Shirkey Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected two of the 18 sampled residents, (Resident #4 and Resident #38). The facility census was 86. Review of the facility's policy, Providing Privacy, dated 4/27/14, showed: - It is the policy of this facility to provide privacy to each and every resident, competent or incompetent; - Facility staff must examine and treat residents in a manner that maintains the privacy of their bodies; - Only authorized staff directly involved in treatment should be present when treatments are given; - People not involved in the care of the individual should not be present without the individual's consent while he/she is being examined or treated; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN), the form Centers for Medicare and Medicaid (CMS) - 10055 to two of the three sampled residents (Residents #32 and Resident #139). The SNF ABN provides information to residents/beneficiaries to inform them of their rights that skilled services may not be paid by Medicare and resident or guardian will assume the financial responsibilities. The facility failed to provided the correct Notice of Medicare Noncoverage (NOMNC), which provides information to residents/beneficiaries to inform them of their covered services, and their right to appeal their discharge, for two of the three sampled residents (Resident #32, Resident #190, and Resident 139. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe. The facility failed to address repairs and cleanliness deficiencies in the 500 Wing Dining Room and failed to fix and repair one resident's faucet (Resident #188) that was unable to be shut off for seven days and when two Resident's sinks were blocked (Resident #28 and #21) and would not drain. The facility census was 86. Review of facility policy, housekeeping room cleaning, dated February 2025, showed: -Housekeeping was 7 days a week. General cleaning is required daily for each occupied unit. Wednesdays are for deep cleaning which was also to be completed when resident discharged or was out to the hospital or on an extended leave of absence. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 of 12 residents who participated in a group meeting knew how to file a grievance in writing, and how to file anonymously. The facility census was 86. Review of facility policy titled Grievance Policy, dated 03/06/17, showed: - Grievances may be filed verbally or in writing and may be filed anonymously; - A verbal grievance can be reported to the Grievance Officer or any member of the facility staff, the staff member will report the grievance to the Grievance Officer; - Grievance forms are available in the front office and nurse's stations. This form can be completed and submitted to the Grievance Officer. An anonymous form will be accepted. 1. During a group meeting on 5/06/25 at 03:10 P.M., 12 of the 12 residents said: - They did not know where a form to file a grievance would be located; [...]

Inspectors wroteBased on the interview and record review, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of nine sampled staff (Licensed Practical Nurse (LPN) B, Certified Nurse Aide (CNA) A, Activity Aide A, Registered Nurse (RN) A, CNA B, Dietary Aide A, Housekeeping Aide A, and Receptionist). The facility also failed to have a criminal record check on file prior to employee's first date working for one of eight sampled staff (Housekeeping Aide A). The facility census was 86. Review of facility policy, dated 11/20/2003, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge notice, including providing the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for two residents (Residents #16 and #21) out of eighteen sampled residents. The facility's census was 86. Facility did not provide a policy on transfer notices. 1. Review of Resident #16's Face Sheet showed: -He/She admitted to facility 3/31/25. -Diagnoses included stroke, muscle weakness, depression, and surgical aftercare following surgery to digestive tract. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed follow their policy regarding expired medications, and insulin when the facility staff did not date opened insulin pens or dispose expired insulin pens, which affected six of the 18 sampled residents, (Resident #7, #10, #12, #23, #61 and #70). The facility census was 86. Review of the facility's policy titled, Expired Meds and Supplies, dated 3/27/19 showed: - On the first of every month when change over is complete, the nurses and Certified Medication Technicians (CMTs) will audit the med carts, treatment carts, refrigerators, cabinets and supply rooms; - Any medication or supply found to be expired or that will expire that month will be destroyed. Review of the facility's policy titled, Insulin Pens,, dated 11/1/16, showed: - Every vial or insulin pen must be dated upon opening; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to record food temperatures in the temperature log after cooking food items and failed to ensure staff served food to the residents that was palatable and at an appetizing temperature when hot food was served at unappetizing temperatures for five (Residents #5, #14, #21, #40, and #42) out of 18 sampled residents. The facility census was 86. Review of facility policy, Food Temperatures, undated, showed: - All hot food items must be served at a temperature of at least 140F; - Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. A recording form is also needed to document temperatures. To take hot food temperatures insert the thermometer and record the temperature and then remove the thermometer from the food item. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food safety when staff failed to annotate receipt dates on incoming deliveries of food, failed to dispose of expired food items, failed to store food items at least 6 inches off the ground, failed to properly label and seal opened food items, and failed to maintain cleanliness in the storerooms and 500 Wing dinging room. This affected all residents by putting them at risk for food borne illness. The facility census was 86. Review of facility policy Food Storage, dated 2005, showed: - All storage areas should have adequate humidity controls to prevent condensation and moisture; - Food items will be stored on shelves, food is stored a minimum of six inches above the floor on clean racks or other clean surfaces; [...]

