Quarters at Des Peres, the

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to prevent pressure ulcers (skin and tissue damage caused by prolonged, unrelieved pressure on the skin) for one resident (Resident #3). Staff failed to provide ordered treatment to the resident's sacral wound after an incontinent episode, leaving the wound exposed to air and failed to complete ordered daily wound care to the resident's right ankle pressure ulcer for three days while documenting the treatment as completed on the Treatment Administration Record (TAR). The sample size was seven. The census was 122. Review of the facility's Wound Management Policy, revised 11/15/22, showed:Policy: To promote Wound healing of various types of Wounds, the Facility will provide Evidence-Based Treatments in accordance with current Standards of Practice and Physician Orders; Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services by not providing multiple prescribed blood pressure and diabetic medications to a resident who was newly admitted for 3 days. (Resident #4). The sample was 13. The census was 129. Review of the facility's Physician Order Policy, last reviewed 9/28/22, included:-Policy: To provide guidance and ensure Physician Orders are transcribed and implemented inaccordance with Professional Standards, State and Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, and Director of Nursing (DON).-Procedure: Medications will be ordered from the Pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy, if available. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party for one resident (Resident #4) following a change in condition, in which the resident fell out of bed, sustained an injury, and was sent to the hospital for an evaluation. The sample size was 11. The census was 123. Review of the facility's Notification of a Change in Condition Policy, revised 2/6/25, showed:Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, according to Standards of Practice and Federal and/or State Regulations. Responsibility: All Licensed Nursing Personnel, Nursing Administration, & Director of Nursing. Procedure:-Guideline for Notification of Physician/Resident Representative (not all inclusive): [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice by failing to document one resident's (Resident #2) insulin administration and blood glucose monitoring on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The sample size was 11. The census was 123. Review of the facility's Notification of a Change in Condition Policy, revised 2/6/25, showed:Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, according to Standards of Practice and Federal and/or State Regulations. Responsibility: All Licensed Nursing Personnel, Nursing Administration, & Director of Nursing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 53 opportunities observed, 7 errors occurred resulting in a 13.2% error rate (Residents #21 and #22). The census was 124. Review of the facility's Medication Administration - General Guidelines policy, dated 12/2017, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.-Five Rights: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide acceptable nursing services by failing to report the results of an immediate (STAT) x-ray for one resident (Resident #5) who had complaints of shortness of breath (SOB). Two days after the x-ray, the resident requested to go to the hospital, the hospital found a large pleural effusion (condition where excess fluid accumulates in the pleural space, the thin membrane that separates the lungs from the chest wall) and a chest tube (drains access fluid) had to be placed. Additionally, the facility failed to administer intravenous (IV, method of administering fluids, medications, or nutrients directly into the bloodstream through a needle or catheter inserted into a vein) medications as ordered for two residents (Resident #3 and Resident #12). The census was 127. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff documented the reason for residents' transfer or discharge in the medical record. The facility failed to record the medically justified reason for 3 residents who were transported to the hospital after a change in condition (Residents #4, #1, and #10). The sample was 20. The census was 127. Review of the facility's Discharge and Transfer-Involuntary policy, last reviewed 10/7/21, showed:-Policy: Transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for four sampled residents who received dialysis (the process of filtering the blood for individuals with kidney failure). Resident #18 had an inconsistent order for dialysis days, with the order showing Monday, Wednesday and Friday and the resident received dialysis on Tuesday, Thursday and Saturday, and the care plan did not list the scheduled chair time and location for dialysis treatment. Additionally, the facility failed to contact and document the notification to the physician and resident representative (RR) when his/her dialysis treatment ended early. Resident #2 did not have physician orders that included the location for the dialysis services and the scheduled dialysis chair time and failed to ensure the dialysis services had been addressed on the resident's individual care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when the facility failed to accurately complete a post (after) fall 72 hour monitoring report (neurological (neuro) evaluation - pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; and equality of hand grip strength) if the fall was unwitnessed or if the resident had an incident hitting their head for one resident (Resident #10). The facility failed to complete incident follow up documentation (IFU) for 72-hours. The facility also failed to update the resident's care plan timely. The facility failed to offer as needed (PRN) pain medications post fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from additional harm after experiencing an unwitnessed fall. Staff transferred the resident back to his/her bed while the resident showed signs of injuries (Resident #8). The resident sustained fractures following the fall. In addition, the facility failed to transfer a resident (Resident #1) appropriately utilizing a mechanical lift. The sample size was 24. The census was 121. Review of the facility's Fall Management Policy, dated 2/28/23, showed: -Policy: To provide an environment that remains as free of accidents and hazards as possible. The Facility will complete a fall evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or reduce injuries; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified eight medication carts and four medication rooms. Four of the eight carts and two of the four medication rooms were checked for medication storage. Issues were found in one of the medication rooms, and on two medication carts. The census was 121. Review of the facility's Storage of Medications policy, revised 11/2018, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to date and cover food. In addition, the facility also failed to discard outdated food and failed to ensure kitchen equipment was kept clean during four of five days of observation. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The sample was 24. The census was 121. 1. Observation of the kitchen on 5/28/25 at 10:12 A.M., 5/29/25 at 3:45 P.M., 5/30/25 at 3:29 P.M., and 6/3/25 at 11:45 A.M., showed: -Dry storage room: -A container of dry grits, with a best by date of 8/12/24; -A package of tortillas opened and exposed to air; -Two boxes of angel food cake mixes, both with expiration dates of 2/14/24; -A box of lasagna pasta noodles opened and without a date; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to change gloves, wash or sanitize hands and wear gowns during care for residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) for four residents (Residents #105, #66, #47 and #1). In addition, the staff failed to disinfect the accucheck machine (used to test blood sugar) properly for one resident (Resident #47). Furthermore, staff placed unbagged dirty linens and briefs on the floor during care of two residents (Residents #105 and #66). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left medication in one resident's room. (Resident #105). In addition, an inhaler was observed at the bedside table of a resident who did not have a physician order for self-administration or for medications to be left at the bedside. (Resident #62) . The sample was 24. The census was 121. Review of the facility's Self-Administration of Medications policy, dated 12/17, showed: -Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for residents who expired. This affected two of two sampled residents who expired and had money in their resident trust account. (Residents #267 and #268). The census was 121. 1. Review of Resident #267's resident trust fund account, showed: -Resident expired on [DATE]; -A balance of $8297.87; -TPL completed and mailed [DATE]. 2. Review of Resident #268's resident trust fund account, showed: -Resident expired on [DATE]; -A balance of $2798.79; -TPL completed and undated time of mailing. 3. During an interview on [DATE] at 2:30 P.M., the Regional Business Office Manager and the Business Office Manager said they just sent the TPL letters for both residents on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice when the facility failed to perform/document post-fall neurological assessment (an assessment that checks the resident's mental status, level of consciousness, pupil reaction, motor (movement) response to stimulation, and sensation) and complete post fall assessments per policy for one resident (Resident #105). The sample was 24. The census was 121. Review of the facility's Fall Management policy, date 2/28/23, showed: -An un-witnessed fall occurs when a resident is found on the floor and resident/employee is unaware how he/she got there; -Prior to moving the resident, the charge nurse will evaluate for injury; -Complete neurological evaluation post-fall on residents with potential head injury or unwitnessed fall; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide care consistent with professional standards of practice, when staff failed to timely administer or document treatment orders and failed to document a description of the wounds on admission for one resident. (Resident #215). The sample was 24. The census was 121. Review of the facility's Wound Management Policy, dated 11/15/22, showed: Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Charge nurse will notify physician in the absence of treatment orders; -Wound characteristics/documentation: -Location of the wound pressure injury & stage; -Size (Shape, Depth, Tunneling and/or Undermining). Volume & Exudate (drainage) characteristics; -Pain evaluation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to obtain a physician order for dialysis and failed to document assessments for two residents (Residents #32 and #217) and failed to ensure the blood pressure was not obtained in the same arm as the dialysis access site (e.g. arteriovenous (AV, a surgically created connection between an artery and a vein, for dialysis shunt or graft (a synthetic tube used to create the connection)) for one resident (Resident #27). The facility identified 24 residents who received dialysis services, four residents were sampled, and issues were found with three. The sample was 24. The census was 121. Review of the facility's undated Hemodialysis policy, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for two of five residents sampled for medication review (Residents #35 and #62). The sample was 24. The facility census was 121. Review of the facility's Medication Regimen Review, revised 8/17, showed: -Policy: The pharmacist performs a comprehensive review of each resident's medical record at least monthly. The medication regimen review (MRR) is 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 interview and record review, the facility failed to ensure a resident was administered Triumeq (Abacavir-Dolutegravir-Lamivudine, a prescription medication used to treat human immunodeficiency virus (HIV, a virus that attacks the body's immune system)) as ordered (Resident #105). In addition, the facility failed to ensure the prescribing Infectious Disease (ID) physician was notified timely when the medication was not available. The facility failed to have a process in place to follow up timely on prior authorizations resulting in the resident missing multiple doses. The sample was 24. The census was 121. Review of the facility's Medication Administration - Prep and General Guidelines policy, dated 12/17, showed: [...]

