Springfield Skilled Care Center

Inspectors wroteBased on interview and record review, the facility failed to obtain a radiology services to meet the needs of all residents when staff failed to obtain an ordered x-ray in a timely manner for one resident (Resident #1) who complained of wrist pain. The facility's census was 107. Review showed the facility did not provide a policy regarding x-rays services. Review of the facility's policy, Physician's Orders, dated 09/28/22, showed the following:-Purpose to provide guidance and ensure physician's orders are transcribed and implemented in accordance with professional stands, state and federal guidelines;-Physician's order sheets (POS) will be maintained with current physician orders as new orders are received. Discontinued orders will be marked as discontinued with the date, and all new order will be written in the appropriate area on the POS with the date the order was received. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable and homelike environment for all resident including (Resident #65, #111, #87, #8, #31, #38, and #82) when the facility failed to eliminate strong urine odors, failed to clean floors in a timely fashion, failed to keep walls clean, failed to repair a faucet timely and failed to remove trash timely. The facility census was 113. Review of a facility policy entitled Basic Cleaning Concepts, undated, showed the following:-General sanitizing: To make a surface or area clean by removing dirt, germs or unwanted substances;-Cleaning: The physical removal of dust, soil, blood and body fluids. Cleaning physically removes germs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain staff in sufficient numbers with sufficient training to ensure call lights were answered in a timely manner for seven residents (Residents #10, #70, #82, #86, #94, #65, and #61). The facility census was 113. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of medication errors greater than 5% when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration per manufacturer's administration instructions for three residents (Resident #10, #38, #97). Three medication errors occurred out of 26 opportunities resulting in an error rate of 11.54%. The facility census was 113. Review of the facility policy titled Medication Administration and General Guideline, dated January 2026, showed the following:-Medications are administered as prescribed;-Medication is administered in accordance with state regulations and using good nursing principles and practices;-Staff familiarize themselves with drug reference material provided by facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration per manufacturer's administration instructions for three residents (Resident #10, #38, #97). Three medication errors occurred out of 26 opportunities resulting in an error rate of 11.54%. The facility census was 113. Review of the facility policy titled Medication Administration and General Guideline, dated January 2026, showed the following:-Medications are administered as prescribed;-Medication is administered in accordance with state regulations and using good nursing principles and practices;-Staff familiarize themselves with drug reference material provided by facility. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a complete infection prevention and control program when staff did not perform appropriate hand hygiene when providing personal care for three residents (Residents #112, #12, and #19). The facility census was 113. Review of the facility policy titled Standard Precautions, reviewed 10/25/22, showed the following: -The facility will use standard precautions which are the minimum infection prevention practices that apply to all resident care regardless of suspected or confirmed infection status of the resident; -These practices help protect the employees and residents from spreading infections; -Standard precautions include hand hygiene; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed promote each resident's right to self-determination when staff failed to honor one resident's (Resident #70) reason shower preference for two showers a week. The facility census was 113. Review showed the facility did not provide a shower policy that addressed frequency of showers. 