Sherbrooke Village

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation or intervention for pain management for two of two residents (Residents #118 and #2). One resident had uncontrolled pain for 20-hours after being discharged from a local hospital with a pelvic fracture. The facility did not administer any pharmacological or non-pharmacological approaches for pain control. The facility nurse did not try to get orders for pain medication from the on-call provider (Resident #118). Facility staff also failed to provide pain control interventions for one resident during a wound treatment (Resident #2). The sample was 24. The census was 121. Review of the facility's Pain Management policy dated 11/22, showed:-Policy: The Facility will use a systematic approach to Pain Management; Recognition, Evaluation, Treatment, & Monitoring of Pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident was treated in a dignified manner (Resident #98), and failed to ensure staff followed the facility's cell phone policy, which affected 4 residents (Residents #12, #3, #100 and #140). The sample size was 24. The census was 121. Review of the facility's resident rights policy, dated 1/28/26, 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 of their rights upon admission. Review of the facility's employment policies and procedures, undated, showed:-Personal cell phones: Use of personal cell phones or other similar devices while on duty is prohibited. Employees must understand that our first priority is the care and welfare of the residents. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure wheelchairs for two residents (Resident #1 and Resident #109), the [NAME] Hall living room carpet, and the Lodge common area were maintained in a clean, comfortable and homelike environment. The sample size was 24. The census was 121. During an interview on 4/10/26 at approximately 7:00 A.M., the Administrator said the facility did not have a policy on cleaning wheelchairs or a wheelchair cleaning schedule. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/26, showed:-Cognitively intact;-Used a wheelchair;-Diagnoses included heart failure, high blood pressure, and renal (kidney) failure. Observation on 4/6/26 at approximately 12:00 P.M., showed the resident sat in his/her wheelchair in his/her room. [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the transfer and discharge notices to the representative of the Office of the State Long-Term Care Ombudsman (resident advocate) for 11 out of 12 months. The census was 121. Review of the facility's Discharge and Transfer policy, last revised 9/17/25, showed a copy of a transfer or discharge notice must be provided to the Ombudsman. Review of the facility's admission and Discharge Report, dated 6/26/24 through 4/6/26, showed 39 residents discharged from the facility. Review of the Social Service Director's (SSD) monthly e-mails sent to the Ombudsman's office showed:-No transfer or discharge notifications were sent to the Ombudsman's office in April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026, and February 2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident received one on one activities (Resident #5) and failed to ensure two residents had activities provided (Residents #3 and #140). In addition, the facility failed to ensure activities were provided on the 300 hallway and failed to ensure activities posted on the activity calendar for the [NAME] hallway were conducted. The sample size was 24. The census was 121. Review of the facility's activities policy, dated 9/14/23, showed:-Policy: It is the policy of the facility to provide an ongoing program to support residents in their choice of Activities based on their comprehensive evaluation, care plan, & preferences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored securely on locked medication carts, and to ensure medication and treatment carts were free from storage of personal items, expired medications, and improperly labeled medications. Five medication carts were observed and problems were found with each. The census was 121. Review of the facility's Storage of Medications policy, dated 11/18, 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 (Registered Nurse (RN), Licensed Practical Nurse), pharmacy personnel, or staff members lawfully authorized to administer medications;-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served to residents at a safe and appetizing temperature (Residents #3, # 23, #76, #100 and #140). The sample was 24. The census was 121. Review of the facility's meal service temperature log, undated, showed:-Hot food needs to maintain at 135 degrees Fahrenheit (F) or above in steamtable;-Cold food needs to maintain at 41 degrees F or below. 1. Observation on 4/8/26 at 12:56 P.M., of lunch on the memory care unit, showed:-Soup measured 126.8 degrees F;-Meatballs measured of 129.3 degrees F. Observation on 4/9/26 at 8:54 A.M., of 300 hall breakfast trays, showed:-Cream of wheat measured 80 degrees F;-Scrambled egg measured 109 degrees F;-Biscuits and gravy measured 111.1 degrees F. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff exhibited appropriate infection control practices while providing feeding assistance to one resident (Resident #12). In addition, the facility failed to ensure food was served from a clean steam table on the [NAME] Hall. The sample was 24. The census was 121. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/6/26, showed:-Severe cognitive impairment;-Diagnoses included aphasia (language impairment), paraplegia (paralysis of lower portion of the body and of both legs), hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), and dementia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure a call light was in reach for one resident (Resident #98). The sample was 24. The census was 121. During an interview on 4/10/26 at approximately 7:00 A.M., the Administrator said the facility did not have a call light policy. Review of Resident's # 98's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26, showed:-Cognitively intact;-Dependent on staff for toileting hygiene;-Frequently incontinent of bowel and bladder;-Diagnoses included Parkinson's disease, dementia, and chronic obstructive pulmonary disease (COPD), a lung disease that cause the airway to become constricted and difficult to breathe. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not following physician orders for daily weights for one resident (Resident #1), and by leaving medications, including pain, blood pressure, and seizure medications in a medicine cup in the resident's room for the family member to administer (Resident #13) . The sample size was 24. The census was 121. Review of the facility's Physician Orders policy, dated 9/28/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received appropriate activity of daily living (ADL, daily care) care to meet the needs of residents by leaving one incontinent resident (Resident #98) soiled and wet for an extended period. The sample was 24. The census was 121. Review of the facility's Perineal Care (cleansing of the genitals and anal area) policy, undated, showed:- Perineal care which includes care of the external genitalia and the anal area, should be offered during the daily bath and it the resident is incontinent for urine or stool; The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate treatment and services for two residents with pressure ulcers (wounds related to prolonged pressure on bony prominences) (Resident #2 and #13) and interventions to prevent pressure ulcers for one resident (Resident #23). The facility failed to provide ordered treatments and a timely wound consult for Resident #2. The facility failed to provide dressing changes when dressings were saturated, for Resident #13. The facility failed to provide Residents #13 and #23 with low air loss mattresses set to the correct settings, which would put the residents at risk for increased pressure on bony prominences. The sample size was 24. The census was 121. Review of the facility's Wound Management policy, dated 11/22, showed:-Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for two residents (Residents #60 and #98). The sample was 24. The census was 121. Review of the facility's Podiatry (foot specialty) Services policy, revised 2/16/26, showed:-Policy: The facility will assist in arranging for residents as needed;-Responsibility: Social Worker (SW) and Licensed Nurse;-Procedure: On admission and as needed, the Licensed Nurse evaluates feet and toenails for any abnormalities. The Licensed Nurse will notify the resident's medical provider of any needs for podiatry services and obtain and order for podiatry consultation. The Licensed Nurse will notify Social Services (SS) of the need for arranging podiatry services. SS will arrange for podiatry services, including transportation if needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to use a gait-belt during a transfer for one resident (Resident #93). The sample size was 24. The census was 121. Review of the facility's Gait Belt Transfer policy dated 10/22, showed:-Policy: The Facility will utilize a Gait Belt for Residents who require one assist with Transfer to promote safety during Resident Transfers;-Responsibility: Nursing Assistants, Licensed Nurses (Licensed Practical Nurse (LPN) and Registered Nurses (RN), Nursing Administration, Assistant Director of Nursing (ADON) and Director of Nursing (DON);-Procedure:--Place Gait Belt around the Resident's waist over their clothing with the buckle forward;--Buckle/Fasten the Gait Belt;-- Slide open hand below belt to ensure the Gait Belt is snug but not too tight;-- Position your body close to the Resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #74) with an external urinary collection device (a noninvasive external tube that drains the urine from the bladder) had appropriate physician orders to include catheter care instructions and monitoring. The sample was 24. The census was 121. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to be free from medication errors of less than 5%. The facility's medication error rate was 11.11% with three errors out of 27 opportunities observed. Staff failed to monitor one resident's blood pressure (BP) prior to administration of Midodrine (a medication to treat low BP) (Resident #86). Staff also used improper technique and failed to follow the facility's policy when they instilled eyedrops for two different types of eye medications without pausing in between types of eyedrops, for one resident (Resident #92). The sample was 24. The census was 121. Review of the facility's Physician Orders policy dated 9/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with acceptable professional standards and practices when staff documented treatments as completed when they had not been administered for one resident (Resident #23). The sample was 24. The census was 121. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/26, showed:-Cognitively intact;-Diagnoses included dementia, muscle weakness, and quadriplegia (paralysis of all four limbs and the torso). Review of the resident's physician's order summary (POS), dated April 2026, showed:-An order, dated 1/5/26, for wound to right great toe. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Aides (CNAs) employed at the facility for more than a year received no less than 12 hours of in-service training per year, for two of five sampled employees. The census was 121. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's (Resident #1's) feet were free from dry skin and failed to ensure skin assessments were accurate. The facility also failed to address the resident's foot care needs on the care plan. The sample was four. The census was 92. Review of the facility's skin integrity policy, dated 7/5/25, showed: -Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate; -Policy: Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity. Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan. Appropriate interventions will be initiated based on the risk factors identified. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of injury of unknown origin to the Department of Health of Senior Services (DHSS) within the required two-hour time frame, when Resident #1 wandered onto another unit, wearing only a brief, with a cord tied around his/her waist and a bloodied face. The sample was two. The census was 74. Review of the facility's Abuse Prevention policy revised [DATE], showed: Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but not later than two hours after the allegation is made if the events that caused the allegation result in serious bodily injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a licensed Administrator, who was legally responsible for establishing and implementing policies regarding the management and operation of the facility. This had the potential to affect all residents of the facility. The census was 128. The Interim Administrator was notified on [DATE] of the Past Non-Compliance. The Director of Business Operations (DBO) filed and received a Temporary Emergency License (TEL). The deficiency was corrected on [DATE]. Review of Administrator A's State of Missouri Nursing Home Administrator's License showed it was valid through [DATE]. Review of the DBO's cover letter for application of licensure/TEL application, dated [DATE], showed: -DBO had a previous TEL which was granted in [DATE]; -The application was dated [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to determine the presence of a federal indicator (used to identify individuals found to have abused, neglected, or misappropriate resident property) with the Nurse Aide (NA) Registry for three of 10 sampled employees hired since the last survey. The facility hired at least 57 new employees since the last survey. The census was 88. Review of the facility's Abuse Prevention policy, approved 6/2022, showed: -Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide and offer snacks at bed time, when snacks were only offered mid-day, between lunch and dinner, and not at bedtime. The census was 88. During an interview on 6/20/24 at 11:53 A.M., the Dietary Manager said breakfast was served at 7:30 A.M., lunch was served at 12:30 P.M. and dinner was served at 5:30 P.M. During a group interview on 6/24/24 at 1:55 P.M., eight residents, who represented the resident counsel, said the facility did not offer snacks anymore. One resident said they got nothing to eat after 5:00 P.M., his/her sugar was low the other night, and he/she was given some pudding. The facility would give residents a snack if their blood sugar was low. During an interview on 6/25/24 at 3:14 P.M., the Activity Director said they pass snacks at 3:00 P.M., and it's called [NAME]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control and prevention practices when staff brought the treatment cart into an isolation room and did not clean and disinfect the cart before taking the cart into another resident's room. In addition, staff failed to perform hand hygiene between glove changes, disinfect a clean field, and disinfect scissors for one resident during wound care (Residents #61 and #238). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one resident's (Resident #239) physician timely when there was change in the drainage from a surgical wound and when there was a change in the resident's blood pressure. The sample was 19. The census was 88. Review of the facility's Clinical Protocol: Guidelines for Notifying Health Care Providers (Physicians) of Clinical Problems Policy, dated last approved 1/23, showed: -Purpose: These guidelines are to help ensure that 1) medical care problems are communicated to the health care provider, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record; -Immediate Notification - Immediate implies that notification should occur as soon as possible, the health care provider or alternate is informed at the time of the event. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional service standards when staff did not clarify medication orders and documented the same medication as given in multiple forms and duplicated doses, for one resident (Resident #67). In addition, the facility failed to follow physician orders when staff failed to send one resident (Resident #238) out to the hospital timely. The sample was 19. The census was 88. 