River City Living Community

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for three residents (Resident #1, #2, and #3) out of three sampled residents. The facility census was 47.1. Review of the facility's Care Plan Comprehensive policy, undated, showed assessment of each resident is ongoing process and the care plan will be revised as the resident's condition changes. A well-developed care plan will be oriented to: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to protect one Resident (Resident #1's) right to be free from inappropriate touching when one resident (Resident #2), was found with his/her mouth on Resident #1's chest. The facility census was 47.1. Review of the facility's abuse policy, undated, showed it is the policy of the facility that each resident will be free from abuse. The residents will be protected from abuse, neglect and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.2. Review of Resident #'1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/22/26, showed staff assessed the resident as cognitively impaired, wandered daily, and with a diagnosis of dementia with behaviors. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement their grievance protocol for one resident (Resident #1) when he/she reported a missing tablet and staff failed to provide the resident with written actions, responses and rationales to his/her concerns. The facility census was 51.1. Review of the facility's Grievance Protocol policy, undated, showed the purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper [NAME]-up through appropriate discipline. The Social Service Director is responsible for the program, although the administrator is ultimately responsible for the proper implementation of the program. Any member of the Social Services staff can complete the Grievance Compliant Report. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement their abuse and neglect policy to investigate an allegation of misappropriation of property for one resident (Resident #1) out of three sampled residents who reported an item missing. The facility census was 51.1. Review of the facility's Investigation policy, dated 2017, showed every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source and misappropriated resident property must be thoroughly investigated. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to report an allegation of misappropriation of property for one resident (Resident #1) within twenty-four hours to the state agency Department of Health and Senior Services (DHSS). The facility census was 51.1. Review of the facility's Abuse and Neglect Reporting Instructions policy, undated, showed staff are directed to report immediately, no later than one hour of the event, because the Administrator or designee is required to report events of abuse to the DHHSS/[NAME] Abuse Hotline within two (2) hours of the vent occurring. It is critical to report the event within the regulatory time frames according to the State and Federal Regulations. Review showed the policy did not direct staff to report misappropriation of property within twenty-four hours. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to obtain a discharge order, and provide the resident and/or his/her representative with a comprehensive Discharge Summary to include a summary of the resident's stay and course of treatment in the facility, including diagnosis, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including pending lab results, special instructions for ongoing care, a post discharge plan of care, advance directive information, and a reconciliation of medications for one resident (Resident #2) out of three sampled residents. The facility census was 44. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent an injury to one resident (Resident #3) when a Nursing Assistant (NA) used an electric nail file to apply acrylic nails to resident's fingernails and cut his/her finger which caused an infection and hospitalization. The facility census was 44.1. Review of facility's Care of Nails - Fingers and Toes policy, undated, showed the purpose of the policy is to provide cleanliness, comfort, and to prevent spread of infection. Nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document they administered three residents (Resident #1, Resident #2 and Resident #3) out of three sampled residents medication as directed by the physician. The facility census was 44.1. Review of the facility's medication administration guidelines, dated 2/7/2013, showed it is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document they administered medications for three residents (Resident #1, Resident #2 and Resident #3). The facility census was 39. 1. Review of the facility's medication administration guidelines, dated 2/7/2013, showed residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to notify the physician in a timely manner for two residents (Resident #1 and Resident #2) when Resident #1 made an accusation that Resident #2 touched him/her in an inappropriate manner. The facility census was 38. 1. Review of the facility's Resident condition change - observing, recording and reporting, not dated, showed staff were directed to observe, record and report any condition change to the attending physician so that proper treatment can be implemented. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 3/19/25, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of anxiety disorder. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week. The facility's census was 40. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's time-keeping records for consecutive hours worked by an RN for December 2024, showed the facility did not have an RN for at least eight consecutive hours a day in the building on Tuesday, 12/31/24. Review of the facility's time-keeping records for consecutive hours worked by an RN for January 2025, showed the facility did not have an RN for at least eight consecutive hours a day in the building on the following dates: -Saturday, 01/04/25; -Sunday, 01/05/25; -Saturday, 01/11/25; -Sunday, 01/12/25: -Saturday, 01/18/25; -Sunday, 01/26/25. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to ensure services provided met professional standards of practice when staff failed to document and complete neurological checks for three residents (Resident #1, #2, and #3) of four sampled residents who had unwitnessed falls. The facility's census was 40. 1. Review of the facility's Event Investigation policy, dated March 2015, showed staff are directed to identify any injuries after a resident sustains an event, and directed staff to document the type of event, such as a fall, and a mental/neurological status after the event. Review of the facility's post-fall flow chart, undated, showed staff are directed as follows: -Charge nurse initiates a fall event in the electronic medical record (EMR). Describe if witnessed or observed on floor, neurological checks initiated or neurological checks not initiated; [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to ensure resident environment remained free of accident hazards when facility staff failed to ensure lighters were kept secure for three (Resident #1, #2, and #3) out of three sampled residents. The facility census was 60. 1. Review of the facility's Smoking-Residents policy, dated March, 2015, showed: -This facility shall establish and maintain safe resident smoking practices; -Smoking articles for residents with independent smoking privileges shall be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession; -Resident may only keep disposable safety lighters. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/19/24, showed staff assessed the resident as mild cognitive impairment and used tobacco. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 39 with a capacity of 87. 1. Review of the facility's Food Preparation and Distribution policy, dated May 2015, showed measured utensils are used to serve proportions as described on menu. 2. Review of the facility menus, undated (Week 2, Day 10), showed the menus directed staff to provide the residents on regular diets six ounces of stroganoff, ½ cup (four ounces) of noodles and ½ cup of vegetable blend at the lunch meal. Observation on 10/01/24 at 12:41 P.M., showed [NAME] I served the residents a #6 scoop (5.3 ounces) of stroganoff, three ounces of noodles, and three ounces of mixed vegetables. Observation showed the portions were less than the menu directed portions. 3. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. This failure has the potential to affect all residents. The census was 39 with a capacity of 87. 1. Review of the facility's Safe Food Handling policy, dated May 2015 showed all food, including bulk items, should be tightly sealed with an identifying label and date. 2. Observation on 10/01/24 at 10:01 A.M., showed the reach in refrigerator contained: -A plastic container of pineapple which was not in its original container and was undated; -A plastic container of hot dogs which was undated; -An opened and undated bag of lettuce; -An opened and undated container of tuna salad; -A cardboard flat of eggs which contained five broken eggs; -A zipper bag of meat, dated 09/01/24, and labeled use until gone which was open to the air; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to store oxygen and nebulizer equipment in a manner to prevent spread of infection for six residents (Resident #1, #2, #3, #5, #13 and #15) of seven sampled residents who used oxygen, when staff failed to cleanse a suction machine for one (Resident #1) of one sampled resident who required as needed suctioning and when staff failed to use appropriate hand hygiene during wound care for two residents (Resident #27 and #36) of three sampled residents with wounds. The facility census was 39. 1. Review of the facility's Oxygen Administration policy, dated March 2015 showed: -Label humidifier with date and time opened; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure provision and documentation of education regarding the benefits, risks, potential side effects associated with the COVID-19 (a disease caused by a novel coronavirus) vaccine for facility staff. The facility census was 39 residents. 1. Review of the facility's Immunization policy dated 02/26/22 showed the policy did not contain direction for COVID-19 vaccine for facility staff. Review of the facility's COVID-19 for LTC policy dated 05/15/23 showed the policy did not contain direction for COVID-19 vaccine for facility staff. 2. During an interview on 10/02/24 at 09:36 A.M., the administrator said the business office manager quit on 10/02/24. The business office does the new hire paperwork to include review of COVID-19 status for employees. [...]

Inspectors wroteBased on interview and record review, staff failed to maintain a professional standard of care when staff failed to obtain physician ordered blood work for four (Resident #1, #2, #4 and #5) of six sampled residents. The facility census was 39. 1. Review of the facility policies showed staff did not provide a policy for obtaining blood work. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/01/24, showed the resident had a diagnosis of diabetes. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed the physician ordered a Hemaglobin A1C (measures average blood sugar over last two to three months) blood test to be obtained every three months on 05/28/24. Review of the resident's medical record showed the resident last Hemaglobin A1C blood test result on 05/30/24. [...]