Inspectors wroteBased on observation,interview and record review, the facility failed to follow the puree recipes for four of the five purees foods observed. This deficient practice had the potential to effect two residents who consumed pureed meals. The sample was 24. The census was 121. 1. Observation on 6/2/25 at 10:15 A.M., showed [NAME] CC prepared pureed peas. He/She added an unmeasured amount of peas into the blender. He/She placed one slice of bread into the blender. He/She then poured an unmeasured amount of broth into the blender and pureed the items for approximately 15 seconds. He/She stopped the blender, removed the lid and placed another half slice of bread into the blender and blended the items for an additional 20 seconds. The puree was thin in consistency. [NAME] CC did not consult the recipe book during the preparation. [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. The census was 121. Review of the facility's admission and Discharge report, dated 1/17/25 through 5/16/25, showed 172 residents transferred or discharged from the facility. During an interview on 5/23/25 at 4:15 P.M., a representative from the LTC Ombudsman said they had not received any monthly transfers since January 2025. During an interview on 6/3/25 at 10:10 A.M., the Social Services Designee (SSD) said the facility had not sent the monthly notice of transfers to the Ombudsman. She was not aware they were required to send the notices. During an interview on 6/3/25 at 5:25 P.M., the Administrator said they had not sent the notices of transfers to the Ombudsman. They would start doing it.

