Spring Valley Health & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice and care plan when staff failed to document full follow-up assessments, including neurological checks, for 72-hours post fall, failed to provide all assessed information to the physician when reporting a change of condition post fall, and failed to transcribe physician orders post fall for one resident (Resident #1) who had multiple falls. The facility census was 157. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed implement a complete and effective infection control program when staff failed to properly discard a blood contaminated glucose (sugar) test strip and sharps (any device with points or edges that can puncture or cut skin) in the designated sharps container for one resident (Resident #2). The facility census was 157. Review of the facility policy titled Standard Precautions, dated 10/25/22, showed the following information:-Place sharps in a puncture resistant container;-Follow procedures for disposal of regulated/infectious waste when items are saturated with blood and meet the definition of regulated infectious waste. Review of the SafeNeedleDisposal.org's What To Do with Used Sharps in Missouri, dated 10/23/25, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide appropriate neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for three residents (Resident #1, Resident #2, and Resident #3) after each resident sustained a fall with potential for head injury. The facility census was 156. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per accepted standards of practice when staff failed to accurately document regarding administration, or lack of administration, of an ordered medication; failed to ensure the medication was available for administration; failed notify the physician of the missed doses in a timely fashion; and failed to care plan the use and/or refusals of the medication for one resident (Resident #1) out of a sample of four residents. The facility census was 156. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents with tube feedings received sufficient nutrition when staff failed to understand how to document tube feeding intake, failed to document when tube feedings amounts varied from the ordered amount, and failed to document physician notification when tube feeding amounts varied from the ordered amount for one resident (Resident #2), who was at nutritional risk, out of a sample of four residents. The facility census was 156. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all food was protected from possible contamination during storage and preparation when staff failed to ensure the air gap for the ice machine had the required two-inch gap between the drain and the floor, when staff failed to wear a hairnet covering all exposed hair, when staff failed to clean the outside of the appliances, when staff failed to date and label opened food, and when staff failed to keep fans and vents above food items clean. The facility census was 149. Review of the facility's policy titled Nutritional Services Sanitation, dated 03/31/21, showed nutritional services shall ensure a clean and sanitary work environment to promote and protect food safety and to maintain compliance with federal, state and local governing food sanitation and safety.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate when staff failed to assess for, care plan regarding, and obtain a physician's order for self-administration and bedside storage one medications for three residents (Resident #37, #148, and #31). The facility census was 149. [...]

Inspectors wroteBased on record review and interview, the facility failed to promote and facilitate each resident's right of self-determination when staff failed to provide timely bathing, in the form the resident preferred, for four residents (Resident #20, Resident #37 and Resident #113) out of a sample of nine resident. The facility census was 149. Review of the facility's policy titled, ADL (activities of daily living) Care Bathing, dated 07/21/22, showed the following: -Nursing staff will assist in bathing residents to promote cleanliness and dignity; -The charge nurse will be made aware of residents who refuse bathing. 1. Review of Resident #20’s face sheet showed the following information: -admission date of 06/06/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to maintain the cleanliness of the floors, walls, doors, and/or bathrooms for 9 residents (Resident #13, #36, #94, #123, #125, #39, #73, #51, and #141), when staff failed to address odors in the rooms of 5 residents (Resident #13, #123, #125, #141, and #135), when staff failed to a provide a clean over the bed table to one resident (Resident #72), when staff failed to maintain the facility at comfortable temperature in a family dining room and two residents' rooms (Resident #148 and #103), and when staff failed to maintain furniture in good condition in the special care unit. The facility census was 149. 1. Review of Resident #13's face sheet showed an admission date of 06/27/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident, or resident's representative, received written notice of transfer and/or discharge when the facility failed to have a process in place to routinely provide transfers letters including three sampled residents (Resident #39, #65, and #103) transferred to the hospital. The facility census was 149. Review of the facility policy titled Discharge / Transfer - Involuntary, dated October 2021, showed the following information:- Transfer and discharge included movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not;- If transferred to another health care facility upon order of the physician, a transfer form is completed, and a copy is sent with the resident. 1. Review of Resident #39's face sheet showed an admission date of 11/21/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activity programs to meet the needs of all residents when staff failed to provide activities as scheduled on the Special Care Unit (SCU); when staff failed to document routinely offering or completing meaningful activities to with three residents (Resident #13, #17, and #123); and when staff failed to provide preferred independent activities for one resident (Resident #123). The facility census was 149. Review of the facility policy titled Activities, dated 09/14/23, showed the following:-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, and preferences. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to document administration or refusal of medications on the Medication Administration Record (MAR) for two residents (Resident #169 and #200) and when staff failed to follow-up with a provider when one resident (Resident #141) went to an outside appointment and received an order for a medication. The facility census was 149. Review of the facility policy titled “ Medication Administration - General Guidelines,” dated December 2017, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of medication errors greater than 5% when the staff failed to administer the correct medication dose for two residents (Resident #109 and #97), when staff administered the wrong medication for one resident (Resident #38), and when staff failed to prime insulin pens prior to administration for two residents (Resident #23 and #132). This resulted in 5 medication errors out of 25 observations opportunities resulting in an error rate of 20%. The facility census was 149.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors when staff failed to document administration of insulin to two residents (Resident #5 and #65) and when staff failed to prime insulin pens prior to administration for two residents (Resident #23 and #132). The facility census was 149. Review of the facility policy titled “Medication Administration - General Guidelines,” dated December 2017, showed the following:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;-The five rights of medication administration were the right resident, right drug, right dose, right route, and right time. These are applied for each medication being administered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in the kitchen in a safe operating condition when three stove knobs were missing. The facility census was 149. Review showed the facility did not provide a policy regarding upkeep of kitchen appliances.1. Observations on 08/17/25, beginning at 3:46 P.M., and on 08/19/25, at 12:36 P.M., showed the cook stove located in the kitchen had three of the seven burner control knobs missing. During an interview on 08/22/25, at 8:50 A.M., Dietary Aide (DA) L said there are knobs missing. He/she didn't know how long they had been missing. He/she was still able to turn the stove burners on and off. The Dietary Manager was aware of the knobs missing. During an interview on 08/22/25, at 9:05 AM., DA M said stove knobs were missing, but they were still able to use them as far as he/she knew. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a sanitary environment for all residents and staff when the floors and walls in the kitchen were not kept clean and free of debris. The facility census was 149. Review of the facility's policy titled Nutritional Services Sanitation, dated 03/31/21, showed nutritional services shall ensure a clean and sanitary work environment to promote and protect food safety and to maintain compliance with federal, state and local governing food sanitation and safety.1. Observations beginning on 08/17/25, at 3:46 P.M., showed the following:-The floors throughout the kitchen had black and white substances in several areas, especially under the sink areas and dishwasher;-There were pieces of food in and around the sink and dishwasher area;-The baseboards in most areas were black with dirt. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement and maintain an effective pest control system when multiple flies were located four resident rooms affected five residents (Resident #62, #123, #125, #141 and #147). The facility census was 149. Review showed the facility did not provide a Pest Control Policy. 1. Review of Resident #62's face sheet (admission data) showed an admission date of 02/28/25. Review of the resident's significant change in status Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 07/08/25, showed the resident's cognitive skills intact. Observation and interviews on 08/17/25, at 5:35 P.M., showed the resident in bed. The resident's pillow had a black substance on it. A fly landed on the resident's pillow and the resident waved his/her hand at the fly. The resident said the fly was annoying. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a name tag for one resident's (Resident #62) door resulting in staff being unsure of the resident's name when addressing the resident and providing cares. The facility census was 149. Review of the facility's policy titled Resident Rights, dated 04/26/23, showed the facility shall treat residents with kindness, respect and dignity and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission. 1. Review of Resident #62's face sheet (admission data) showed the following:-admission date of 02/28/25;-Diagnoses included malignant neoplasm of upper lobe, right bronchus or lung (lung cancer) and dermatophytosis (infections caused by a group of fungi). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a process in place that clearly and consistently noted each resident's code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) when two residents (Resident #12 and Resident #18) were not listed on the Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped) list who had DNR orders/directive in place. The facility census was 149. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate wound tracking of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device), failed to obtain treatment orders for an identified pressure ulcer in a timely manner, and failed to document wound treatments per physician orders for one resident (Resident #169) who was admitted from the hospital. The facility's census was 149. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents with urinary catheters (a tube inserted into the bladder, allowing urine to drain freely), received appropriate treatment for the catheter and prevent urinary tract infections per standards of practice when staff failed to document monitoring of urine output, abnormal urine color, and care of the catheter as ordered for one resident (Resident #169) The Facility census was 149. Review of the facility's policy titled Catheter Care, dated 07/13/22, showed the facility will maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. 