Inspectors wroteBased on observation, interviews, and record review, facility staff failed to provide an ongoing activity program on the weekends and evenings and failed to provide a program that met the needs of two dependent residents (Resident #6, and #1). The facility census was 39. 1. Review of the facility's Activity, Volunteer and Recreational Services, dated March, 2012, showed the facility provides an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical , mental, and psychosocial well-being of each resident. The activity program must be directed by a qualified professional (Activity Director) who is directly responsible to the Administrator. 2. Review of the facility's activity calendar, dated September 2024, showed the weekend activities as follows: -On 09/07/24 10:00 A.M. bible study, 1:00 P.M. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs for the residents by not providing in-services, re-evaluating and documenting skills and competencies on a regular basis for each employee and failed to ensure nurse aides received the required 12 hours in-service education annually. The facility census was 39. 1. Review of the facility's Orientation and Training policy, dated April 2011 showed: -Each department head is responsible for the job-specific training required. -The policy did not include how often the education should be provided, how the education is to be documented or a list of inservices to include: abuse and neglect, dementia care, resident rights, communication, behavioral health or specialized resident needs to include: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement an effective and complete antibiotic stewardship program when staff failed to track residents on antibiotics for various infections in the facility, by not completing a current and ongoing antibiotic log of residents with active infections. The facility census was 39. 1. Review of the facility's Antibiotic Stewardship Program, undated, showed: -The Infection Preventionist (IP) will be the hub of the Antibiotic Stewardship Program. They will have the knowledge and expertise to effectively develop, implement and monitor the Antibiotic Stewardship Program; -The IP/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to document the administration or refusal of the pneumococcal (lung inflammation caused by bacterial or viral infection) vaccine for three (Resident #1, #4, and #37) of five sampled residents. The facility census was 39 residents. 1. Review of the facility's Immunization policy, undated, showed: -A physician order, consent to receive signed by the resident and/or legal representative, information sheet included with the consent to administer pneumococcal vaccine, includes general information, risks and side effects and the resident will be monitored for fever up to 72 hours; -The schedule for administration will be determined according to the pharmacy and Centers for Disease Control (CDC) recommendations; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical, and nursing needs, when staff failed to address oxygen use and self-administration of medication for one resident (Resident #2) who received oxygen and kept medication at bedside, failed to address shower preferences for one resident (Resident #13), and failed to address falls for one resident (Resident #27) who had falls out six sampled residents. The facility census was 39. 1. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed: -The Interdisciplinary team (IDT) with input from the resident, family and/or legal representative will develop and maintain a comprehensive care plan for reach resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure the activities program was directed by a qualified professional. The census was 39. 1. Review of the facility's Activity, Volunteer and Recreational Services, dated March, 2012, showed the facility provides for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical , mental, and psychosocial well-being of each resident. The activity program must be directed by a qualified professional (Activity Director) who is directly responsible to the administrator. During an interview on 10/04/24 at 10:29 A.M., the Activity Director said he/she was not certified and was not aware he/she needed to be certified. He/She said he/she has been in the position since February 2024. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse, when Certified Nurse Assistant (CNA) A sexually assaulted the resident. The facility failed to protect the resident from further abuse when CNA D witnessed the assault, did not intervene, and did not report it immediately. CNA A worked an additional 18 overnight shifts after the sexual abuse was observed. The facility census was 52. The Administrator was notified on [DATE], of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of sexual abuse for one resident (Resident #1) to the administrator on 4/17/24, after witnessing the event. The alleged perpetrator worked 18 additional shifts before the nurse aide reported what was seen to the administrator on 5/13/24. The administrator failed to report the allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two hour timeframe. The facility census was 52. The Administrator was notified on 06/26/24, of an Immediate Jeopardy (IJ) which began on 04/17/24. The IJ was removed on 05/30/24 as confirmed by surveyor onsite verification. 1. Review of the facility's policy titled, Investigation, undated, showed staff were directed to: [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement abuse and neglect policies and procedures to ensure all staff providing care to residents were trained on the facility's abuse and neglect policy for two staff Certified Nurse Aides (CNA A and D) out of four sampled staff upon hire. The facility census was 52. 1. Review of the facility's policy titled, Screening Components, undated, showed all new employees and volunteers will receive training on the abuse policy prior to direct or indirect resident contact. All new employees/volunteers will be oriented to the Abuse Policy and made aware of their responsibility to report any suspected maltreatment as defined and described in this policy. Attendance at a yearly in-service on the Abuse Policy and on Resident Rights is mandatory for all employees/volunteers. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a thorough investigation when a staff member reported Certified Nurse Aide (CNA) A sexually assaulted one resident (Resident #1). The facility census was 52. 1. Review of the facility's policy titled, Investigation, undated, showed staff were directed to: -It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated; -When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: -Who was involved; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to prevent misappropriation when Licensed Practical Nurse (LPN) A, without authorization of the resident or the resident's responsible party, misappropriated one residents' (Resident #1's) pain medication. The facility census was 52. The administrator was notified on 9/27/23 of Past Non-Compliance which occurred on 9/14/23. On 9/14/23, the administrator identified Licensed Practical Nurse (LPN) A misappropriated a bottle of morphine that belonged to a resident without permission by the resident or his/her responsible party. Upon discovery, staff suspended the employee, conducted an investigation, notified appropriate parties, and terminated the LPN. Facility staff reviewed their abuse and neglect policies, and in-serviced all employees on abuse and neglect. Staff corrected the deficient practice on 9/15/23. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide a safe, clean, comfortable and homelike environment. The facility staff failed to ensure resident rooms on the memory care unit had personalized decorations or items for four residents Resident #14, #284, #285 and #290). Facility staff also failed to provide routine maintenance services to maintain windows in good repair, one hallway was free of debris, and one resident's (Resident #11) room was clean, and free of odors. The facility census was 44. 1. Review of the policies provided by the facility showed they did not contain a policy in regard to maintaining a comfortable and homelike environment for the residents. Observations from 1/9/23 at 10:00 A.M. through 1/12/23 at 1:00 P.M., showed Resident #284 did not have any personalized items or decorations in his/her room or on the walls. [...]

Inspectors wroteBased on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) in accordance with their facility policy for four out of nine sampled staff (Certified Nurse Aide (CNA) S, Nurse Aide (NA) A, the Social Services Designee (SSD), and Maintenance Supervisor U). Additionally, staff failed to check the Family Care Safety Registry (FCSR) or complete a complete Criminal Background Check (CBC) for one employee (Maintenance Supervisor U). The facility census was 44. 1. Review of the facility's Background Checks policy, undated, showed: -The FCSR or the EDL and CBC must be checked before the applicant/employee has any contact with residents; -Check if the applicant is registered with the FCSR; [...]