1. Review of Resident #70's face sheet (brief resident profile sheet) showed the following:-admission date of 02/23/26;-Diagnoses included chronic obstructive pulmonary disease (COPD - lung disease), type two diabetes mellitus (DM - metabolic disease), amputation of right leg above knee, cellulitis (deep inflammation of the tissues just under the skin, caused by infection) of left lower limb, depression, and generalized muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure notifications were made to resident responsible parties and physicians of all resident refusal of a scheduled medical appointments when staff failed to document notification of the one resident's (Resident #1) responsible party and physician when the resident refused to attend a scheduled medical appointment related to the removal of an inserted ureteral stent (thin, flexible tube placed in ureter to keep the passageway open for urine to flow from the kidney to the bladder). The facility census was 105. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow wound physician recommendations to obtain wound cultures and an X-Ray for one resident (Resident #7) with a vascular wound to his/her left shin. The facility census was 106. Review of the facility policy titled, Notification of a Change in Condition, revised on 02/06/25, showed:-The attending physician/nurse practitioner will be notified of a change in the resident's condition;-Responsibility: All licensed nursing personnel, nursing administration, and Director of Nursing (DON). 1. Review of Resident # 7 face sheet showed:-admission date of 9/27/25;-Diagnoses of traumatic ischemia (lack of sufficient blood flow) of muscle, peripheral artery disease (when narrowing of the arteries leads to reduced blood flow to the limbs) and diabetes mellitus, type II. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician medication orders and/or medication recommendations resulting in significant medication errors for 4 residents (Resident #3, #4, #1, and #8) when staff transcribed Resident #3's medication order incorrectly for digoxin (a cardiac medication used to treat heart failure and irregular heartbeat, which has a narrow therapeutic range requiring careful monitoring for side effects), resulting in digoxin toxicity (dig tox, a condition resulting from taking too much digoxin causing symptoms like nausea, vomiting, confusion, vision changes, and serious cardiac issues) and hospitalization, when staff transcribed Resident #4's order incorrectly for Coumadin (warfarin, an anticoagulant medication/ blood thinner) resulting in elevated blood levels placing the resident at an increased bleeding risk, when staff [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective system of reconciliation for all controlled substances, when nursing staff failed to maintain signature sheets for counting of the controlled substances at the beginning and end of each nurse shift for two of two nurse carts. These two carts were referred to as Skilled 1 and Skilled 2 which contained all as needed (PRN) controlled resident medications. The facility census was 106. 1. Review of the controlled medication books located on each cart showed no sheet for nurses to sign when counting controlled medications at the beginning and end of each shift. Observation on 01/13/26 at 2:00 P.M., showed two medication carts located inside the locked nurse station. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor residents' request for funds as soon as possible, but no later than the same day for amounts of $50.00 for Medicaid residents, for two residents (Resident #1 and Resident #2). The facility census was 106. Review of the undated facility's policy titled Business Office-Resident Trust Fund Policy and Procedure, showed the following: -Residents of a Skilled Nursing Center are to have their funds managed and personal spending money available to them. Regardless of payment source, residents have the right to choose whether or not to open a Resident Trust Fund account with the Center. If the choice to open a trust fund account is made, the resident has the right to have their money safeguarded and accounted for by the Center. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered resident medications as ordered by the physician, when during medication administration observation for Residents # 5 and #6, staff made 4 errors out of 27 opportunities for error, resulting in a medication error rate of 6.75%. The facility census was 106. Review of the facility policy titled, Medication Administration-General Guidelines, revised August 2014, showed:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). [...]