Inspectors wrote2. Review of Resident #16's admission MDS, dated [DATE], showed: - Cognition moderately impaired; - He/She had a feeding tube; - He/She received 51% or more of total calories through parenteral or tube feeding; - He/She received 51% 501 cc/day or more of his/her fluid intake via tube feeding; - He/She was independent with eating; - Diagnosis included: surgical aftercare following surgery on digestive system, dysphagia, absence of part of digestive tract, and malnutrition. Review of care plan, revised 4/14/25, showed: - Resident required enteral feeding tube for nurtrition; - He/She used a EnFit 20 g-tube (type of gastrostomy or jejunostomy tube designed for delivering enteral nutrition directly into the stomach or intestines). - Administer medications through the g- tube. Evaluate/record/report effectiveness and any adverse side effects. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to keep the scoops out of food storage bins and ensure stored food was dated. This had the potential to affect 86 of 86 residents who resided in the facility and consumed food prepared from the facility's kitchen. Review of the facility's undated policy titled Resident Food Storage, revealed 1 .Food or beverages brought into the facility for resident consumption will be labeled and dated for monitoring food safety. Food or beverages in the original container marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage During an initial tour of the kitchen on 04/02/24 at 8:55 AM, with the Dietary Manager (DM), the following observations were made: Dry Storage and kitchen: a. One 5-pound bag, containing yellow cake mix, was observed open and undated. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the 11/28/23 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked, unable to attend. Review of the 02/20/24 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked as, unable to attend. During an interview on 04/05/24 at 11:53 AM, the QAPI Nurse was asked if the Medical Director or their designee attended the quarterly meetings. The QAPI Nurse stated, He does attend the meetings, but not the last ones. The QAPI Nurse was asked if she was aware that the Medical Director or their designee are to attend the meetings, as required in the regulation. She stated, Yes.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure resident Care Plans were updated/revised for two residents (Residents (R) 84, R6) of 21 sampled residents. The facility failed to update the Care Plan for R84 related to her behaviors and oxygen usage for R6. This failure created an increased risk for the residents to care and services that may not be appropriate for their current clinical condition. Review of the facility policy titled, Updating Care Plans, dated 04/05/18 revealed, . Care Plans need to be continually updated as the resident's needs change. The Care Plan needs to reflect the resident's current status at any given moment . 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide showers to two residents who preferred showers (Residents (R)8, and R73) of five residents reviewed in a total sample of 21 residents. This failure placed the residents at risk of a diminished quality of life.

Inspectors wroteBased on observations, record review, staff and family interviews, and facility policy review, the facility failed to (1) assess resident (R) 23's falls, monitor the effectiveness of the interventions, or modify the interventions to prevent further falls and/or injuries for one of three residents reviewed for falls (R23, R46, and R57); (2) provide a fire blanket and fire extinguisher in the three designated resident smoking areas to reduce the risk of harm for the three residents who smoke (R26, R30, and R42); and (3) to conduct a smoking assessment for one of three residents (R)26, to determine independent versus supervised smoking needs. 1. Review of the facility's 2006 policy titled, Unusual Occurrences, provided by the Administrator, revealed the following: All incidents will require that an incident report be filled out by the charge nurse. [...]