Inspectors wroteBased on interview and record review facility staff failed to complete and transmit Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, assessments for 12 residents (Residents #4, #8, #10, #13, #14, #16, #21, #25, #229, #285, #294 and #298). The facility census was 44. 1. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2019, showed: -Transmitting Data: Submission files are transmitted to the QIES ASAP system using the Centers for Medicare and Medicaid Services (CMS) wide area network. Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to accurately identify care areas for eight residents (Residents #4, #10, #11, #14, #18, #21, #23, and #25) in the resident's comprehensive care plans. The facility census was 44. 1. Review of the Care Plan Comprehensive policy, dated March 2015, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to meet professional standards when staff failed to obtain laboratory services for one resident (Resident #1), and failed to obtain a physician's order for oxygen for one resident (Resident #11). Additionally, facility staff failed to document when one resident's (Resident #229's) enteral feeding (calories delivered directly to the stomach) tube flush bag (bag that holds water used to flush a feeding tube via a pump) and tubing were changed. The facility census was 44. 1. Review of the facility's Physician Orders Policy, dated March 2015, showed: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Physician orders are needed for laboratory work. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to properly propel one resident (Resident #13) in a wheelchair in a manner to prevent accidents. Additionally, staff failed to ensure razors/sharps and hazardous chemicals were stored in a safe manner. The facility census was 44. 1. Review of the policies provided by the facility showed they did not contain a policy for wheelchair use or for the storage of hazardous chemicals and sharps. Review of Resident #13's 5 Day Scheduled Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/19/22, showed staff assessed the resident as: -Severe cognitive impairment; -Used a wheelchair for mobility. Observation on 1/10/23 at 8:18 A.M., showed Licensed Practical Nurse (LPN) L propelled the resident down the hallway without foot pedals. The resident's feet touched the floor. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure Pharmacist Medication Regimen Reviews (MRRs), a monthly review of each residents' medications to check for irregularities, were documented as reviewed and completed by the physician for four residents (#10, #14, #15 and #18). The facility census was 44. 1. Review of the facility's Drug Review Policy, dated March 2015, showed: -All medications given to each resident will be reviewed on a monthly basis; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas. The report lists any problems noted, and the date and signature of reporter; -Problems identified shall be addressed according to need in consultation with physician; -Follow up on problems needs either the Director of Nursing (DON)'s or pharmacist's signature to show that the problem has been addressed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when staff failed to use appropriate hand hygiene during the provision of care and failed to use appropriate infection control procedures during incontinence care for two residents (Residents #29 and #13), and failed to follow the manufacturer's direction for disinfection and/or use of a glucometer for five residents (Resident's #282, #22, #2, #24, and #23). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity by failing to close the privacy curtain during care for two residents (Residents #4 and #23). Additionally staff failed to provide a privacy curtain for two residents (Residents #13 and #18) room. The facility census was 44. 1. Review of the facility's Patient [NAME] of Rights Policy, undated, showed: -Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. [...]

Inspectors wroteBased on observation, staff interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage rooms and in one of three medication storage carts. The facility census was 44. 1. Review of facility's Medications, Storage of Policy, dated March 2015 showed no discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. Observation on 1/9/23 at 2:33 P.M., showed the 100 hall medication cart contained: -One open bottle of Niacin (vitamin) 500 milligrams (mg), with an opened date of 6/30/22 and expiration date of 6/2022, that contained 100 tablets; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to residents and visitors, and failed to post the name, address and phone number for the Long-Term Care Ombudsman and resident rights on the secured unit. The facility census was 44. 1. Review of the policies provided by the facility showed they did not contain a policy for the required postings. 2. Observations from 1/9/22 at 10:00 A.M. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for two residents (Residents #1 and #20). The facility census was 44. 1. Review of the facility's Bed Hold Guidelines, undated, showed the facility will notify all residents and/or their representative of the bed hold policy guidelines upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Review of Resident #1's census information showed staff documented the resident was transferred to the hospital on [DATE]. Further review showed staff did not document they notified the resident or the resident's representative of the facility's bed hold policy. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the facility census, and the the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 44. 1. Review of the policies provided by the facility showed they did not contain a policy for the nurse staff posting. 2. Observation on 1/09/23 at 11:27 A.M., showed the nurse staff posting at the front entrance did not include the total number of actual hours worked for licensed or unlicensed nursing staff, or the facility census. Observation on 1/10/23 at 8:43 A.M., showed the nurse staff posting at the front entrance did not include the total number of actual hours worked for licensed or unlicensed nursing staff, or the facility census. [...]

