Rehab of Kansas City South

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #2) was free from abuse when on 6/3/26 Resident #1 hit Resident #2 causing a bloody lip out of 13 sampled residents. The facility census was 87 residents. On 6/12/26, the Administrator was notified of past non-compliance which occurred on 6/3/26. Immediate interventions were put into place for both Resident #1 and Resident #2. All staff received education prior to working their next shift. The deficiency was corrected on 6/4/26. Review of the facility's policy titled Abuse Prevention and Prohibition Program dated 10/24/22 showed:-Each resident had the right to be from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.-The policy provided did not define physical abuse or resident-to-resident altercations. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate discharge when transferring one sampled resident (Resident #2) out of 7 sampled residents, to a new facility. The resident was not allowed to return to the facility as requested during the appeal process. The facility census was 95 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure odors were not pervasive on the 300 Hall. The facility census was 89 residents. Review of the facility Resident Rights Policy dated 8/2020 showed: -All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. 1. During an interview on 6/16/25 at 3:18 P.M. Family Member A said: -He/She visited in the facility approximately five times over the last three months. -During the visits there was the presence of strong body odor smell of feces and urine. -The facility is unclean. -He/She was so overwhelmed with the smell he/she was unable to pay attention to anything else. -He/She was unable to stay and visit with his/her family member due to the smell. [...]

Inspectors wroteBased on interview and record review, the failed to ensure an allegation of possible misappropriation of resident's funds was investigated timely when on 5/23/25 Resident #2's family reported a $300 charge from the resident's CashApp on his/her phone out of 12 sampled residents. The facility census was 89 residents. Review of the facility Abuse and Prohibition Program policy dated 10/24/22 showed: -The purpose was to ensure the facility established, operationalized, and maintained an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting abuse, neglect, mistreatment, misappropriation, and crime in accordance with federal and state requirements. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the toilets securely in place in the 100 and 300 Hall Spa Rooms, 200 Hall Spa Room toilet was blocked with equipment, 400 Hall Spa Room was inaccessible and the toilet in room [ROOM NUMBER] was inoperable. From 6/15/25 to 6/16/25 Resident #3 was unable to utilize his/her toilet and when using the 100 Hall Spa Room toilet it moved causing him/her to become unbalanced and fearful of using the toilet. Resident #3 then attempted to utilize the 300 Hall Spa Room toilet to find it was not secured. This practice potentially affected all residents who utilized the spa bathroom toilets. The facility census was 89 residents. 1. During an interview on 6/17/25 at 1:56 P.M. the Administrator said: -He/She was informed on 6/15/25 at approximately 4:00 P.M. about a toilet being clogged. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for two sampled residents (Resident #3 and #4) out of nine sampled residents. The facility census was 94 residents. On 5/7/25, the Administrator was notified of the past non-compliance which occurred on 4/25/25. Facility staff were educated on the root-cause of the abuse and keeping the back patio doorway/area clear. Interventions were put into place to mitigate future occurrences. The deficiency was corrected on 4/26/25. Review of the facility's policy titled Abuse Prevention and Prohibition Program dated August 2020 showed each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Review of the facility's policy titled Reporting Abuse showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three sampled dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidney were not functioning properly) residents (Resident #23, Resident #32, and Resident #33) and one supplemental resident who had a feeding tube (a medical device that delivers liquid nutrition directly to the stomach through a surgically created opening in the abdominal wall), (Resident #42) were on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) out of 18 sampled residents and one supplement resident, failed to adequately educate the staff about EBP, and failed to have EBP or isolation signs on the door and isolation carts (a [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation related to attending the dialysis (a procedure that filters the blood when the kidneys were no longer able to do so) unit and coming back from the dialysis unit was completely filled out and accurate for four sampled dialysis residents, (Residents #10, #23, #32, and #33), and failed to document assessments in the computer in a consistent manner for two sampled resident, (Resident# 23, Resident #32) out of 19 sampled residents. The facility census was 92 residents. Review of the facility Dialysis Care policy dated June 2022 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post staffing information that consistently included the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 92 residents. Review of the facility's Nurse Staffing Posting Policy, revised June 2020 showed: -The facility would post the staffing on a daily basis and would have included: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: ---RN's. ---LPN's. ---CNA's. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside unattended for three sampled residents (Residents #53, #57, and #23), out of 19 sampled residents, failed to ensure medication carts were maintained and locked when unattended by staff, failed to maintain cleanliness in the medication room, and failed to maintain the medication refrigerator temperatures within recommended ranges. The facility census was 92 residents. Review of the facility's policy, Storage of Medications, dated 8/2020 showed: -Medications and biologicals were to have been stored safely, securely, and properly, following manufacturer's recommendations. -The medication supply was accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure written notification to the resident and/or family prior to transfer from the facility for one sampled resident (Resident #10) out of 18 sampled residents. The facility census was 92 residents. Review of the facility Transfer and Discharge policy dated June 2020 showed: -Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. 1. Review of Resident #10's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/8/24 showed the resident was moderately cognitively impaired. Review of the resident's Change of Condition progress note dated 12/20/24 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment such as tubing, nebulizer (a machine that converts liquid medication into a fine mist that could be inhaled through a mouthpiece or mask) and Bilevel Positive Airway Pressure machine (BiPAP- a non-invasive ventilator that helps patients breathe by providing two different air pressure levels for inhaling and exhaling) were stored in a clean plastic bag when not in use for two sampled resident's (Resident #55 and #57) and failed to have a physician's order for two sampled residents to use a nebulizer and/or BiPAP (Resident #55 and #57) out of 18 sampled residents. The facility census was 92 residents. Review of the facility's policy, BiPAP Support, revised 5/2015 showed: -A physician's order is required to initiate BiPAP support and should include BiPAP settings as prescribed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate three out of three sampled residents' (Residents # 1, #2, #3) preferences related to showering. The facility census was 91 residents. Review of the facility's Resident Rights - Accommodation of Needs policy, revised 8/2020 showed: -Residents' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. -In order to accommodate residents' individual needs and preferences facility staff attitude and behavior are directed toward assisting the residents in maintaining independence, dignity, and well-being to the extent possible according to resident wishes. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to properly secure one sampled resident (Resident #3) during transport in the facility van out of three sampled residents. The facility census was 91 residents. Review of the facility's Safe Transportation Unloading Procedure, undated, showed: -Always make sure the resident is secure with wheelchair locks engaged and tie down hooks secured to frame of wheelchair. -If transporting multiple residents, ensure other resident wheelchair(s) are fully secured (wheel locks engaged and tie down straps on wheels) until ready for unloading. -If for any reason you must step away from the resident reapply the wheel locks, hook straps and make sure the resident is fully secured. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide ordered pressure ulcer wound dressing changes on a consistent basis for two sampled residents (Resident #5 and #8), and failed to prevent an acquired pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one sampled resident (Resident #2) who was at high risk out of nine sampled residents. The facility census was 86 residents. Review of the facility Wound Management Policy, updated 6/2020 showed: -The purpose of the policy was to provide a system for the treatment and management of residents with wounds including pressure ulcers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staffing for residents needing a mechanical lift for transfers so they could get out of bed as desired for six sampled residents (Residents #4, #5, #12, #13, #16, #17) out of 23 sampled residents. Additionally, staff reported shifts weren't covered as reflected by the Daily Staffing Sheets and Time Card Records. The facility census was 89 residents. Review of the facility's Nursing Department Staffing, Scheduling and Postings policy, dated 10/22/24 showed: -The facility will employ sufficient nursing staff on a 24-hour basis to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and home like environment when multiple leaks occurred in the facility on 1/18/24 affecting two sampled residents (Resident #2 and Resident #3) out of 14 sampled residents; the facility also failed to ensure the floors of rooms of three sampled residents (Residents #10, #6 and #4) were maintained, free of a buildup of grime and debris. The facility census was 82 residents. Review of the Facility's undated policy titled Rapid Response Guide: Flood showed the first initial action would be to rescue anyone in immediate danger. NOTE: There was no specific policy or guideline related to water leaks in resident rooms. 1. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Other Acute Osteomyelitis (a serious infection of the bone), left ankle and foot. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three sampled residents (Resident #3, #4, and #5) out of five sampled residents. The facility census was 83 residents. Review of the facility Care and Services Policy dated 6/20 showed: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of long-term care facility. -Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Review of the facility Communication-Call System Policy dated 10/24/22 showed: -Purpose: To provide a mechanism for residents to promptly communicate with nursing staff. -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document wound care orders and treatment for one sampled resident (Resident #3) out of five sampled residents. The facility census was 83 residents. Review of the facility Wound Management Policy dated 6/20 showed: -Purpose: -To provide a system for the treatment and management of residents with wounds including pressure -Policy: -A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. -Procedure: -Assessment: --A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse will ---Measure the wound (length, width, depth. ---Initiate a wound monitoring record sheet for each wound. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident dignity was maintained for one sampled resident (Resident #1) when on 8/31/23 there was an allegation that Certified Medication Technician (CMT) A threw water on the resident, out of three sampled residents. The facility census was 78 residents. On 9/1/23 the Administrator was notified of the past noncompliance which occurred on 8/31/23. On 8/31/23 the facility administration was notified of the incident and the investigation was started. CMT A was suspended on 8/31/23 and later terminated. No employees were allowed to work prior to reeducation completed 8/31/23. The deficiency was corrected on 8/31/23. Review of the facility's policy titled Privacy and Dignity dated June 2020 showed: -The staff assist residents in maintaining self-esteem and self-worth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a locked compartment, that medications were labeled, and that medications stored in a refrigerator were monitored for temperature. The facility census was 74 residents. Record review of the facility's policy, dated November 2020, and titled Storage of Medications showed: -Drugs used in the facility were to be stored in locked compartments under proper temperature. -Drugs were to be stored in the packaging in which they were received. -Compartments (including carts, rooms, and refrigerators) that contained drugs were to be locked when not in use. 1. Observation on 2/27/23 at 8:49 A.M. showed a treatment cart containing scissors and medications was unlocked on the north hall. Observation on 2/27/23 at 9:06 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Dietitian (RD) was in the facility to perform dietary assessments and to consult with dietary staff in the kitchen. This practice affected two sampled residents (Residents #8 and #18) who needed dietary assessments during the time span there was not an RD coming to the facility. This practice also affected all residents because dietary staff did not get dietary consultation. The facility census was 74 residents. 1. During an interview on 2/27/23 at 1:50 P.M., the Administrator said he/she started at the facility on 2/6/23 and there has not been an RD at the facility during that time. During a phone interview on 2/27/23 at 2:03 P.M., the Chief Operating Officer (COO) from the former RD consult Company A said: -12/27/22 was the last time an RD from his/her company was last in the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure molded green peppers were not stored in the walk-in fridge; to label containers with the name of the substances that were in those containers; to ensure paper towels were located at the hand washing station close to the south exit door of the kitchen; to remove burnt on debris from the top of the six burner stove; to ensure the maintain the gasket (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects) in the fridge labeled old; to place items which required refrigeration in the fridge; to maintain two fans free of a heavy dust buildup; and to clean the nozzle of the hose from the soft drink dispenser. This practice potentially affected at least 70 residents who ate food from the kitchen. The facility census was 74 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding residents not receiving showers on a regular basis. The facility also failed to implement a QAPI program to ensure skin assessments and assessments of pressure ulcers were obtained on regular basis. The facility census was 74 residents. 