1. Review of Resident #169's face sheet (admission data) showed the following:-admission date of 06/10/25;-Diagnoses included acute kidney failure. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure all residents were offered sufficient meals and fluid intake to maintain proper hydration and health when staff failed to ensure all residents received breakfast, including on dialysis (life-sustaining medical treatment that removes waste, excess fluid, and toxins from the blood when the kidneys can no longer perform their filtering function) days when staff failed to provide breakfast tray one day and failed to provide a sack meal prior to dialysis for one resident (Resident #48). The facility census was 149. 1. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure all residents who required dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) services received care consistent with professional standards when staff failed to document regarding missed dialysis appointments, failed to document resident education regarding missed dialysis appointments, and failed to document physician notification of missed dialysis appointments for one resident (Resident # 10). The facility census was 149.1. Review of Resident #10's face sheet (brief information sheet about the resident) showed the following:-admission date of 06/07/24;-Diagnoses included end stage renal disease and kidney failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete medical records for all residents when staff failed to document full details related to one resident (Resident #169) who left against medical advice (AMA) and later returned to the facility. The facility census was 149. Review showed the facility did not provide a policy related to documentation. 1. Review of Resident #169's face sheet (admission data) showed the following:-admission date of 06/10/25;-Diagnoses included acute kidney failure, cognitive communication deficit, Type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood) with hyperglycemia (high blood sugar levels), and pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents with catheters (a thin, flexible tube inserted into the urethra (the tube that carries urine from the bladder to the outside of the body) to drain urine from the bladder) received care per standards of practice and in a manner to prevent possible infections when staff failed to document completion of monitoring of output and signs/symptoms of infection, failed to document catheter changes timely, failed to document catheter care completion, failed to update physician orders appropriately, and failed to update the care plan regarding the care/changes of the catheter for one resident (Resident #1). The facility census was 157. Review of the facility's inservice titled, Catheter Care/Orders, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received care per professional standards of practice when staff failed to obtain an ordered urinalysis in a timely fashion for one resident (Resident #1) out of ten sampled residents. The facility census was 152. Review of the facility's policy titled, Laboratory Test, last updated on 04/2023, showed the following: -Staff shall obtain the lab ordered by the physician or physician extender; or labs to be completed routinely per policy, and enter the information on the lab scheduling/tracking form, indicating the resident, room number, month and date lab orders are to be obtained and when results were received; -Any newly ordered lab test needing immediate attention will be added to the lab scheduling/tracking form and the lab will be obtained as ordered; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of physical abuse by one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 159. Review of the facility's policy titled, Abuse Prevention, revised October 2022, showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to: facility staff; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish or emotional distress; -Abuse is an employee purposefully beating, striking, wounding, or injuring any consumer; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to immediately begin an investigation and take steps to protect all residents after all allegations of possible abuse when staff failed to follow their abuse policy by not completing an abuse investigation and taking steps to protect all residents immediately after one resident's (Resident #1) allegation of possible abuse by staff. The facility census was 159. Review of the facility's policy titled, Abuse Prevention, revised October 2022, showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to: facility staff; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish or emotional distress; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide care for all residents per standards of practice when staff failed to obtain wound orders for all wounds and failed to provided wound care according to physician orders for two residents (Residents #6 and #7) and when staff failed to administer medication and treatments according to physician orders for two residents (Residents #5 and #9) of five sampled residents. The facility census was 160. Review of a facility policy titled Wound Management, reviewed 11/15/22, showed the following information: -The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatment will be provided in accordance with physician's order regarding cleansing method, type of dressing, and frequency of dressing change; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from significant medication errors when staff failed to document administration of multiple medications for three residents (Residents #8, #9, and #5) of 15 sampled residents. The facility census was 160. Review of a facility policy titled Physician Orders, dated 09/2022, showed staff to ensure physician orders are transcribed and implemented in accordance with professional standards and state and federal guidelines. Review of a facility policy titled Medication Administration - Preparation and General Guidelines, revised August 2014, showed the following information: -Medications are administered as prescribed in accordance with good nursing principles and practices; -Medications are administered in accordance with written orders of the prescriber; [...]