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to: have a system in place to ensure respiratory equipment to include oxygen tubing was dated/labeled when changed out, failed to ensure documentation of cleansing of C-pap masks(Continuous positive airway pressure- a form of positive airway pressure that is continuously applied to the upper respiratory tract of a person), C-pap tubing, and water chamber were being cleaned and changed as per physician orders on Sundays, failed to ensure a C-pap machine was kept off the floor, and failed to have clean oxygen filters, maintain oxygen in the nose, and apply oxygen continuously for two of two residents (Resident (R) 51 and R48) reviewed for respiratory therapy out of a total sample of 21 residents. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility assessment, the facility failed to ensure sufficient nurse staffing to meet the needs of the residents resulting in residents not receiving showers for two (Residents (R) 73, R8) of five sampled residents, activities to meet residents' needs in the secured dementia unit. These failures placed residents at risk of a diminished quality of life and potential unmet care needs. 1. This tag is cross-referenced to F676; ADL [maintain activities of daily living] as not diminish or decline. Based on interview and record review, including shower schedules, the facility failed to consistently provide showers for R73, and R8. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an Abnormal Involuntary Movement Scale [AIMS-a test that rates involuntary muscle movements (tardive dyskinesia) on residents who are administered antipsychotic medications] assessment for two residents (Resident (R) 65 and R84) and failed to re-evaluate the need for an antipsychotic medication for one resident (R4) of five residents reviewed for unnecessary medications in a total sample of 21. These failures placed residents at risk for unrecognized side effects. 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R65 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, and pulmonary disease. [...]

Inspectors wroteDuring an observation, interview, and review of facility policy, the facility failed to prepare, store, and label medications according to standard nursing practice for one of four Certified Medication Aide (Certified Medication Aide (CMA3) observed during medication pass. This failure placed prescription-based medications readily accessible to residents, increased health complications, and the possibility of giving the wrong medication to the wrong resident. Review of an untitled facility policy, dated 04/29/14, revealed, Medication is never to be left unattended. If you must leave your cart, then all medications are to be locked inside. During a medication pass observation on 04/05/24 at 7:40 AM, Medication cart 5 [NAME] was parked outside a room. CMA3 was not stationed at the cart but was in a resident's room. [...]

Inspectors wroteBased on employee record review and interviews, the facility failed to have documentation of completion of a minimum of 12 hours of required in-service training to include Dementia care and Abuse, Neglect, and Exploitation for five of five Certified Nursing Assistants (CNAs) (CNA 1, 2, 4, 6, and 7). By not ensuring employees are meeting the required trainings and in-services, residents may be at risk and unable to get their needs met. Review of the facility's Facility Assessment updated February 28, 2024, indicated, Staff Education: Orientation, Annual: Required annual education/training (minimum of 12 hours annually for Nursing Assistants) . During an interview on 04/04/24 at 9:52 AM, CNA1 was asked about trainings and in-services on dementia care and abuse and neglect. CNA1 stated, We have annual in-services, and we cover abuse and neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident and/or representative (Resident (R) 65) of five residents reviewed for unnecessary medications out of a total sample of 21 residents was informed of the risk and benefits of physician ordered psychotropic medications. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of the medications. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R65 was admitted to the facility on [DATE] with diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to investigate an injury of unknown source for one resident (Resident (R) 65) of one resident reviewed in a total sample of 21. This failure to investigate a fractured leg placed the resident at risk for potential abuse. Review of the facility policy titled, Policy and Procedure Regarding Investigation and Reporting of Alleged Violation of Federal and State Laws involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Residents property, dated 11/20/03 revealed, Investigation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences for one resident (R84) of nine residents reviewed for activities in the secured dementia unit out of a total sample of 21 residents. This failure placed R84 at risk of a diminished quality of life. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date of 02/27/24 revealed R84 had a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated she was severely impaired in cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four Certified Medication Aide (Certified Medication Aide (CMA) 3) observed during medication pass, had the skills and competency to safely perform medication administration. Refer to F761. Review of the Staff Roster provided by the Director of Nursing (DON) revealed CMA 3 was hired by the facility on 07/11/02. Review of the 2023 and 2024 Skills and Drills sheet provided by Licensed Practical Nurse (LPN) 5 showed CMA 3 had not been assessed for medication competency since 04/11/23. The Skills and Drills sheet further revealed that CMA 3 was only observed for insulin, eye drops, and inhalers and had not been assessed for any other medication pass requirements. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to notify the resident's physician and to have new interventions in place for a resident with significant unplanned weight loss to prevent the resident from further weight loss for one sampled resident (Resident #56) out of 19 sampled residents. The facility census was 95 residents. The facility did not provide a policy for weight loss. 1. Review of Resident #56's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/18/22 showed: -Brief Interview for Mental Status (BIMS) of 7 (indicates moderate cognitive impairment) -Total dependence on staff for all Activities of Daily Living (ADLs) -Weight of 116 pounds (lbs) -No physician prescribed weight loss. -Weight loss of 5% or more -No difficulty swallowing or chewing -No meal percentages noted. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to assure staff treated two sampled residents (Residents #44 and #18) in a manner that maintained their psychosocial well being and dignity when staff treated one resident (Resident #44) rudely. The facility census was 95. The facility did not provide a policy on dignity. Review of Resident #44 admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff ) dated 2/8/22 showed: -Brief Interview of Mental Status (BIMS) of 15 (indicates no cognitive impairment); -No exhibited behaviors; -Resident able to understand and make self understood. Review of Resident #44 Face Sheet showed diagnosis of: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected 3 additional residents (Residents #247, #248, and #250). the facility census was 95. Review of the undated facility policy for Resident Trust Funds showed: -If a patient leaves, the funds are disbursed to the patient. -If a patient passes away, a funds report is emailed to mhd.costrecovery.dss.mo.gov. (A program that states any open estate may not be closed with respect to a decedent who, at the time of death, was enrolled in MO HealthNet until a release of the Estate Recovery Claim by MO HealthNet is obtained.) Response from this program will determine where money will be refunded. Refund within 3 days of response. [...]

Inspectors wroteBased on record review and interviews, the facility failed to purchase a surety bond in a sufficient amount to ensure the security of all residents' personal funds deposited with the facility. The facility census was 95. Review of the undated facility policy for Resident Trust Funds showed: -There was no mention of maintaining a surety bond. Review of the facility's surety bond dated 3/30/2017, showed a bond amount of $9,000.00. Review of the Residents Funds Worksheet on 4/13/2022, completed with the last twelve months of reconciled bank statements and petty cash amounts showed the required bond amount needed was $21,000.00. During an interview on 4/13/2022 at 10:41 A.M , the Business Office Manager (BOM) said: -He/she is aware the bond amount is not high enough. The resident's stimulus money has increased the required amount of the bond. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential to affect all residents. The facility census was 95 1. Observation on 4/11/22 beginning at 11:00 A.M. showed the following in the following rooms: - #616- Beach ball brown stain on a ceiling tile in the bathroom, ceiling tile sagging; - #621- Four ceiling tiles with brown stains varying in size from a softball to beach ball; - #619- Two cantaloupe size stains on a ceiling tile and one watermelon sized stain in bathroom; - #320- Cantaloupe sized stain on a ceiling tile; - #318, 3 stained ceiling tiles of various sizes up to the size of a beach ball, one beach ball sized stain on the ceiling in the shared bathroom; - #315- 2 beach ball stains on the ceiling tiles; - #312- Missing ceiling light cover in the shared bathroom; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents and their representative, including the reason for the transfer, in writing and in a language they understood. This affected three of 19 sampled residents, (Resident #28, #74 and #97). The facility census was 94. The facility did not provide a policy for transfers and discharges. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/22, showed: - Cognitive skills severely impaired; - Dependent on the assistance of two staff for bed mobility, transfers, and dressing; - Dependent on the assistance of one staff for toilet use; - Upper and lower extremities impaired on both sides; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and the resident's family/legal representative of the facility's bed hold policy at the time of transfer/discharge to the hospital for three of 19 sampled residents, ( Resident #28, #74 and #97). The facility census was 94. Review of the facility's undated bed hold policy, showed, in part: - The resident may need to be absent from the facility temporarily for hospitalization or therapeutic leave. The resident may request that the facility hold open the resident's bed during this time. This is known as bed hold. The resident and a family member or legal representative shall be given notice of the bed hold option at the time of hospitalization or therapeutic leave; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff met as an interdisciplinary team with the resident and/or representative to establish and provide the resident a baseline or 48 hour care plan for one of 19 sampled residents, (Resident #147). The facility census was 94. The facility did not provide a policy for baseline care plans. 1. Review of Resident #147's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; - Lower extremity impaired on one side; - Always continent of bowel and bladder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for eight of 19 sampled residents, ( Resident #28, #74, /#23, #56 #80, #15, 24 and #33). The facility census was 94. Review of the facility's policy for care plan, dated 7/30/07, showed: - It is very important to know exactly how to care for the residents. The care plan is a tool to aide all nursing staff on how to do just that: all nursing staff need to know where the care plans are located on the wing; all nursing staff need to know that they have access to the care plans; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain a physician's order for a surgical wound treatment for one of 19 sampled residents, ( Resident #147) and failed to notify the physician of significant weight loss for one resident (Resident #56). The facility census was 94. The facility did not provide a policy for following physician's orders or notification of physician. 1. Resident #147 was admitted on [DATE] and did not have a baseline care plan. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22 showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of 19 sampled residents, (Resident #36, #74 and #147), and when staff failed to provide morning care such as oral care and comb/brush Resident #74's hair. The facility failed to provide assistance for one resident (Resident #18) in a timely manner, when the resident asked for assistance in using the bathroom. The facility census was 94. Review of the facility's policy for male peri care, dated 3/29/19, showed: - Wash the lower abdomen, groin area and inner legs; - Using a circular motion wash the skin fold from the tip down; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of 19 sampled residents, (Resident #36 and #74) with the mechanical lift ; and use of a damaged sling to transfer one resident (Resident #18) from bed to chair. The facility census was 94. Review of the undated manufacturer's guidelines for the Invacare Reliant 450 mechanical lift, showed: - When using the adjustable base lift, the legs MUST be in the maximum opened/locked position before lifting the resident; - Invacare does not recommend locking of the rear casters of the resident lift when lifting an individual. Doing so could cause the lift to tip and endanger the resident and assistants. Review of the facility's policy for electric Hoyer lift transfer, dated 5/12/17, showed, in part: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care when staff failed to date oxygen tubing for one of 19 sampled residents, (Resident #74) and failed ensure physician orders were in place for one resident (Resident #70) using oxygen. The facility census was 94. Review of the facility's policy for oxygen use, dated 2/28/19, showed: - All oxygen concentrator filters need to be cleaned every week on Sunday night. Even concentrators that are not being used; - Oxygen tubing must be changed weekly and dated; - Oxygen tubing and nebulizer tubing must be stored in a plastic bag. 1. Review of Resident #74's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/22/22 showed: - Cognitive skills intact; [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that staff provided adequate pain control for two sampled residents (Resident #7 and Resident# 44). The facility census was 95. The facility did not provide a policy regarding pain management. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/22/22, showed: -Scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) (a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur.) A score of 3 indicates severe cognitive impairment. -Adequate hearing /vision, is able to make self understood and understand others. -He/she requires extensive assistance with activities of daily living(ADL's), including, dressing, toileting, personal hygiene. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure communication between the facility and dialysis center and standards of practice when staff failed to document assessments of one resident (Resident #15) before and after dialysis. The facility census was 95. The facility did not have a policy for dialysis. 1. Review of the medical record for Resident #15 dated 3/1/21 showed: -Dialysis orders read: Start date 3/1/2021, Resident to go to outside dialysis clinic for dialysis Monday, Wednesday and Friday per week. Check bruit and thrill to left forearm shunt daily. If not present call the physician at the dialysis clinic. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/29/22, showed: [...]