Inspectors wroteSee Event ID 0WE513. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/18/24 and 10/31/24. Based on interview and record review, the facility failed to ensure staff followed their change in condition policy for two residents. The facility failed to report to the physician two residents' (Resident #50 and Resident #47) change of condition and failed to follow the speech therapy recommendations for a modified diet and 1:1 mealtime assistance for one resident (Resident #50) with dysphagia. Resident #50 was hospitalized . Resident #47 complained of nausea and vomiting and staff administered medication to stop the nausea and vomiting, but failed to notify the resident's physician and failed to provide on-going assessments and monitoring of the resident. [...]

Inspectors wroteSee Event ID 0WE513. Based on interview and record review, the facility failed to ensure staff followed the change of condition policy for one resident (Resident #50) when staff failed to ensure the resident's physician was aware of the resident's change of condition identified on 12/13/24. The resident was transported to the hospital for assessment and treatment when the physician was notified on 12/15/24 after the resident was found unresponsive and with slow shallow breaths. Four residents were sampled for change in condition. The census was 116. Review of the facility's Notification Of A Change In Condition policy, revised on 4/26/23, showed: -Policy: [...]

Inspectors wroteSee Event ID 0WE513. Based on interview and record review, the facility failed to provide services that meet professional standards of clinical practice. On the day shift (7:00 A.M.-3:00 P.M.) of 12/15/24, on [NAME] Hall, the facility failed to ensure a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) was available to administer medications and gastrostomy (g-tube) flushes, provide treatments, complete assessments, and/or monitoring of residents as ordered and the Director of Nursing (DON), who arrived at the facility between 3:00 P.M. and 4:00 P.M. on 12/15/24, falsely documented he/she administered medications and g-tube flushes, completed treatments and assessments and/or monitoring of residents from 7:00 A.M. through 3:00 P.M. Forty-one residents resided on [NAME] hall. [...]

Inspectors wroteSee Event ID 0WE513. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 10/31/24. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 32 opportunities observed, 10 errors occurred resulting in a 31.25% error rate (Residents #53, 54, 51, and 52). The census was 116. Review of the facility's Medication Administration - General Guidelines policy, dated 12/2017, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). [...]

Inspectors wroteSee Event ID 0WE512. Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118.

Inspectors wroteSee Event ID 0WE512. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/18/24. Based on interview and record review, the facility failed to ensure staff were readily available to respond to residents' needs as evidenced by not answering call lights timely. One resident, with a history of bypass surgeries (Resident #24) was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. The resident was admitted to the hospital with atrial fibrillation (a-fib, abnormal heart rhythm characterized by a rapid and irregular heartbeat). [...]

Inspectors wroteSee Event ID 0WE512. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. [...]