Inspectors wroteBased on observation and interview, the facility failed maintain an effective infection prevention and control program when staff failed to ensure multi-use resident equipment was sanitized between uses, failed to place appropriate barriers for supplies, and failed to perform hand hygiene per standards of practice while checking resident blood sugar levels and administering insulin with four residents (Resident #2, #4, #3, and #1). The facility census was 160. Review of a facility policy titled Hand Hygiene, dated 04/28/22, showed the following: -Hand hygiene should be performed before and after providing care; before and after performing aseptic (to prevent infection) task; contact with blood, body fluids, or contaminated surfaces; before and after applying and removing gloves or personal protective equipment; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided pressure ulcer care was provided per standards of practice when staff failed to care plan a pressure ulcer and failed to provide wound care to a pressure ulcer according to physician orders for one resident (Resident #10) of five sampled residents. The facility census was 160. Review of a facility policy titled Wound Management, reviewed 11/15/22, showed the following: -The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatment will be provided in accordance with physician's orders regarding cleansing method, type of dressing, and frequency of dressing change; -Treatments will be documented on the Treatment Administration Record (TAR). 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all medications per standards of practice when staff left medication at bedside for one resident (Resident #7) and when staff left medication carts unlocked and unattended with medications accessible to unauthorized staff and residents. The facility census was 160. Review of a facility policy entitled Medication Administration - Preparation and General Guidelines, revised August 2014, showed the following information: -When administering as needed medications (PRN) medications at times other than the medication pass, the dose may be prepared in the medication cart storage area and taken to the resident's bedside, leaving the cart locked and secured; -During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient housekeeping and maintenance services in order to maintain a sanitary and comfortable environment in resident access areas when floors, shower rooms, bathrooms, and walls were found dirty and/or with odor. The facility census was 143. Review showed the facility did not provide a written policy specific to maintaining the facility's cleanliness. 1. Observation on 04/09/24, at 10:15 A.M., of the 200 hall shower room showed a disorganized array of used towels and plastic gloves. A bucket along the wall contained a rusty, dirty substance. The shower room floor was soiled with an unknown substance. 2. Observation on 04/09/24, at 11:10 A.M., of the 600 hall shower room showed the spa tub was dirty inside. The surface contained discolored water residue/stains and bits of paper. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegation of possible abuse were reportedly immediately to the Administrator and within two hours to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when staff did not report an allegation of possible abuse received from one resident (Resident #1). The facility census was 147. Review of the facility's policy titled Abuse Prevention, last reviewed 10/21/22, showed the following information: -Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely investigation of an allegation of sexual abuse and failed to immediately take steps to protect all residents when staff documented an allegation of sexual abuse and failed to report the allegation of abuse and initiate an investigation. The facility census was 147. Review of the facility's policy titled, Abuse Prevention, last reviewed 10/21/22, showed the following information: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served per professional standard when the kitchen walls, floors, and appliances were not clean and in good repair; when proper handwashing was not utilized; and when food was not properly stored. This had the potential to affect 153 of 154 residents who received meals prepared in the kitchen. Review of the facility's policy titled Nutritional Services Sanitation, dated 11/27/23, showed the following: -Nutritional Services shall ensure a clean and sanitary work environment to promote and protect food safety and to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety; -Cleaning assignments shall include equipment, cabinets, storage areas, walls, food service-related carts, and refrigeration units. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure that it provided full visual privacy to all residents when five resident rooms (rooms 404, 407, 409, 411, and 413) did not have sufficient privacy curtains to provide each resident full privacy in the semi-private rooms. 