1. Review of Resident #67's medical record, showed: -Diagnoses included Alzheimer's disease, unspecified dementia, and gastroesophageal reflux disease (GERD, heart burn); -An electronic physician order dated 10/21/22, for pantoprazole (used to treat heartburn) 40 milligram (mg) tablet delayed release, by mouth (PO), twice a day (BID), for GERD; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a stop date of 14 days or less on an as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in an alteration in perception, mood, consciousness, or behavior) for one resident (Resident #76). The sample size was 19. The census was 88. Review of the facility's Psychotropic Drugs policy, dated November 2022, showed: -Psychotropic medications may be considered for residents but only after medical, physical, functional psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored appropriately. The facility identified five medication/treatment carts and two medication rooms. Three of the five carts and both medication rooms were checked for medication storage. Issues were found in both medication room medication refrigerators. Staff failed to discard an expired bottle of Pantoprazole suspension (used to treat heartburn) for one resident (Resident #67) and failed to date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution. In addition, the staff failed to check the refrigerator temperatures and keep the log sheets updated. The census was 88. Review of the facility's Storage of Medications policy, dated 12/2017, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to post in a place readily accessible to residents, family members, legal representatives of residents and visitors the results of the most recent survey and complaint investigations. The census was 88. Observations on 6/20/24, 6/21/24 and 6/24/24, 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 were posted for the location of the survey results and/or availability of the last survey or complaint investigations. During a group interview on 6/24/24 at 1:55 P.M., eight residents who represented the resident counsel said they did not know where to locate the survey binder. During an observation and interview on 6/24/24 at 3:16 P.M., eight residents from the group meeting approached the receptionist area and requested the survey binder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate and assess one resident after falls and also failed to provide adequate supervision on the facility's memory care unit. Staff did not complete documentation of two falls for one resident (Resident #4) and left unsupervised medications next to one resident (Resident #5) in the dementia/memory care dining room. The sample was five. The census was 80. Review of the facility's Fall policy, revised July, 2023, showed: -The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall; -The [NAME] Fall Risk Assessment form (fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process; [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to properly contain COVID-19. This failure resulted in an Immediate Jeopardy, when resident (Resident (R) 69) was identified to have COVID-19 and was in the communal area, unmasked for several hours increasing the risk of exposure for staff and other residents residing on the [NAME] Unit. The failure placed residents and staff on the [NAME] Unit at risk for exposure, contracting COVID-19, and adverse outcomes up to and including death, and to failed to ensure Emergency Medical Technicians (EMT) wore source control. On 10/24/22 at 9:00 PM, the Director of Nursing and Administrator were notified of the Immediate Jeopardy (IJ) at F880-K Infection Control. The Immediate Jeopardy began on 10/24/22 when the survey team identified that R69 was sitting in the communal area, unmasked for several hours. [...]

Inspectors wroteBased on interviews and review of facility documentation, the facility failed to ensure the quality assessment and assurance committee attendees included the Medical Director or Designee. This failure had the potential to affect all 93 residents who currently live in the facility. Review of the document titled Quality Assurance and Performance Improvement (QAPI) Program, dated 09/2020, revealed at a minimum the following individuals serve on the committee: Administrator, Director of Nursing, Medical Director, Director of Quality, Infection Preventionist, Two other associates, Others as deemed necessary. During review of the QAPI attendance records 01/2022 through 09/2022 the Medical Director was not listed as attending. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed notify the physician when physician's orders for medications were not followed for three of 19 sampled residents (Resident (R) 52, 65, and 294) and three supplemental residents (R10, R57, and R240). Routine medications were not administered for R52 and R57. Medications were not administered on the day of admission to the facility per physician's orders for R10, R240, R294, and R65. 1. Review of R294's Profile Face Sheet, provided by the facility, revealed R294 admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, acute on chronic diastolic (congestive) heart failure (CHF), type 2 diabetes mellitus without complications, unspecified atrial fibrillation, and presence of automatic cardiac defibrillator. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure physician's orders were followed for the oxygen flow rate (3-4 liters), the nasal cannula oxygen tubing was monitored for occlusions/kinks, and the oxygen humidifier maintained a sufficient water level (empty) and/or provide respiratory treatments for two of two residents (Resident (R) 293 and R10) sampled for oxygen administration in a total sample of 26 residents. The facility's deficient practice increased residents' potential risk for respiratory complications, including respiratory distress. 1. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide routine drugs and biologicals to residents for three of 19 sampled residents (Resident (R) 52, 65, and 294) and three supplemental residents (R10, R57, and R240). Nursing staff routinely entered orders for new admissions to start the following day resulting in evening medications not being administered the night of admission. Additionally, the facility did not have a system in place to identify that medications were unavailable in advance, removing the opportunity to have medications delivered and avoid missed administration. The facility's pharmacy was unable to deliver STAT (immediate) medications. [...]