Inspectors wroteSee Event ID 0WE512. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, eight errors occurred resulting in a 26.66% error rate (Residents #41 and #42). The census was 118.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from neglect. Facility staff failed to provide prompt and adequate incontinence care. Four out of four sampled residents, who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), were observed with two incontinence briefs on, both of which were saturated and with strong odors of urine and feces. Three residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take several hours for staff to answer call lights. Additionally, facility staff neglected to respond to a call light for one resident, with a history of bypass surgeries (Resident #24) who was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118. Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy by failing to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and perform wound treatments for three of three residents sampled (Residents #10, #8 and #1). The facility also failed to assess a resident at the time of admission for one of three sampled residents (Resident #18). The census is 129. Review of the facility Wound Management policy, last reviewed on 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: Wound Management: -Wound treatment will be provided in accordance with physician's orders: Cleansing method, type of dressing and frequency of dressing change; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. When EMS responded, they were unable to find facility staff, until they found one staff member curled up on the couch asleep. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services that meet professional standards of clinical practice. On the day shift (7:00 A.M.-3:00 P.M.) of 12/15/24, on [NAME] Hall, the facility failed to ensure a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) was available to administer medications and gastrostomy (g-tube) flushes, provide treatments, complete assessments, and/or monitoring of residents as ordered and the Director of Nursing (DON), who arrived at the facility between 3:00 P.M. and 4:00 P.M. on 12/15/24, falsely documented he/she administered medications and g-tube flushes, completed treatments and assessments and/or monitoring of residents from 7:00 A.M. through 3:00 P.M. Forty-one residents resided on [NAME] hall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, eight errors occurred resulting in a 26.66% error rate (Residents #41 and #42). The census was 118. Review of the facility's medication administration-Preparation and General Guidelines, revised August 2014, showed: -For residents able to swallow or who have difficulty swallowing tablets which can be appropriately crushed may be ground coarsely and mixed with appropriate vehicle (such as applesauce) so that the resident receives the entire dose ordered; Please consult with the product literature or Do Not Crush lists which the facility may have or with the pharmacist if there is a question about the medications to be crushed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed the change of condition policy for one resident (Resident #50) when staff failed to ensure the resident's physician was aware of the resident's change of condition identified on 12/13/24. The resident was transported to the hospital for assessment and treatment when the physician was notified on 12/15/24 after the resident was found unresponsive and with slow shallow breaths. Four residents were sampled for change in condition. The census was 116. Review of the facility's Notification Of A Change In Condition policy, revised on 4/26/23, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain air temperature at the preference of Resident #6 in his/her room and failed to maintain a properly functioning thermostat in the same resident's room. He/She complained about the cold room temperature. Per the resident, the cold temperature caused him/her to not get enough sleep. This had the potential to affect Resident #6 and Resident #19. The census was 129. Review of the facility's Maintenance Supervisor job description, revised 05/2022, showed: -Essential functions of Maintenance Supervisor: -Report to the Administrator regarding the physical and structural conditions of the center and the status of work in progress; -Perform all assigned tasks in a professional manner to reflect the highest integrity of the Maintenance Department; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their written policy when staff did not permit one resident (Resident #2) to return to the facility after he/she had been transported to the hospital. The census was 129. Review of the facility's Discharge Transfer Involuntary policy, last reviewed 10/7/21, showed: Policy: -Transfer and discharge include movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria, as outlined below, are met. Responsibility: -All staff monitored by the Director of Nursing (DON) and Administrator; Procedure: -A written or telephone order is required from the attending physician for the discharge of a resident, except in emergency situations; [...]

Inspectors wroteSurveyor: [NAME], [NAME] Based on interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of one of three sampled residents (Resident #10). The census was 129. Review of the facility's Comprehensive Person-Centered Care Plan Policy and Procedure, reviewed [DATE], showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that identify how the interdisciplinary team will provide care; -Procedure: The comprehensive care plan shall be fully developed within 7 days after the completion of the admission Minimum Data Set (MDS). The interdisciplinary team, along with the resident and/or resident representative, will identify the resident problems, needs, strengths, life history, preferences, and goals. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were revised timely. One resident returned from the hospital with a diagnosis of aspiration pneumonia (a type of lung infection that is due to material from the stomach or mouth entering the lungs) and aspiration precautions to be used during meals which had not been added to the care plan (Resident #5). In addition, the facility failed to add fall interventions to another resident's care plan (Resident #13). The census was 129. Review of the facility Fall Management policy, last reviewed on 2/28/23, showed: -Policy: To provide an environment that remains as free of accident hazards as possible. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed aspiration precautions for one resident with a recent diagnosis of aspiration pneumonia (a type of lung infection that is due to material from the stomach or mouth entering the lungs) (Resident #5). In addition, the facility failed to ensure one resident with a history of falls, had a mat on the floor on both sides of his/her bed, and failed to ensure staff kept the resident's bed in the lowest possible position when the resident was in bed and unattended (Resident #13). The census was 129. Review of the facility Fall Management policy, last reviewed on 2/28/23, showed: -Policy: To provide an environment that remains as free of accident hazards as possible. [...]

Inspectors wroteSurveyor: [NAME], [NAME] Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident (Resident #12) received two different blood thinner medications simultaneously. The sample size was three residents. The census was 129. Review of the facility's Physicians Orders Policy, reviewed 9/28/22, showed: -Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines; -Procedure: Physician orders will be transcribed to the appropriate administration record. Physician orders must be documented clearly in the medical record. Telephone/Verbal orders should be read back and verified with the prescriber. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receiving dialysis (a treatment for kidney failure that rids the body of unwanted toxins, waste products, and excess fluids by filtering your blood) received their diets as ordered (Residents #5 and #17). The facility identified 14 residents that received in-house dialysis. Two were sampled and problems were found with both. The census was 129. Review of the Dietary Aide job description, revised 5/2022, showed: -Essential Functions of Dietary Aide: Prepare food trays for general and therapeutic diets. Prepare special diet foods as necessary. Review of the Certified Nursing Assistant (CNA) job description, revised on 1/2024, showed: -Essential Functions of CNA: Provides for activities of daily living (ADL) by assisting with serving meals and feeding residents as necessary. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented, in accordance with accepted professional standards and practices, for one resident who had a change of condition on 8/6/24 and went to the hospital where he/she was admitted (Resident #2). The sample was 18. The census was 129. Review of the facility's Discharge Transfer - Involuntary Policy, last reviewed 10/7/21, showed: -Responsibility: All staff monitored by the Director of Nursing (DON) and Administrator; Procedure: -The Interdisciplinary team and the resident's physician must document in the resident record when a resident is transferred or discharged ; [...]