1. Record review of a book showed a plan to address the shower issue December 2022. Record review of an in-service training report dated 12/21/22 showed only nine employees received training on topics which include showers, shower sheets, shower documentation and refusals. During an interview on 3/3/23 at 2:29 P.M., the Director of Nursing (DON) stated that training was started by an Administrator who was at the facility back in December 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an on-going monitoring facility-wide Infection Prevention Control Program (IPCP) was established and to ensure surveillance logs were maintained for 11 months out of 12 months surveillance to include but not limited to: monitor, track, and identify trends of infections in the facility. The facility failed to ensure proper hand hygiene during wound care for two sampled residents (Resident #19 and #4), during perineal care for two residents (Resident #8 and Resident #41); during transfers for one sampled resident (Resident #54); failed to ensure reusable supplies for multiple residents were sanitized before or after use for one resident (Resident #4); and failed to ensure a barrier was used during blood sugar testing for one sampled resident (Resident #33) out of 23 sampled residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain tube feeding poles in resident rooms [ROOM NUMBERS] free of grime; to maintain wheelchairs in resident rooms 308, 211 and 302 free of debris in and on the wheelchairs; to maintain the floors of resident rooms 413, 412, 411, 408, 309, 304, 102, 215, 211, 208 and 204, free from a heavy buildup of dust and debris; to maintain the sprinkler heads in the main dining room (MDR) free from a dust buildup; to maintain the blue shower pads in the 100 Hall spa room and the South Side soiled utility room, free from damaged areas which rendered the blue shower pads as not easily cleanable; to maintain the knee rest of the standup lift on the south side free of a tear that made the knee rest not easily cleanable. This practice potentially affected at least 60 residents who used or resided in those areas. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's care plan accurately reflected the resident's condition upon admission for three sampled residents (Resident #6, #19, and #4) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Care Planning dated 10/24/22 showed: -Each resident's comprehensive care plan will describe the following: -Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Any specialized services including rehabilitative service as a result of the Pre admission Screening and Resident Review (PASARR) recommendations. 1. Record review of Resident #6's undated face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide baths for six sampled residents (Resident #41, #15, #31, #58, #37 and #6); to provide oral care for one sampled resident (Resident #4), and to provide timely incontinence care for one sampled resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. The following policies were requested and not received at the time of exit: -Oral care. -Bathing. -Incontinence care. -Activities of Daily Living (ADL) assistance. 1. Record review of Resident #4's face sheet showed he/she was admitted with the following diagnoses: -Encephalopathy (a broad term for any brain disease that alters brain function or structure). -Cognitive Communication Deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive skin assessment that showed the location, measurement, and description of all pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) upon admission and weekly and to treat and cover pressure ulcers after removing the dressings for three sampled residents (Residents # 4, #8 and #38) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy Wound Management dated June 2020 showed: -Staff were to ensure wounds maintained moisture. -Staff were to protect the skin surrounding the wound from moisture. -A licensed nurse was to perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen orders were transcribed and in place for one sampled resident (Resident #19); to ensure oxygen nasal cannulas (a medical device used to deliver supplemental oxygen to people who have lower oxygen levels or respiratory difficulty) and tubing were kept covered when not in use for two sampled residents (Resident #47 and #41) and to care plan the resident's need for oxygen for one sampled resident (Resident #47) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Oxygen Administration dated June 2020 showed: -A physician's order is required to initiate oxygen therapy, except in an emergency situation. -The physician's order for oxygen should include: --Oxygen flow rate. --Method of administration. --Usage of therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 74 residents. Record review of the facility's policy titled Nursing Department-Staffing, Scheduling, and Postings dated [DATE] showed: -The facility will post the following information on a daily basis: --Facility name. --The current date. --The total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs). --Resident Census. -Posting Requirements: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's preferences were assessed and honored for one resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. 