Inspectors wroteBased on interviews and record reviews the facility failed to communicate the consultant pharmacist's recommendations to the resident's physicians for four of 19 sampled residents, (Resident #4, #36, #74 and #147) and failed to provide a rationale when the recommendation was declined which affected Resident #147. The facility census was 94. The facility did not provide a policy for drug regimen reviews. 1. Review of Resident #147's Drug Regimen Review (DRR), dated 2/2/22 showed the consultant pharmacist recommended: - The resident is [AGE] years old and takes citalopram 40 milligrams (mg.) for depression. The is medication is recommended to not exceed 20 mg. per day in people greater than [AGE] years old due to increased risk of QT prolongation (the time it takes the ventricles of the heart to contract and relax); [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure PRN (as needed) psychotropic medications were limited to 14 days unless the resident's physician believed it was appropriate for PRN use and documented their rationale and can be renewed only after being evaluated by the attending physician, which affected one of 19 sampled residents, (Resident #4). As well as, the facility failed to ensure that one resident (Resident #23), had an appropriate diagnosis for psychotropic medication, and received a gradual dose reduction (GDR), and/or a rationale from the physician as to why the GDR was not attempted for one additional residents (Resident #73). The facility census was 94. The facility did not provide a policy regarding PRN use of psychotropic medications or Gradual Dose Reduction and Medication Review. 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made two medication errors out of 31 opportunities for error, a medication error rate of 6.45%, which affected two of 19 sampled residents, (Resident #10 and #75). The facility census was 94. Review of the facility's policy for medication administration, dated 6/13/14, showed: - The right drug; - The right patient; - The right dose; - The right time; - The right route; - The right reason; - The right response; - The right documentation; - The right disbursement technique: each resident shall have their medication administered immediately after each individual's medication preparation. Review of the facility's policy for eye drops, dated 7/30/07, showed, in part: - Gently pull the lower eye lid down; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff discarded expired medications, and biologicals stored in the medication room on the 200 hall, failed to ensure the bottles of Morphine Sulfate (used to treat moderate to severe pain) were in containers that could be measured which affected four of 19 sampled residents, (Resident #9, #35, #87 and #90) and failed to discard expired Morphine Sulfate and Ativan (used to treat anxiety and seizure disorders) which affected two Residents, (Residents #9 and #35) and failed to ensure there were no loose pills in the day medication cart on the 200 and 500 hall. The facility census was 94. Review of the facility's policy for medication destruction, dated 7/30/07, showed: - Every medication that needs to be destroyed will be logged onto the drug destruction log; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain the kitchen in sanitary condition and ensure they stored food in a sanitary manner. The facility census was 95. Review of the facility policy titled Kitchenettes and Pantries, dated 2005, included the following: - Clean and sanitize refrigerator on a regular cleaning schedule, and as needed for spills. Review of the facility policy titled Cleaning Instructions Cleaning Refrigerators, dated 2005, included the following: - The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be wiped up as they are noticed. The facility did not provide a policy regarding dating food. Observation on 4/11/22 beginning at 10:13 A.M. showed the following: [...]

Inspectors wroteBased on record review and interviews the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility census was 95. Record review of the facility's QAA meeting minutes, dated May 5, 2021. showed the following: -All the members met; -The members included the administrator, the director of nursing (DON), the Medical Director (MD), the Minimum Data Set (MDS) coordinator, business office manager, human resources, environmental service director and activities director. During an interview on 4/19/22 at 11:26 A.M. The Quality Assurance Nurse said: -The last QAA QAPI (Quality Assurance and Performance Improvement) meeting held was in May 2021. -He/she reviews the CASPER report quarterly . -He/she brings the CASPER report information to weekly Clinical meetings. -There are no sign in sheets for the weekly clinical meetings. [...]

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public when when they failed to maintain their ceilings in good condition. The facility census was 95. 1. Observation and interview on 4/19/22 beginning at 12:45 P.M. showed the following: - room [ROOM NUMBER] had a gray substance all around the ceiling vent in the bathroom; - room [ROOM NUMBER] had a black substance all over the ceiling in the bathroom. The Maintenance Director said it looked like mold to him; - Unit 6 medication room had a baseball sized area on the ceiling that was yellow in color and flaking away from the ceiling. The Assistant Maintenance Director said he had not been in that room and did not know what the substance was. Observation 4/11/22 beginning at 11:00 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to fully develop and implement their staff vaccination policy for COVID-19 when all required components, including a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19, were not included in the policy. The facility had no COVID-19 positive resident cases in the previous 4 weeks and 100% of the 110 employees were either fully vaccinated or had an approved exemption. Facility census was 95. 1. Review of the facility's policy COVID 19 Update, dated 1-14-22 showed the following: [...]