Inspectors wroteSee citation written at event ID # 8BCQ12. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 1/17/24. Based on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences. The facility also failed to provide showers/baths per resident preferences and failed to provide appropriate personal care items for residents. This affected three of 18 sampled residents (Resident #89, #36, and #71). The census was 107.

Inspectors wroteSee citation written at event ID # 8BCQ12. Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure common areas and resident rooms were free from strong odors of urine that persisted throughout the survey process. The sample size was 18. The census was 107.

Inspectors wroteSee citation written at event ID # 8BCQ12. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 1/17/24. Based on observation, interview and record review, the facility failed to provide residents with the necessary services to maintain adequate personal hygiene for three residents observed with odors and dirty clothing (Resident #89, #36, and #71). The sample size was 18. The census was 107.

Inspectors wroteSee citation written at event ID # 8BCQ12. Based on observation, interview and record review, the facility failed to uphold a resident's right to a dignified existence when staff left a bag of briefs soiled with bowel movement (BM) on the resident's nightstand, approximately one foot from the head of the resident's bed for an extended amount of time (Resident #89). The resident reported having a fear of retaliation from the facility. In addition, staff left a soiled towel on the floor of the resident's room and failed to remove a trash can smeared with BM from the resident's room. The sample size was 18. The census was 107.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the second floor unit with functioning, alarmed doors for one of three second floor stairwell doors. Observation on 1/9/24 at 10:40 A.M. and 1/10/24 at 8:00 A.M., showed the second floor door to the stairwell, adjacent to room [ROOM NUMBER], alarmed at the nurse's station with the same sound as the call light system. The door was also equipped with a local alarm, but the local alarm did not function when the door was opened. The door's delayed-egress function did not operate, and the door opened immediately when pushed. Observation on 1/9/24 at 11:05 A.M. and 1/10/24 at 8:00 A.M., showed the door at the bottom of the stairwell also alarmed at a nurse's station with the same sound as a call light, and had no functioning local alarm at the door. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to uphold a resident's right to a dignified existence when staff left a bag of briefs soiled with bowel movement (BM) on the resident's nightstand, approximately one foot from the head of the resident's bed for an extended amount of time (Resident #89). The resident reported having a fear of retaliation from the facility. In addition, staff left a soiled towel on the floor of the resident's room and failed to remove a trash can smeared with BM from the resident's room. The sample size was 18. The census was 107. Review of the facility's Resident Rights policy, dated 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect and dignity and ensure Resident Rights are being followed. The Resident/Resident Representative will be informed on their rights upon admission; -Procedures: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences. The facility also failed to provide showers/baths per resident preferences and failed to provide appropriate personal care items for residents. This affected six of 32 sampled residents (Residents #58, #89, #60, #75, #42 and #56). The census was 107. Review of the Resident Rights Policy, dated 4/26/23, showed: -The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are being followed. The resident/resident representative will be informed on their rights upon admission; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure common areas and resident rooms were free from strong odors of urine that persisted throughout the survey process. The sample size was 18. The census was 107. Review of the facility's undated Basic Cleaning Concepts policy, showed: -General Sanitizing: To make a surface or area clean by removing dirt, germs or unwanted substances; -Contamination: The presence of germs on hands or on a surface such as clothes, gowns, gloves, bedding, toys, surgical instruments, patient care equipment, dressing or other inanimate objects. Review of the facility's undated Hospital Clean policy, showed: -Hospital clean is a measure of cleanliness routinely maintained in care areas of the health care setting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for six of 32 sampled residents (Residents #49, #263, #12, #86, #75, and #9). The census was 107. Review of the facility's Comprehensive Person-Centered Care Plan Policy, dated 10/23/19, showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Responsibility: Interdisciplinary Team Members; -Definitions: -Interdisciplinary: All disciplines will collaborate and develop a plan of care that meets the resident's needs, preferences and goals; -Comprehensive Person-Centered Care Plan: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with the necessary services to maintain adequate personal hygiene for four residents (Residents #265, #89, #12 and #68) observed with long and dirty fingernails, unkempt facial hair, and soiled clothing. The sample size was 32. The census was 107. Review of the facility's Activities of Daily Living (ADL) Care Bathing policy, last reviewed 7/21/22, showed: -Policy: Nursing staff will assist in bathing residents, to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing. Review of the facility's ADL Care Shaving policy, last reviewed 7/21/22, showed: -Policy: The facility will provide aid with shaving as directed in the plan of care. ADL care will include shaving to promote cleanliness and preserve dignity. [...]