Inspectors wroteBased on record review and interview, facility staff failed to maintain an ongoing Quality Assessment and Assurance (QAA), (identification, assessment, correction and monitoring of important aspects of resident care to enhance quality) program and committee that consisted of the minimum required members. The facility census was 44. 1. Review of the facility's QAA Policy, undated, showed: -Facility leaders may include, but are not limited to the administrator, Director of Nursing (DON), Dietary Manager (DM) and Director of Activities (DA). -Indicate goals the plan strives to meet; -Goals should be specific, measurable, relevant and have a timeline for completion; -The leadership of the building will ensure appropriate and adequate resources are available for the facility to carry out the QAPI (Quality Assurance and Performance Improvement) plan; [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement policies and procedures to ensure one staff member was fully vaccinated for Coronavirus 2019 (COVID-19). The facility had 4% of employees not fully vaccinated or with an approved exemption. The facility had zero resident COVID-19 infections in the previous four weeks, and zero resident hospitalizations. The facility census was 44. 1. Review of the facility's COVID-19 Staff Vaccination Requirements, dated 1/18/22, showed: -By, March 15, 2022, the COVID-19 primary vaccination series be completed and that staff are fully vaccinated, except staff who have been granted exemptions, or those whom COVID-19 vaccination must be temporarily delayed as recommended by the Centers for Disease Control (CDC) due to clinical precautions and considerations; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to prevent the spread of bacteria and other infection causing organisms. Staff failed to clean and sanitize the multiple use resident glucometer (a device for monitoring blood sugars) before and after each use, for three sampled residents (Residents #7, #12, and #34). Additionally, facility staff failed to implement policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) The facility census was 37. 1. Review of the facility's blood glucometer disinfecting policy, dated March, 2015, showed staff are directed to place equipment on a clean surface. The glucose monitor is to be disinfected after use and returned to the cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to update the plan of care with changes in the resident's needs for four residents (Resident #8, #16, #30, and #185) out of 12 sampled residents. The facility census was 37. 1. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed staff are directed: -The comprehensive care plan will be based on a thorough assessment that includes, but not limited to, the MDS; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: a. When there has been a significant change in the resident's condition; b. At least quarterly; c. When changes occur that impact the resident's care (i.e. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to meet professional standards by failing to consistently assess, document and maintain proper wound documentation for four of four sampled residents (Resident #8, #12, #25, and #186) with a pressure ulcer. The facility census was 37. 1. Review of the facility's Wound Care and Treatment Policy, dated March 2015, directed staff as follows: -Prevention strategies- on-going skin assessment with weekly documentation of status, minimize dry skin by applying moisturizers to areas of dry skin after a bath and as needed (prn), avoid massage over bony prominences, minimize friction and sheer through proper positioning, transferring, and turning, and develop and implement method of communicating position changing. 2. Review of Resident #8's annual minimum data set (MDS), dated [DATE], showed staff assessed the resident as: [...]

Inspectors wroteBased on observation and interview, the facility failed to store food in a safe and sanitary manner. The facility failed to ensure opened food items were dated to prevent staff from using outdated food items. The facility failed to discard molded and rotting food items. The facility also failed to ensure food items were stored in closed air tight packaging and at appropriate levels to prevent physical contamination. Additionally, facility staff failed to ensure the employee break room ice machine's drainage pipe contained an air gap between the pipe and floor drain. The facility census was 37. 1. Observation on 7/29/19 at 10:30 A.M., showed the following in the resident kitchen pantry located in the rear of the kitchen: -undated, open bag of hot dog buns with molded bun; -undated, open bag of hamburger buns with molded buns; -undated, open plastic bag of potatoes with rotten potatoes; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow the menus by failing to offer all the menu food items to one resident (Resident #16) on a pureed diet. The facility census was 37. 1. Review of Resident #16's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/05/19, showed the following: - admission date of 04/06/19; - Severely impaired cognition; - Required supervision for eating; - Diagnosis of Alzheimer's disease; - Weight loss of 5% or more in the last month or 10%or more in the last six months; - Ate a mechanically altered diet; - On hospice. Review of the resident's physician order sheet (POS), dated July 2019, showed an order for the resident to receive a diet consisting of nectar thick liquids with pureed foods. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide residents with a pureed diet as ordered by the physician for one out of one resident who ate a pureed diet (Resident #16). In addition, the facility failed to provide thickened liquids as order by the physician for one out of 12 sampled residents (Resident #30). The census was 37. 1. A policy regarding pureed diets was requested, but the facility did not provide the policy. A policy regarding thickened liquids was requested, but the facility did not provide the policy. 2. Review of Resident #16's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/19, showed the following: - admission date of 4/6/19; - Severely impaired cognition; - Required supervision for eating; - Diagnosis of Alzheimer's disease; [...]