Inspectors wroteBased on interview and record review, the facility failed to document a change in condition and discharge to the hospital in one resident's (Resident #8) progress notes. The facility census was 106.1. Review of Resident #8's face sheet showed the following:-The resident admitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive lung condition causing airflow obstruction, leading to shortness of breath, cough (often with mucus), and wheezing, primarily from lung damage due to smoking or pollution), bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity), extrapyramidal and movement disorder (EPS-involuntary movement disorders, often caused by medications like antipsychotics), anxiety and insomnia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound prevention and treatment per standards of practice when staff failed to complete a full assessment and obtain treatment orders timely upon discovery of a wound, failed to follow physician orders for interventions, completion of wound treatments and labs, and failed to care plan interventions for one resident (Resident #95) who developed facility acquired 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). The resident developed infection and was referred to a surgeon for possible amputation of the right lower leg. The facility census was 98. The Administrator was notified on 02/07/25, at 4:59 P.M., of an Immediate Jeopardy (IJ) which began on 12/05/24. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care per physician's orders and professional standards of practice for all residents when staff failed to document complete and thorough assessments, provide care per physician's orders, and to care plan treatment of a burn for one resident (Resident #2). The facility census was 98. Review of the facility's policy titled, Accident and Incident Documentation and Investigation, revised 04/26/23, showed the following: -The licensed nurse at the time of an incident is responsible for documenting the incident in the resident's medical record; -The licensed nurse shall document the incident and notify the supervisor and Director of Nursing (DON) for follow through as needed; -The licensed nurse may complete a nurses' note and update the resident's care plan as needed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from significant medication errors. The facility failed to ensure physician orders were entered and/or reviewed by nurses, failed to document monitoring of medication side effects, and failed to follow physician orders to discontinue Xanax (a drug in a class of medications called benzodiazepines (class of medications that act as central nervous system (CNS) depressants) that works by decreasing abnormal excitement in the brain) for one resident (Resident #94) who suffered a hospitalization due to a benzodiazepine overdose. The facility staff failed to notify management and the physician of the medication error. The facility census was 98. Review of the facility's policy titled Physician Orders, dated 09/28/22, showed the following information: [...]