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 document usage in the resident's care plan for four of 32 sampled residents (Resident #12, #86, #75 and #9). The census was 107. Review of the facility's Physical Restraint policy, dated 7/26/23, showed: -Policy: Physical restraints are not to be used to limit resident mobility for the convenience of staff and must comply with life safety requirements. If a resident's behavior is such that it may result in injury to the resident or others and any form of physical restraints is utilized, it should be in conjunction with treatment procedures designed to modify the behavioral problems for which the resident is restrained, or as a last resort, after failure of attempted therapy; -Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent. Out of 37 opportunities, five errors occurred, resulting in a 13.51% error rate (Residents #60, #47, #28, and #266). The census was 107. Review of the facility's Medication Administration-Preparation and General Guidelines policy, dated revised August 2014, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medication and medical equipment in accordance with professional principles, including abiding by the expiration date on wound and ostomy (surgery that creates an opening from an area inside the body to outside the body) care supplies. Concerns were found in two of five medication rooms and in one of five treatment carts in the facility. The sample size was 32. The facility census was 107. Review of the facility's Storage of Medications policy, dated 11/2018, showed the following, under the Expiration Dating (Beyond-use dating) section: -Expiration dates (Beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing; -The nurse will check the expiration date of each medication before dispensing it; -No expired medications will be administered to a resident; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide and offer snacks at bed time. The census was 107. During a group interview on 1/10/24 at 1:43 P.M., seven residents, who the facility identified as alert and oriented, attended. All seven residents said the facility did not offer snacks anymore. They used to receive them but had not in several months. One resident said family members had to bring in snacks. Another resident said if they wanted snacks, they had to go to the vending machine. During an interview on 1/10/24 at 2:10 P.M., Resident #35 said residents have to wait a long time for meals. They are served breakfast between 8:00 and 9:00 A.M. and dinner is around 5:00 P.M. During an interview on 1/12/24 at 11:28 A.M., Certified Nursing Assistant (CNA) M said he/she worked at the facility for approximately a month and had not seen snacks given out to residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to store food in a safe and sanitary manner, failed to date food items and to discard outdated food, and failed to use utensils to the serve food. The census was 107. Review of the facility's Refrigeration Policy, dated 3/31/23, revised on 8/16/23, showed; -POLICY: Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety; -RESPONSIBILITY: Dietary Aide, Dietary Cook, & Dietary Manager; -PROCEDURE: Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with an expiration; [...]

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 a part of a regular maintenance program to identify areas of possible entrapment for four (Residents #12, #86, #75 and #9) of 32 sampled residents. The census was 107. 1. Observation on 1/8/24 at 11:14 A.M., 1/9/24 at 7:48 A.M. and 9:18 A.M., 1/10/24 at 7:08 A.M., 1/11/24 at 4:05 A.M. and 1/12/24 at 8:28 A.M., showed the Resident #12 lay in bed on his/her back. Quarter length U-rails/side rails were raised on both sides. Review of the resident's medical record, showed no Maintenance Assessment for the use of side rails. 2. Review of Resident #86's admission Minimum Data Set, (MDS) a federally mandated assessment completed by facility staff, dated 11/30/23, showed: -Cognitively intact; -Exhibited no behaviors; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure code status was entered into the medical record for two of 32 sampled residents (Residents #263 and #89). The census was 107. Review of the facility's Advanced Directive Policy, dated last reviewed [DATE], showed: -Policy: It is the policy of the facility to respect the resident's right of self-directed care including the right to issue advance directives on health care, to refuse/accept treatment, to make informed decisions, and/or appoint a health care agent to make decisions on behalf of the resident when the resident lacks the capacity to do so. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nursing services that met professional standards of quality to residents at the facility. Facility staff failed to document a missed imaging test appointment as well as subsequent follow up actions for one resident (Resident #56), and failed to document the administration of a blood-thinning agent for another resident (Resident #209). Additionally, the facility failed to identify one resident (Resident #265) had an intravenous (IV, a thin flexible tube inserted into a vein) in his/her right forearm and failed to obtain a physician order to discontinue the IV or obtain orders to maintain the IV. The resident sample was 32. The facility census was 107. Review of the facility's Medication Administration - General Guidelines policy, revised December, 2017, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is fed by enteral means (also known as tube feeding, a way of sending nutrition right to the stomach or small intestine) safely received the appropriate treatment and services when the head of bed was not elevated during feeding. This affected one of 32 sampled residents (Resident #49). The census was 107. Review of the facility Policy & Procedure Tube Feeding: Continuous Tube Feeding Policy, dated February 2016, showed: -Purpose: To provide nourishment to the resident who is unable to obtain nourishment orally. -Verify physician order for feeding; -Gather necessary equipment for procedure; -Identify resident and explain procedure; [...]