Inspectors wroteBased on interview and policy review, the facility failed to have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and systems review) program when deficient practice related to pharmacy services was identified and the facility did not identify appropriate plans to correct the identified practice and monitor for improvement. This deficient practice resulted in an ineffective QAPI program necessary to improve the quality of care provided to its residents and improve facility systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and families when three residents (Resident (R) 8, R69, and R241) tested positive for COVID-19 on 10/23/22. Review of a document provided by the facility titled Procedure: COVID-19 Infection and Prevention Guidelines, dated 10/2022, revealed -Notifications of Residents, Resident Representatives, Associates; -Report infections, COVID-19 positive cases by 5 P.M. the next day after a positive confirmation to resident and resident representatives. Review of a document provided by the facility titled Positive Covid Residents, undated, revealed R8, R69, and R241 tested positive for COVID-19 on 10/23/22. Review of the Resident and Family Member Letter: [...]

Inspectors wroteBased on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure one of 26 sampled residents (Resident (R) 293) had a physician's order and was assessed and care planned for the self-administration of medications prior to self-administration of medication by the resident. Review of facility provided policy titled Self-Administration of Medication, dated 12/21, revealed Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The nurse will complete the self-administration of medication assessment. If the nurse and physician determines that a resident can safely self-administer an order will be obtained for self-administration of medication. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency for one of five residents (Resident (R) 58) reviewed for abuse. Review of the facility's Abuse Investigation and Reporting, policy last revised 07/2022 revealed all reports of resident abuse and/or mistreatment shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. If an incident or suspected incident of resident abuse is reported, the Administrator or designee will assign the investigation to an appropriate individual . [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed in response to allegations of abuse to maintain documented evidence that all violations were thoroughly investigated for one of five residents (Resident (R) 58) reviewed for abuse. Review of the facility's Abuse Investigation and Reporting, policy last revised 07/2022, revealed all reports of resident abuse and/or mistreatment shall be thoroughly investigated by community management. If an incident or suspected incident of resident abuse is reported, the Administrator or designee will assign the investigation to an appropriate individual. [...]

Inspectors wroteBased on observation, interview, and record review, and policy review, the facility failed to ensure treatments were administered as ordered for one of one resident (Resident (R) 65) reviewed for non-pressure skin conditions in the sample of 26 residents and failed to ensure the medical record was updated with skin integrity identification changes or the development and implementation of care plan interventions regarding a catheter leg strap for one of one resident (Resident (R) 291) reviewed for skin integrity in a total sample of 26 residents. 1. A policy for following physician orders was requested and none was provided. Review of R65's undated Profile Face Sheet, provided by the facility, indicated he/she was admitted [DATE] with diagnoses including fracture of left tibia (shin bone) and infection following a surgical procedure. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 291) reviewed for urinary catheter had a leg strap (stat lock) to reduce friction and movement of R291's indwelling urinary catheter at the insertion site in a total sample of 26 residents. The facility's deficient practice had potential to injure R291's urinary tract system. Review of facility provided policy titled Catheter Care, Urinary, dated 01/22, revealed Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: [...]

Inspectors wroteBased on interviews, record reviews, and review of the facility assessment, the facility failed to ensure clinical staff had chest tube skills and knowledge to provide chest tube care effectively and safely for one of one resident (Resident (R) 293) reviewed for care of a chest tube in a total sample of 26 residents. The facility deficient practice increased the risk of respiratory complications for R293. Review of the facility assessment with the implementation date of 08/13/21 revealed practices, frequent education, and re-education with all clinical and non-clinical staff. Education is provided in a variety of ways including immediate face to face education when resident needs change. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions (GDR), if not contraindicated, and/or monitor specific behaviors for three of five residents (Resident (R) 64, R38, and R291) reviewed for unnecessary medications in a total sample of 26 residents. Review of facility policy titled, Psychotropic Medication, dated 07/2020, revealed, the health care practitioner and other associates will gather and document information to clarify a resident's behavior. A resident who used psychotropic medication will receive gradual dose reduction (GDR) and behavioral interventions. The pharmacist will report on the medication regiment review (MRR) and will submit recommendations to the physician and Director of Nursing (DON). [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure staffing information was complete and accurate and posted in a prominent place, in a readable format and readily available to residents and visitors. There were 93 residents residing at the facility. Review of facility policy titled Posting Direct Daily Staffing Numbers last revised 07/20 revealed Notification should be made to associates, residents and visitors of the community census, the number of nursing associates by category scheduled for each shift, as well as the number of actual hours worked by licensed and unlicensed nursing associates per shift that are responsible for providing direct care to residents. [...]