Inspectors wroteBased on record review and interview, the facility failed to have the required minimum of six staff members attend the Quality Assessment Committee (QAA) meetings. The facility census was 98. Review of the facility's Quality Assurance Process Improvement (QAPI) policy showed the following: -QAPI takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. -Responsibility of the interdisciplinary team to meet at a minimum of quarterly and as needed; -Best practice is to meet monthly; -The QAPI members shall include representatives from all departments in the interdisciplinary teams; -This also includes seeking input from residents, residents representatives, and frontline care staff. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an ongoing evaluation of bed rails and failed to complete regular inspections of the bed frame and side rails for risk of entrapment for one resident (Resident #2) whose side rails were loose. The facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to care plan side rail use; and failed to complete initial and ongoing assessments to ensure the side rails were appropriate for use for two residents (Resident #12 and # 93 ). The facility census was 98. Review of the facility procedure titled, Restraints: Bed Rail Safety Check, undated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and effective medication system in a manner that met the needs of each resident when staff failed to document administration of multiple doses of scheduled medications for three resident (Resident #1, #3, and #4) with no reason documented. In addition, staff documented administration of medications not available in the facility for administration for two residents (Resident #3 and #4). The facility census was 97. Review of the facility policy titled, Medication Administration-Preparation and General Guidelines, revised August 2014, showed the following: -Medications are administered in accordance with written orders of the prescriber; -A schedule of routine dose administration times is established by the facility and utilized on the administration records; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents only self-administer their medication once assessed by an interdisciplinary team and if clinically indicated when staff failed to observe one resident (Resident #28) take his/her medications, who had not been assessed for self-administration. The facility census was 98. Review of the facility's policy titled Self Administration of Medications, dated 12/2017, showed the following information: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team (IDT) of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. The resident should be re-assessed quarterly; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident or resident representative with a Notice of Medicare Provider Non-Coverage (NOMNC-form CMS-10123) when all covered Medicare services were ending for two residents (Resident #62 and #98) and failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #98) who remained in the facility after discharge from Medicare Part A services. The facility census was 98. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 01/09/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate with the appropriate state-designated authority to ensure that individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs, when the facility failed to obtain and maintain a copy of a level II Pre-admission Screening and Resident Review (PASRR) for one resident (Resident #61). The facility census was 98. Review showed the facility did not provide a policy regarding PASRR requirements. 1. Review of Resident #61's face sheet (brief look at resident information) showed the following information: -admission date of 10/17/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when the facility failed to obtain an order for, care plan, and monitor the use of a brace for one resident (Resident #12). Facility had a census of 98. 1. Review of Resident #12's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 11/17/22; -Diagnoses included cerebral infarction (stroke that occurs when the blood supply to part of the brain is blocked or reduced), hemiplegia (paralysis or weakness on one side of the body) of the left side, foot drop, and left ankle contracture. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/02/24, showed the following: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a discharge summary for an anticipated discharge (a discharge that is planned and not due to the resident's death and/or emergency) for one resident (Resident #102). The facility census was 98. Review of the facility's policy titled Discharge Plan/Summary Voluntary, dated 11/01/18, showed the following information: -A physician order must be obtained; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide good grooming and personal hygiene for residents who were unable to carry out activities of daily living (ADL- basic care tasks that are essential for maintaining independence and daily life) for themselves when the facility failed to document bathing attempts for one resident (Resident #205), who was dependent on staff for bathing. The facility census was 98. Review of the facility's policy ADL Care Bathing, dated 07/21/22, showed the following information: -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 #205's face sheet (brief look at resident information) showed the following information: -admission date of 01/16/25; [...]

