 4.1: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct rate, at the correct time, for the correct resident; -Confirm that the Medication Administration Record (MAR) reflects the most recent medication order; -Check the expiration date on the medication; -Check for allergies to the medication; -If necessary, obtain vital signs. 1. Review of Resident #16's physician's order sheet (POS), dated 10/1/20 through 10/31/20, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure insulin (used to regulate blood sugar levels) vials and flex pens (pre-filled insulin pens) were labeled with the date opened on one of two nurse medication carts for nine of nine vials and flex-pens observed. In addition, the facility failed to write the resident name on multi-use medications and relied solely on bins with resident room numbers for two of two certified medication technician carts. The census was 55. Review of the undated facility policy regarding insulin, showed: -Opened/in use Humalog insulin is good for 28 days; -Opened/in use Novolog insulin is good for 28 days; -Opened/in use Lantus insulin is good for 28 days; -Levemir insulin not addressed; -No information in the policy regarding steps to follow when opening a new vial or flex-pen of insulin. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. In addition, the facility failed to review their antibiotic utilization during the quarterly quality assessment and assurance meetings. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 55. Review of the facility antibiotic stewardship policy, dated 10/2017, showed: Policy statement: -Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two expanded sampled residents (Residents #39 and #47) who remained in the facility upon discharge from Medicare Part A services. The census was 55. 1. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and federal regulations by not reporting one resident's injury of unknown origin to the state licensing agency (Department of Health and Senior Services (DHSS)) within the required time frame. This failure affected one resident (Resident #38). The sample size was 14. The census was 55. Review of the facility's Abuse Prevention Program policy, last revised 12/16/16, showed the following: -External Reporting of Potential Abuse: -In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all physician orders were followed when staff failed to complete treatments for wound care and administer insulin as ordered for one sampled resident (Resident #53) and failed to notify the physician when one resident's blood sugar was outside parameters as ordered (Resident #60). The sample was 14 and the census was 55. 1. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/1/20, showed: -admission date 8/26/20; -Cognitively intact; -Required extensive assistance with dressing, toileting and personal hygiene; -Diagnoses included heart failure, diabetes, end stage renal disease and wound infection; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for one sampled resident (Resident #53) and one resident (Resident #15) selected from an expanded sample. The facility identified five residents as receiving dialysis. The sample size was 14. The census was 55. 1. Review of the Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 9/1/20, showed the following: -admission date of 8/26/20; -Cognitively intact; -Required extensive assistance with transfers, dressing and personal hygiene; -Diagnoses included high blood pressure, diabetes and end stage renal (kidney) disease; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have adequate indications to support the use of a behavior altering medication for one resident (Resident #38) and failed to inform the resident's responsible party of the order for and use of the medication. The sample size was 14. The census was 55. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/20, showed: -Severe cognitive impairment; -Extensive assistance required for transfers, bed mobility, dressing and personal hygiene; -Unable to ambulate; -Behaviors not exhibited; -Diagnoses included heart failure, diabetes, Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination) and dementia. Review of the physician's order sheet (POS) showed: [...]