1. Observation on 12/19/23, at 2:30 P.M., of resident room [ROOM NUMBER] showed the door was open and two beds were occupied by two residents with one privacy curtain track. The track went to the footboard of each bed but did not go around the bed for full visual privacy. Observation from the hallway showed one could see both residents even if the curtain was pulled. Observation on 12/19/23, at 2:40 P.M., of resident rooms 407, 409, 411, and 413, showed two occupied beds in each room, with two tracks each around each bed, but only one curtain. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure they provided a homelike environment and made needed repairs in six resident rooms (Rooms 104, 105, 106, 113, 404, and 407) and the facility failed to ensure the dining room on the 400 Hall was clean and in good repair. 1. Observations during a tour of the facility on 12/19/23, at 2:17 P.M., showed the following: -Resident room [ROOM NUMBER] was had a metal pole behind the head of the resident bed without an attached trapeze bar; -Resident room [ROOM NUMBER]'s call light switch was without a protective cover; -Resident room [ROOM NUMBER], bed B, overbed table was missing the laminated cover around the edge exposing the splintered wood edging; -Resident room [ROOM NUMBER]'s bathroom floor had a tile that was loose and the corner was folded back. The base of the wall in the bathroom had a large gaping hole. [...]

Inspectors wroteBased on record review, interview, and record review, the facility failed to ensure an environment as free of accident hazards as possible when staff failed to accurately complete initial and quarterly smoking risk assessments and failed to care plan related to smoking for five (Resident #5, #35, #136, #116, and #129) reviewed out of 28 residents the facility identified as smokers. Review of facility policy titled Smoking Protocol, reviewed date 10/25/22, showed the following: -Safety concerns, residents may be supervised during smoking based on their smoking evaluation; -Smoking safety screens will be completed upon admission, readmission, quarterly, annually, after significant change, or as needed. 1. Review of Resident #5's admission Record, located in the Profile tab of the electronic medical record (EMR), showed an admission date of 11/09/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of six medication/treatment carts on the 400 Hall (dementia hall) were secure when staff were not present. The facility also failed to ensure that expired medications were removed from one medication cart on the 300 Hall. Review of the facility policy titled Medication Administration - General Guidelines, reviewed December 2017, showed the following: -During administration of medications, the medication cart is kept closed and locked when out of the sight of the medication nurse or aide; -No medications are kept on top of the cart; -The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 1. Observation on 12/20/23, at 6:44 A.M., on the 400 Hall dementia care unit, showed the office door was open. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences and/or provide options of similar nutritive value to residents who choose not to eat the food served for three residents (Resident #21, #43, and #63) of 11 residents reviewed for food preferences. Review of the facility's policy titled Menu Alternates & Substitutions, dated 11/27/23, showed the following: -Alternates shall be available for all meals for residents who dislike the menu item; -In cases when the menu item as well as the alternate is refused, staff shall investigate a reasonable solution within product availability. 1. Review of the Resident Council Minutes, dated 07/23 through 11/23, showed the following: -A comment, dated 08/17/23, to read resident dietary cards better; -A comment, dated 09/21/23, of still need to be reading dietary cards. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate records for all residents when staff failed to document regarding administration of medications for three residents (Resident #24, #39, and #63) out of a selected sample of 38 residents. Review of the facility policy titled Medication Administration - General Guidelines, reviewed December 2017, showed the following: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Medications are administered in accordance with written orders of the prescriber. 1. Review of Resident #24's admission Record, located in the resident's Electronic Medical Records (EMR) under the Profile tab, showed the following: -admission date of 08/23/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control standards were maintained during intravenous (IV- existing or taking place within, or administered into, a vein or veins) medication administration for one resident (Resident #307), of one sampled resident, who received IV antibiotic medications. The facility failed to ensure personal protective equipment (PPE) removal containers were near the door for for one resident (Resident #51) on COVID-19 isolation. The facility failed to ensure glucometers were sanitized per the manufacturer's guidelines in between the use for three residents (Resident #52, #76, and #97). These failures placed the residents at risk for cross contamination from infectious agents. 1. Review of Resident #307's admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a wheelchair readily accessible for one resident (Resident #37), of one resident reviewed for accommodation of needs, who did not have a record of documented offers or refusals to get out of bed. A total sample of 38 residents was reviewed. 