Inspectors wroteBased on record review and interview, the facility failed to keep an environment free from accident hazards when staff did not complete and document a timely investigation or assessment into the cause of a coffee spill that resulted in a burn and did not update the resident's care plan timely regarding new interventions to prevent future burns for one resident (Resident #2). The facility census was 98. Review of the facility's policy titled, Accident and Incident Documentation and Investigation, revised 04/26/23, showed the following: -Accidents and/or Incidents involving residents will be investigated and documented on an Incident Report in the electronic health record (EHR). An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure catheters (a thin, flexible tube used to drain fluids, including urine, from the body) were only used when indicated and were maintained in a manner to prevent possible infection when staff failed to obtain an order with indication for use for an indwelling catheter, failed to obtain timely orders for catheter care, failed to complete the catheter care as ordered, and failed to care plan catheter use timely for one resident (Resident #95). The facility census was 98. Review of the facility policy titled, Catheter Care, dated 07/13/22, showed it was the the policy of the facility to maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with standards of practice and residents' care plans when staff failed to ensure staff changed oxygen equipment per physician order for two residents (Resident #12 and #83) and failed to include the use of oxygen on the care plan for one resident (Resident #12). The facility had a census of 98. Review of the facility policy titled, Oxygen Administration, undated, showed the policy did not address care of oxygen concentrators, humidifiers, or oxygen tubing. 1. Review of the Resident #12's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 11/17/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain records that were complete for all residents, when staff failed to document how a burn occurred, and assessment of the burn for five days, and failed to document regarding the reason for a follow-up hospitalization for one resident (Resident #2). The facility census was 98. Review of the facility's policy titled, Accident and Incident Documentation and Investigation, revised 04/26/23, showed the following: -Accidents and/or Incidents involving residents will be investigated and documented on an Incident Report in the electronic health record (EHR); -The licensed nurse at the time of the incident was responsible for initiating/completing the Incident report; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to have a working call light system for all residents when the call light was not working properly in one resident room, affecting two residents (Resident #34 and #91). The facility census was 98. Review of the facility's policy titled, Resident Call System, revised 10/20/22, showed the following: -The facility call system relay calls directly to a centralized work area from the resident's bedside, toilet, and bathing area. The call system is accessible to a resident lying on the floor as required by state/federal guidelines; -During rounds nursing and the Interdisciplinary Team (IDT) members will ensure resident call systems are within reach of residents; -In the event the resident call system is down, call bells will be utilized until power is restored; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the prior survey results were kept current and complete in a readily accessible, public location for residents, family members, and residents' legal representatives. The facility census was 98 at the time of survey. 1. Observation on 02/04/25, at 10:50 A.M., showed the following; -A maroon binder located in a wall pocket close to the television/day area near the junction of 100, 200, and 300 halls. -The binder contained the most recent survey results for 05/02/24. -The binder did not contain the other survey results from the previous three years including the results of the last recertification survey completed on 02/03/23. During interviews on 02/05/25, starting at 10:00 A.M., during the resident council group meeting, the residents said they did not know where any survey results were available at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the required nurse staffing in a prominent place readily accessible to residents and visitors on a daily basis. The facility census was 98. Review of facility policy Direct Care Staff Daily Report, updated 02/28/23, showed the following: -The facility will post direct care staffing hours daily, as required by federal/state agencies. -The posting will include actual hours worked and total hours worked. -The responsibility for the report falls on the Staffing Coordinator, nursing, nursing administration, Director of Nursing (DON), and the Administrator. 1. During interviews on 02/05/25, starting at 10:00 A.M., at the resident council group meeting, residents said the following: -Most residents said they did not know staffing levels were posted anywhere in the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice discharge, including the reason for discharge and right to appeal, to all resident upon discharge when the home failed to provide a written discharge notice to one resident (Resident #1) when they refused to accept the resident back to the facility after hospitalization. The facility census was 99. 1. Review of Resident #1's face sheet showed the following: -admission date of 05/13/19; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff present to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents when there was insufficient staff to answer call lights in a timely manner for four residents (Resident #2, #3, #4 and #5), in a review of 16 sampled residents. The facility census was 106. Review showed the facility did not provide a policy regarding answering call lights. 1. Review of the facility's Resident Council Meeting Minutes, dated 08/15/24, showed residents requested administration to hire more nursing staff. Review of the facility's Resident Council Meeting Minutes, dated 09/19/24, showed one resident complained of aides not answering call lights quickly enough. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated with dignity and respect at all times when one staff member (Licensed Practical Nurse (LPN F)) raised his/her voice at one resident (Resident #1) and told the resident he/she could lose the right to smoke after a fall. The facility census was 106. Review of the facility's policy titles (Resident Rights), dated April 2023, showed the facility staff shall treat residents with kindness, respect, and dignity and ensure resident rights are being following. 1. Review of Resident #'1's face sheet showed the following: -admission date of 06/15/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient a fully functional call light system for all residents when the call lights for two residents (Resident #2 and #4) did not function properly. The facility census was 106. Review of the Facility's Resident Call System, dated 10/22, showed the following: -During rounds nursing an Interdisplinary Team (IDT) Member will ensure the resident call system is within reach of the resident; -In the event the resident call system is down, call bells will be utilized until power is restored; -The Maintenance Director will complete routine resident call system checks. 1. Review of Resident #'2's face sheet showed the following: -admission date of 10/25/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all abuse allegations were reported to the State Survey Agency (Department of Senior Services -DHSS) within two hours of staff being made aware of the allegation when the facility failed to report an anonymous allegation of possible verbal/mental abuse by a staff member to DHSS. The facility census was 110. Record review of the facility's protocol titled, Abuse Prevention, dated 08/30/18 and last revised 10/21/22, showed the following information: -Staff members, volunteers, family members, and others shall be encouraged to report incidents of abuse; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse; [...]