1. Record review of Resident #41's face sheet showed he/she was admitted with: -Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Unsteadiness on feet. Record review of the resident's Care Plan, revised 1/13/23, showed: -Staff assistance was required for the resident to bathe, perform personal hygiene, and for oral care. -Staff did not address resident preferences. Record review of the resident's Minimum Data Set (MDS-a federally mandated tool used for assessments) 5 Day PPS Assessment, completed 2/10/23, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of the facility bed hold policy for one sampled resident (Resident #326) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Bed Hold dated June 2020 showed the facility notifies the resident or his/her representative, in writing, of the bed hold policy any time the resident is transferred to general acute care hospital even if the facility has not met the occupancy requirements. 1. Record review of Resident #326's undated face sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of unspecified Atrial Fibrillation (an irregular heart beat). Record review of the resident's Electronic Medical Record (EMR) dated February 2023 showed: -The resident was sent to the hospital on 2/7/23, 2/10/23, and 2/12/23. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure care plans were updated to accurately reflect the resident's condition for one sampled resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy Care Planning dated 10/24/22 showed staff were to: -Include services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Update a resident's care plan per the Resident Assessment Instrument (RAI-used in conjunction with Minimum Data Set [MDS-a federally mandated tool used for care planning]) schedule. -Update a resident's care plan as dictated by changes in the resident's condition. -Update a resident's care plan to address changes in behavior and cares. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medication was available as ordered and documentation of control substance medication, reordering medication in timely manner and provide ongoing pain management for one sampled resident (Resident #50) out of 23 sampled resident. The facility census was 74 residents. Record review of the facility's policy and procedure undated for Medication Administration showed: -The nursing staff will document each medication given with time and initial of nurse who gave the medication. -For as needed medication the nurse will document the reason for the medication, name of the medication, time given and effect. 1. Record review of Resident #50's admission Face-Sheet showed he/she had a diagnosis of chronic pain, Multiple Sclerosis (MS, is a potentially disabling disease of the brain and spinal cord). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pharmacist's recommendations were received from the pharmacist and addressed by the physician for one sampled resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy Drug Regimen Review dated June 2020 showed: -The pharmacist was to review each resident's medication regimen at least once a month. -The pharmacist was to report any irregularities to the attending physician, the medical director, and the Director of Nursing (DON), and the reports must be acted upon. -The physician must document his/her rationale if the pharmacist's recommendations were not acted upon. -The DON was responsible for ensuring the physician followed up on all pharmacy recommendations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have recipes available for the chicken alfredo sauce over pasta, pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) chicken alfredo sauce over pasta and the pureed season cauliflower in the recipe books. This practice potentially affected residents who ate pureed food from the kitchen. The facility census was 74 residents. 1. Record review of the Week at a Glance menu for Week 2 on 2/27/23 showed the following for the lunch meal hearty meat sauce over mostaccioli (a smooth textured pasta in the form of a short tube with oblique ends), seasoned broccoli and seasonal fruit cup. During an interview on 2/27/23 at 9:35 A.M., Dietary [NAME] (DC) A said: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure hot foods (cauliflower and chicken alfredo sauce over pasta) were served at or close to a temperature at 120 degrees Fahrenheit (ºF) at the time of service to the residents in who received room tray in the 200 Hall. This practice potentially affected at least five residents whose trays were delivered towards the end of the delivery session. The facility census was 74 residents. 1. Record review of the minutes from the resident food council meeting dated 2/21/23 showed the residents said meals that were being received for lunch and dinner are sometimes cold. Observation on 2/27/23, of the delivery of room trays to the 200 Hall, showed: - At 12:30 P.M., the Dietary Department delivered the cart for the 200 Hall residents. - From 12:32 P.M. through 12:51 P.M., room trays were delivered to rooms in the 200 Hall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food in the resident use refrigerators were labeled with the date and the name of the resident, the food was for. This practice potentially affected an unknown number of residents for whom, food was stored in the South and North Unit resident use refrigerators. The facility census was 74 residents. 1. Record review of the facility's policy entitled Food Brought in by Visitors and revised on 2/2021, showed: - Purpose: To provide residents with the option of having food prepared by the resident's family brought into the facility. - Policy: Food may be brought to a resident by the family members, the resident's responsible party, or friends (visitors) if the food is compatible with the physician's diet order. [...]