1. Review of Resident #37's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) date of 09/27/23, located in the MDS tab of the Electronic Medical Record (EMR), showed the following: -admission date of 08/12/21; -Cognition was severely impaired; -Dependent on a help to transfer from bed to chair; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician, and document notification of the resident's physician notification in the medical record, of elevated blood sugar levels for one resident (Resident #51), of one resident reviewed for change of condition, in the sample of 38 residents. Review of the facility's policy titled, Notification of a Change in Condition, dated 04/26/23, showed the following: -The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and federal guideline for Notification of Physician/Resident Representative (not all inclusive); [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that a new Preadmission Screening and Resident Review (PASARR) Level 1 assessment was submitted after a new mental illness diagnosis for one resident (Resident #68) out of eight residents reviewed for PASARR. Review showed the facility did not provide a policy related to the PASARR process. 1. Review of Resident #68's admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 05/14/21; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), encephalopathy (a group of conditions that cause brain dysfunction), cognitive communication deficit, and essential hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for two residents (Residents #39 and #63) that address all pertinent health concerns. A sample of 38 residents was reviewed. Review of the facility policy titled Comprehensive Person-Centered Care Plan, review date of 10/23/19, showed the following: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The Interdisciplinary Team, along with the resident and/or resident representative, will identify resident problems, needs, strengths, life history, preferences, and goals; -For each problem, need, or strength a resident-centered measurable goal is developed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide bathing/showers for two residents (Residents #119 and #308) of 14 sampled residents in a total sample of 38, who were dependent or required extensive assistance from staff to complete their activities of daily living (ADLs.) This failure placed the residents at risk for a diminished quality of life and unmet care needs. Review shoed the facility did not provide a policy related to dependent residents who required assistance with ADLs. 1. Review of Resident #119's admission Record. located in the Profile tab of the electronic medical record (EMR), showed an admission date of 11/03/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to ensure acceptable parameters of nutrition were maintained for all residents when staff failed to monitor daily weights as ordered for two residents (Resident #119 and #308) and when staff failed to care plan the nutritional needs of one resident (Resident #119). Six sampled residents were reviewed for nutrition. Review showed the facility did not provide a policy regarding weight management and nutrition. 1. Review of Resident #119's admission Record, located in the Profile page of the electronic medical record (EMR) showed the following: -admission date of 11/03/23; -Diagnoses included of end-stage renal disease (ESRD) and was dependent on hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) care and services to meet the needs of one resident (Resident #119) of one sampled resident reviewed for dialysis. The facility failed to initiate a dialysis communication form, to indicated the resident's current weight, any medications administered, and any complication related to the dialysis access catheter, prior to dialysis treatments three times weekly, since admission to the facility. This had the potential to place the resident at risk for complications that might otherwise have gone unnoticed. Review of the facility's Dialysis Contract, dated 01/04/23, showed the following: -It is essential that communications process be established between the SNF (skilled nursing facility) and the clinic; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the trauma and triggers for one resident(Resident #39) with a diagnosis of post-traumatic stress disorder (PTSD - makes a person feel stressed and afraid after the danger is over) from a total of 38 sampled residents. This failure has the potential for staff being unable to identify when the resident is experiencing a PTSD episode. 1. Review of Resident #39's admission Record, located in the electronic medical record (EMR), under the Profile tab, showed the resident admitted to the facility on [DATE] with diagnoses that included PTSD. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date of 03/23/23, located in the EMR under the MDS tab, showed the following: -Resident had moderate cognition impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was below five percent (%) when staff made five medication errors out of 27 opportunities, involving two residents (Residents #15 and #105), resulting in an error rate of 18.5% Review of facility policy titled Medication Administration General Guidelines, review date of December 2017, showed the following: -Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record are compared with medication label; -Medications are administered within 60 minutes of schedule by the facility, except before, with, or after meals orders. 1. Review of Resident #15's 'Medication Administration Record (MAR), located in the electronic medical record (EMR) under the Reports'' tab, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) with a gastrostomy tube feeding (a tube involving or passing through the intestine, either naturally via the mouth and esophagus (part of the canal that connects the throat to the stomach) or through an artificial opening), received adequate nutrition when staff failed to document that they administered the ordered volume (amount) of tube feeding on multiple shifts; failed to document they administered water flushes as ordered; and failed to transcribe an order for tube feeding correctly. The facility census was 154. Review of the facility policy Tube Feedings, undated, showed the following: [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain complete and accurate records for all residents when staff failed to document regarding administration of medications for one resident (Resident #3) out of a selected sample of 10 residents. Facility census was 154. Review of the facility's policy, undated, titled Medication Administration-Preparation and General Guidelines, Charting and Documentation, revised August 2014, showed the following: -Medications are administered in accordance with written orders of the prescriber; -The medication administration record (MAR) is always employed during medication administration; -The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free from manual restraint for the convenience of staff when two staff members (Certified Nurse Aide (CNA) X and Registered Nurse (RN) V) physically restrained one resident (Resident #1) against the resident's wishes and without physician's orders. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to start an immediate investigation and take steps to protect all residents when an allegation of a manual restraint, type of abuse, involving two staff (Registered Nurse (RN) V and Certified Nurse Aide (CNA) X) and one resident (Resident #1) was reported. The facility census was 134. The administrator was notified on 07/16/21, at 8:20 P.M., of an Immediate Jeopardy (IJ) which began on 07/11/21. The IJ was removed on 07/16/21 as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse Prevention, dated 8/30/18, showed the following: -Employees shall be able to provide appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Employees shall be able to recognize signs of burnout, frustration and stress that may lead to abuse; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the steam table wells and frying pans were free of a buildup and food debris and failed to ensure all opened or leftover food was dated. The deficient practice had the potential to affect all residents. The census was 127. 1. Record review of the facility's policy titled, Refrigeration, dated 3/31/21, showed the following: -Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a left over. All leftovers shall be labeled and dated with expiration date no more than three days later. Record review of the 2013 Missouri Food Code showed the following: [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure all floors, walls, and nightlight grates were maintained and in good repair; failed to ensure all resident's bathrooms had a night light; failed to ensure all closets had doors; and failed to ensure all hoses, which extended beyond the flood plain, had a backflow preventer. The facility had a census of 127. 1. Observation on 5/11/21, starting at 11:30 A.M., showed the following: -No backflow preventer on the 100 hall shower room hose; -No backflow preventer on the 200 hall shower room hose; -No backflow preventer on the 400 hall shower room hose; -No backflow preventer in the storage room hose next to room [ROOM NUMBER]; -No backflow preventer on the shower hose in the bathroom in room [ROOM NUMBER]; -No backflow preventer on the 500 hall shower room hose; -No backflow preventer on the 600 hall shower room hose; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to ensure the resident trust accounts were reconciled for an accurate accounting of all monies held in the accounts for the 12 month period of May 2020 through April 2021. The facility managed funds for 84 residents. The facility census was 127. Record review of the (undated) facility policy, Business Office - Resident Trust Fund Policy and Procedure, showed the following information: -For the benefits of its residents, the facility shall provide a resident trust cash box and a separate bonded interest-bearing account for all residents who choose to have their personal money safeguarded and managed by the facility; -The facility will have, at all times, a current copy of the surety bond, per state regulations, to cover resident trust funds; [...]