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to adequately and in a timely manner clean the floor of the resident room and failed to change the soiled bedding for one resident (Resident #2). The facility census was 110. Record review of the facility's policy titled, Resident Room Cleaning Procedures, dated 05/09/23, showed the following: -In each room bag and remove all trash from room. Clean inside and outside of trash cans when needed; -Always disinfect high touch areas in resident rooms; -Sweep bathroom and resident room floor, including under the bed. If the bed can be moved, move and clean the floor up against the wall; -Mop the resident room floor first and mop the bathroom floor last; [...]

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00240384 Based on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #2) to include new information on communicating with the resident effectively when the resident returned from the hospital and failed to ensure all staff were aware of the change. The facility's census was 110. Review of the facility's policy titled, Comprehensive Person-Centered Care Plan, last reviewed 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; [...]

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00240384, MO00240390 Based on observation, interview, and record review, the facility failed to ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when staff failed to complete routine attempts to change urine-soaked clothing and complete bathing and/or showering for one resident (Resident #2) . The facility had a census of 110. 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; -Ensure bathing area is at a comfortable temperature; -Be gentle and do not rush the procedure. Allow for breaks if needed; [...]

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to to place the call light in reach of one resident (Resident #1) as care planned for fa fall intervention. The facility census was 110. Review showed the facility did not provide a policy regarding care light accessibility. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 02/21/23; [...]

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. Based on observation, interview, and record review, the facility failed to implement an effective infection control program when staff failed to clean urine on a resident's floor in a timely manner, stepped in the urine and walked through the facility without the cleaning of shoes, and left a resident's bare feet in a urine puddle for one resident (Resident #1). Staff also failed to clean the blood pressure monitor between making contact with the floor and using on one resident (Resident #1). The facility census was 110. Review of the facility policy's entitled, Blood/Body Fluid Spill, dated 07/21/22, showed the following: -The facility will clean and disinfect blood/bodily fluid spills following a two-step method; -This task is the responsibility of housekeeping, environmental services, and the Administrator; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an ongoing monitoring process to include accurate documentation and accountability of expired or unusable medications, failed to ensure medications that could not be returned to the pharmacy were destroyed in a timely manner for eleven residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11), and failed to develop a policy to address the proper documentation, destruction, and disposal of medications. The facility census was 105. Review of the facility's policy titled Controlled Substance Disposal, revised [DATE], showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations; [...]

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00240384, MO00240390 Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to adequately and in a timely manner clean the floor of the resident room and failed to change the soiled bedding for one resident (Resident #2). The facility census was 110.

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00240384 Based on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #2) to include new information on communicating with the resident effectively when the resident returned from the hospital and failed to ensure all staff were aware of the change. The facility's census was 110.

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00240384, MO00240390 Based on observation, interview, and record review, the facility failed to ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when staff failed to complete routine attempts to change urine-soaked clothing and complete bathing and/or showering for one resident (Resident #2) . The facility had a census of 110.

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00239914, MO00240161 Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to to place the call light in reach of one resident (Resident #1) as care planned for fa fall intervention. The facility census was 110.

Inspectors wrote1. Please refer to event ID JJ94112 for citation details. MO00240390 Based on observation, interview, and record review, the facility failed to implement an effective infection control program when staff failed to clean urine on a resident's floor in a timely manner, stepped in the urine and walked through the facility without the cleaning of shoes, and left a resident's bare feet in a urine puddle for one resident (Resident #1). Staff also failed to clean the blood pressure monitor between making contact with the floor and using on one resident (Resident #1). The facility census was 110.