Inspectors wroteBased on interview and record review, facility staff failed to obtain stop dates of 14 days or less on as needed (PRN) psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior), or specify conditions present to administer the medication for three residents out of 32 sampled residents (Residents #68, #9 and #263). The facility census was 107. Review of the facility's Psychotropic Management Guidelines, dated 7/26/23, showed: -Policy: A psychotropic drug is any drug that affects brain activities associated with mental health processes and behavior. These drugs include but are not limited to drugs in the following categories: [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error when one resident (Resident #261) was admitted to the facility with an order for an intravenous (IV, into a vein) antibiotic and staff failed to transcribe the antibiotic correctly into the electronic medical record (EMR), which resulted in the resident receiving the medication at the wrong time and he/she received the wrong dose of medication from 1/3/24 through 1/12/24. The sample was 32. The census was 107. Review of the Physicians Orders policy, dated last reviewed 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state & federal guidelines; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control and prevention practices when staff failed to place a cap on the end of an intravenous (IV, a thin bendable tube that is inserted into a vein that carries fluids and/or medicine) line for one resident (Resident #261) and failed to position one resident's catheter (a flexible tube inserted into the body to remove fluid) drainage bag (bag used to collect urine) off the floor (Resident #12). In addition, staff failed to store one resident's urinary drainage supplies appropriately when not in use (Resident#263). The sample was 32. The census was 107. 1. Review of the facility's Infusion Therapy Medication Administration: Medications Added to Infusion Preparations by the Nurse in the Facility, dated 12/17, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately track one resident's antibiotic (Resident #261). This had the potential to affect all residents who were on antibiotics. The sample was 32. The census was 107. Review of the facility's Antibiotic Stewardship Plan policy, dated 4/2017, showed: -The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents; -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: drug name; dose; frequency of administration; duration of treatment; start and stop date, or number of days of therapy; route of administration; and indications for use; [...]

Inspectors wroteBased on observation and interview, the facility failed to post in a place readily accessible to residents, family members and legal representatives of residents, the results of the most recent survey and complaint investigations. The census was 107. Observations on 1/8/24 through 1/10/24, showed no survey results maintained at the entrance of the building, in the lobby of the building or at the desk with the receptionist. No signs posted for the location of the survey results and/or availability of the last survey or complaint investigations. During a group interview on 1/10/24 at 1:43 P.M., seven residents, whom the facility identified as alert and oriented, attended the group meeting. All seven residents said they were unaware of where the state survey results were located. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents/resident representatives with a written letter stating the reason the resident was transferred to the hospital and failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of residents who were transferred/discharged from the facility. The facility transferred 49 residents to acute care hospitals between 11/1/24 and 1/5/24. The census was 107. The Administrator was notified on 1/17/24 at 4:00 P.M., of past noncompliance. The facility provided education on providing written notice of transfers and how to contact/ notify the Ombudsman. The date of correction was 1/5/24. Review of the facility's admission and Discharge Report, dated 11/1/23 through 1/5/24, showed 49 residents were transferred to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative with written information on the facility's bed hold policy at the time of transfer for two of 32 sampled residents (Resident #263 and #68). The census was 107. Review of the facility Bed Hold Policy, dated 11/15/22, showed: -The facility will provide written information to the resident and/or the resident representative regarding Bed Hold Policy prior to transferring a resident to the hospital or therapeutic leave as required by State/Federal Guidelines; -DEFINITIONS: -Bed-Hold: Holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization; -Reserve Bed Payment: Payments made by the State to the facility to hold a bed during a resident's temporary absence from a nursing facility; -Therapeutic Leave: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the total and actual number of hours worked on each shift by licensed and unlicensed nursing staff in a location readily available to visitors and residents. Prior to exit, the facility had the nursing staff hours posted at the front door of the facility, making it accessible to visitors but not readily available to residents. The sample was 32. The census was 107. The facility did not have a policy on required posting of staffing hours. Observation of the first floor [NAME] nurse's station on 1/9/24 at 7:59 A.M., showed no posted nurse staffing hours at or near the nurse's station for residents or visitors to view. Observation of the first floor Joliet nurse's station on 1/9/24 at 8:01 A.M., showed no posted nurse staffing hours at or near the nurse's station for residents or visitors to view. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide accessible information on the location of the State Survey Agency hotline number that was readily available to residents in the facility without assistance. The census was 107. Observations throughout the survey on 1/8/24, 1/9/24, and 1/10/24, showed: -A Long Term Care Ombudsman program ([NAME]) poster in the first-floor front lobby with the State Survey Agency hotline number on a label attached to the poster; -A Long Term Care Ombudsman program poster on the second floor by the back elevator without the State Survey Agency hotline number; -State Survey Agency number not observed anywhere else in the facility. During a group interview on 1/10/24 at 1:43 P.M., seven residents, whom the facility identified as alert and oriented, attended the group meeting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had physician orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) and assessment/monitoring of dialysis access sites. The facility failed to ensure residents receiving dialysis were served renal diets (diet to help promote kidney health) in accordance with physician orders, or to ensure residents had physician orders for renal diets as indicated in the residents' hospital discharge summaries. In addition, the facility failed to maintain ongoing communication with dialysis centers for residents receiving dialysis treatment. Four residents were sampled for dialysis and problems were found with all four (Residents #9, #1, #2 and #8). The sample was 15. The census was 107. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff appropriately transferred one resident (Resident #24) using a Hoyer lift (mechanical lift) and two residents (Resident #17 and #50) with a gait belt. The facility also left a medication cart unlocked, unsupervised and accessible to residents. The sample was 21. The census was 92. Review of the facility's Hoyer lift Competency form, provided as the Hoyer lift policy, showed: -Secure the assistance of another nursing assistant or licensed nurse; -Move the lift away from the bed, turn the resident so that he/she faces you while the other assistant guides the resident's body toward the chair by standing behind the resident. 1. Review of Resident #24's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/22/21, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, when the facility failed to properly document narcotic counts for controlled substances, for two out of two nurse medication cart narcotic books reviewed. The census was 97. Review of the Controlled Substance Storage Policy, revised 8/2014, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in accordance with federal, state and local laws and regulations; -Procedures: [...]