Inspectors wroteBased on interview and record review, the facility failed to revise and update the comprehensive care plans for one resident (Resident #95) and failed to invite the resident, or the resident's family representative, to the care plan meeting for three residents (Resident #34, #93, and #94). The facility census was 127. 1. Record review of the facility's policy titled Interdisciplinary Care Plan Meeting, dated 1/23/19, showed the following: -The social service staff will notify the resident, and if applicable the resident's representative, prior to each meeting; -If the resident and/or representative is unable to attend, the care plan will be reviewed with the resident/representative and their response will be documented; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to utilize acceptable infection control practices while performing pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care for three residents (Resident #8, # 88, and #173); failed to follow or obtain physicians' orders in a timely manner to promote pressure ulcer healing for two residents (Resident #8 and #173); failed to document timely and complete tracking and assessments of wounds for one resident (Resident #8); and failed to update care plans to reflect current wounds and interventions for one resident (Resident #8). The facility census was 127. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, Treatment of Pressure Ulcers, showed the following: [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to dispose of expired medications and supplies by the expiration date. The facility census was 127. Record review of the facility's medication storage policy, dated November, 2018, showed the following information: -The nurse will check the expiration date of each medication before administering it; -No expired medication will be administered to a resident; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining; -The medication will be destroyed in the usual manner. 1. Observation on 5/12/2021, at 10:15 A.M., of the 500 Hall medication administration cart showed the following over the counter medications and supplies being stored for current and future use: -One bottle of Folic Acid 400 micrograms (mcg) with expiration date 4/2021; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meals in a timely manner in accordance with the residents' preferences when staff served meals outside the posted hours. The facility census was 127. Record review of the facility's policy titled, Meals and Snacks, dated 3/31/2021, showed the following: -Meal service shall be provided to residents on a regularly scheduled basis according to facility established times; -Nutritional services shall be responsible for all food preparation including snacks and shall deliver meals (with assigned assistance) to the residents or to the nursing units. Nursing shall be responsible for delivering snacks to the residents; -Mealtimes shall be scheduled to ensure a maximum of fourteen hours from dinner to breakfast on the following day. An example of meal times is: [...]

Inspectors wroteBased on record review and interview, the facility failed to keep two residents (Resident #415 and Resident #64) free from misappropriation of property when staff took the resident's debit card and/or the resident's cash. The facility census was 127. Record review of the facility policy Abuse Prevention, dated 3/20/19, showed the following information: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Misuse of Funds/Resident Property: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of misappropriation of resident property within 24 hours to the State Survey Agency (Department of Health and Senior Services (DHSS)) for one resident (Resident #64). The facility census was 127. Record review of the facility's Abuse and Neglect Prevention Policy and Procedure, revised on February 2017, showed the following information: -Policy is for all residents to have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice when staff failed to administer one resident's (Resident #34) oxygen as ordered and failed to care plan the resident's oxygen usage. The facility census was 127. 1. Record review showed the facility did not provide a policy regarding oxygen usage or following physician's orders. Record review of Resident #34's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date 5/4/2020; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 2/10/21, showed the following: -Moderately impaired cognition; [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to complete wound care as ordered for two residents (Resident #167 and #173). The facility census was 127. Record review showed the facility did not provide a policy regarding following physician's orders. 1. Record review of Resident #167's face sheet showed, the following: -admit date of 4/22/21; -Diagnoses included open wounds of the right and left upper arms, psychoactive (affecting mind or mental processes) substance abuse, muscle wasting and atrophy (decreased muscle mass) of right and left upper arms, elevated white blood count, and osteomyelitis (bone infection) of vertebrae. Record review of the resident's care plan, dated 5/5/21, showed the following: -Impaired skin integrity as evidenced by trauma injuries to bilateral forearms related to surgical history; [...]