Inspectors wroteBased on observation and interview, the facility failed to place a cover on the trash container located in the kitchen, before and during meal preparation on 2/27/23. This practice potentially affected at least 70 residents who ate food from the kitchen. The facility census was 74 residents. 1. Observations on 2/27/23 at 9:07 A.M., 9:31 A.M., 9:52 A.M. 10:16 A.M., and 11:22 A.M., showed an uncovered trash container open during the lunch meal preparation. During an interview on 2/27/23 at 11:25 A.M., the Dietary Manager (DM) said he/she was not sure where the cover was located.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and failed to practice sanitary procedures before food preparation tasks. These practices potentially affected the residents and staff who received and ate their meals from the facility's kitchen. The facility census was 70 residents. 1. Observations and interviews on 4/20/21 between 6:05 A.M. and 8:23 A.M. in the kitchen showed the following: -At 6:13 A.M. The refrigerated walk-in unit that stored fruits, produce, eggs and meat had a portable thermometer on its shelf displaying a temperature of 50 degrees Fahrenheit (ºF). -At 6:15 A.M. a second digital thermometer was placed side-by-side to the shelf thermometer to determine the accuracy of the walk-in refrigerated unit and its thermometer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an essential piece of kitchen equipment - the refrigerated walk-in unit - for properly storing food at the acceptable temperature ranges. This situation potentially affected the residents and staff who received and ate their meals from the facility's kitchen. The facility census was 70 residents. 1. Observations and interviews on 4/20/21 between 6:05 A.M. and 8:23 A.M. in the kitchen showed the following: -At 6:13 A.M. The refrigerated walk-in unit that stored fruits, produce, eggs and meat had a portable thermometer on its shelf displaying a temperature of 50 degrees Fahrenheit (ºF). -At 6:15 A.M. a second digital thermometer was placed side-by-side to the shelf thermometer to determine the accuracy of the walk-in refrigerated unit and its thermometer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staffing to provide cares needed for three sampled residents (Residents #8, #15, and #61) and one supplemental resident (Resident #24) out of 19 sampled residents. The facility census was 70 residents. 1. Record review of Resident #8's care plan dated 4/18/17 showed the resident required assistance with activities of daily living (ADL's-such as grooming, hygiene, etc.) and transferred from one surface to another with the use of a full body mechanical lift. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/21/21 showed the following staff assessment of the resident: -Was cognitively intact. -Displayed no altered mood symptoms or behaviors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #8) and one supplemental resident (Resident #24) who required mechanical lifts and assistance of two people were gotten out of bed when requested out of 19 sampled residents. The facility census was 70 residents. 1. Record review of Resident #8's care plan dated 4/18/17 showed the resident required assistance with activities of daily living (ADL's-such as grooming, hygiene, etc.) and transferred from one surface to another with the use of a full body mechanical lift. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/21/21 showed the following staff assessment of the resident: -Was cognitively intact. -Displayed no altered mood symptoms or behaviors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #27) out of 19 sampled residents (five of the 19 residents smoked) wore a smoking apron and was supervised while smoking. The facility identified 19 residents as residents who smoke. The facility census was 70 residents. Record review of the facility's Smoking by Residents policy dated June 2020 showed: -Instructions to ensure residents who chose to smoke, to do so safely. -Resident who wanted to smoke would be assessed for their ability to smoke safely prior to being allowed to smoke. -Residents who were not able to smoke safely would be accompanied by facility staff while smoking. -Residents who smoke should wear a smoking apron if they were found not to be safe. -All smoking sessions were to be supervised by facility staff members. 1. [...]