Inspectors wrote\Based on observation, interview and record review, the facility failed to ensure biologicals were labeled and stored in accordance with currently accepted professional standards, for two of three nurse medication carts observed. The census was 92. Review of the facility's Medication Administration Preparation and General Guideline policy, revised 8/2014, showed: -Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use and disposal; -Procedure: -Vials and ampules dispensed by the pharmacy are maintained in the box or container, with the pharmacy label, in which they are dispensed; -Expiration dates: Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and maintain complete accounting of records for the resident trust acccount, regarding transaction receipts for clothing in the amount of $1702.19 and $200.00 for one resident (Resident #51). The facility held and managed funds for 21 residents. The census was 92. Review of the facility's updated admission Agreement, showed residents have the right to manage their own personal financial affairs or have someone they trust do so, including the facility. With written approval, the facility will open a personal account for the resident through Resident Fund Management Service (RFMS). This personal resident trust account is controlled by the resident or the resident's representative only. The money placed in the personal resident trust account will accrue interest. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure a resident who had an appointed guardian, had verified with the guardian the elected code status for one resident (Resident #17) since assuming guardianship. The sample was 21. The census was 92. Review of the facility's Advanced Directive policy, dated [DATE], showed: -Policy: It is the policy of the facility to respect the resident's right of self-directed care including the right to issue Advanced Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so; -Each competent adult has the right to control his or her own health care decisions; -Definitions: Guardian: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed their Abuse and Neglect Policy, when staff failed to conduct a thorough investigation into an allegation of missing money when a resident reported to the charge nurse $150.00 went missing from his/her possessions for one resident (Resident #175). In addition, the facility failed to follow their Abuse Prevention, by assessing a resident who wished to participate in a sexual relationship and determining their capacity to consent for one resident (Resident #223). The sample was 21. The facility census was 92. Review of the facility Abuse Prevention Policy, last reviewed 3/20/19, showed the following: -Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an admission policy or protocol to ensure accurate accounting of residents' personal belongings, to prevent resident liability for resident possessions if items were missing or stolen, when the facility failed complete an inventory list for five of 21 sampled residents (Residents #42, #30, #51, #22, and #17). The census was 92. Review of the facility's undated admission agreement, showed we may not require you or your Resident representative, to agree to waive or limit our liability for loss of personal property suffered as a result of the negligence of our administrator, employees, or agents. However, we are only responsible for loss of personal property that is caused by the negligence of our administrator, our employees, or agents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for one of 21 sampled residents (Resident #31). The resident was admitted to the facility with a medical history significant for surgical removal of part of the digestive tract. The facility failed to care plan dietary/nutritional problems for the resident. The resident experienced weight loss while at the facility. The census was 92. Review of the facility's comprehensive care plan policy, dated April 2017, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided necessary services, care or assistance for dependent residents who were unable to perform self-care hygiene activities of daily living (ADL). Staff failed to provide thorough and appropriate perineal (area from the front of the hips, in between the legs and buttocks) care for two of three observations (Residents #19 and #50). The sample was 21. The census was 92. Review of the facility's Perineal care policy and procedure, dated 1/1/14, showed: -Purpose: To provide cleanliness and comfort to the resident, prevent infection and skin irritation and observe the resident's skin condition; -Procedure: -Cleanse the resident's groin using an approved no rinse incontinence cleaning product; [...]

Inspectors wroteBased on observation and interview, the facility failed to post the complete information for daily nursing staffing information by not posting the daily census for three of five days of observation. The census was 92. Observation on 4/19/21 at 2:30 P.M., 4/21/21 at 12:05P.M., and on 4/22/21 at 9:38 A.M., showed no daily census posted on the nurse staffing information sheet. During an interview on 4/23/21 at 4:05 P.M., the Director of Nursing said the staffing coordinator is responsible for posting the daily nursing staff information as required. He/she was working the floor all week. The daily nursing staff information posted should contain the census. She would expect for the daily nursing staff information form to be filled completely and accurately daily.