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 adequately and in a timely manner clean the floor of the resident room and failed to change the soiled bedding for one resident (Resident #2). The facility census was 110. Record review of the facility's policy titled, Resident Room Cleaning Procedures, dated 05/09/23, showed the following: -In each room bag and remove all trash from room. Clean inside and outside of trash cans when needed; -Always disinfect high touch areas in resident rooms; -Sweep bathroom and resident room floor, including under the bed. If the bed can be moved, move and clean the floor up against the wall; -Mop the resident room floor first and mop the bathroom floor last; -Identify and report any maintenance or cleanliness issues. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #2) to include new information on communicating with the resident effectively when the resident returned from the hospital and failed to ensure all staff were aware of the change. The facility's census was 110. Review of the facility's policy titled, Comprehensive Person-Centered Care Plan, last reviewed 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; -Comprehensive Person Centered Care Plan (CCP) contains services provided, preference, ability and goals for admission, desired outcomes, and care level guidelines; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when staff failed to complete routine attempts to change urine-soaked clothing and complete bathing and/or showering for one resident (Resident #2) . The facility had a census of 110. 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; -Ensure bathing area is at a comfortable temperature; -Be gentle and do not rush the procedure. Allow for breaks if needed; -Encourage resident to bathe him/herself and assist as needed; -Assist with dressing/grooming as needed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to to place the call light in reach of one resident (Resident #1) as care planned for fa fall intervention. The facility census was 110. Review showed the facility did not provide a policy regarding care light accessibility. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 02/21/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure all residents were free from significant medication errors when staff failed to have a system to accurately document the timely administration of medications per professional standards when staff frequently documented two doses of medications administered at or near the same time and medication administered out of scheduled time frames for one resident (Resident #1), when the facility failed to have a policy related to a liberalized medication administration system, and when the facility failed to train nursing staff on a liberalized medication administration system. The facility census was 104. Review of the facility policy titled, Medication Administration-Preparation and General Guidelines, revised August 2014, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective infection control program when staff failed to clean urine on a resident's floor in a timely manner, stepped in the urine and walked through the facility without the cleaning of shoes, and left a resident's bare feet in a urine puddle for one resident (Resident #1). Staff also failed to clean the blood pressure monitor between making contact with the floor and using on one resident (Resident #1). The facility census was 110. Review of the facility policy's entitled, Blood/Body Fluid Spill, dated 07/21/22, showed the following: -The facility will clean and disinfect blood/bodily fluid spills following a two-step method; -This task is the responsibility of housekeeping, environmental services, and the Administrator; -Staff should clean spills in resident areas as soon as possible; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when staff failed to don the appropriate Personal Protective Equipment (PPE - gloves, gowns, and masks) when entering isolation rooms with residents positive with influenza A, when staff failed to perform appropriate hand hygiene when exiting isolation rooms, and when staff failed to dispose of contaminated PPE properly. The facility census was 104. Review of the Center for Disease Control and Prevention's (CDC), Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission, last reviewed 08/09/23, showed the following: -A combination of infection prevention control strategies are recommended to decrease transmission of influenza viruses in health care settings; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and homelike environment for all residents when staff failed to replace and/or fix the resident room walls and closet ceiling where a black substance was present in one resident's room (Resident #1). The facility census was 104. Review showed the facility did not provide a policy pertaining to maintenance of the building. 1. Review of Resident #1's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), showed the following: -admission date of 12/07/23; -Resident required supervision or touching assistance with most activities of daily living (ADL's - dressing, grooming, bathing, eating, and toileting); -Diagnoses included pulmonary disease (a group of lunch diseases that block airflow and make it difficult to breathe. Observations on 01/31/24, at 10:30 A. [...]

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 obtain orders related to dialysis services, failed to ensure the resident received scheduled dialysis services, failed to document monitoring due to missed dialysis services, and failed to notify the dialysis clinic and physician of the missed dialysis services for one resident (Resident #1). The facility census was 107. Review of the facility policy titled Physician Orders, dated 09/2022, showed the following information: -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a fully functional call light system since August 2023, for resident Halls 100, 200, 300 and part of 400 Halls. The facility census was 111. Review showed the facility did not provide a policy addressing the call light system. 1. Review of facility records shows the following: -Weekly checks for call bell placement in resident rooms beginning 08/15/2023 through 11/13/2023; -On 08/09/23, quote to supply/install the parts to repair/replace non-functional nurse call system; -On 10/30/23, the company completed installation new equipment and connections. 2. Review of Resident # 1's face sheet (gives basic profile information) showed the following: -admission date of 09/15/22; [...]

Inspectors wroteBased on record review and interview, the facility failed to protect all residents from misappropriation of property when narcotic medications for multiple residents (including Residents #1, #2, #3, and #4) went missing while in the possession of the facility. The facility census was 108. The facility Administrator and the Director of Nursing (DON) were notified on 11/06/23 of the Past Non-Compliance which occurred on 11/06/23. The facility staff began an investigation on 11/06/23, suspended all involved certified medication technicians (CMT), notified the Department of Health and Senior Services (DHSS), local law enforcement agency, the pharmacy, and the residents' physicians. The facility made system changes that allow only nurses to have access to narcotics. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to four residents (Residents #2, #19, #29, and #102). The facility had a census of 109. Record review of the facility policy titled, ADL Care Bathing, last reviewed on 7/21/22, 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. (The policy did not address how many showers per week residents should receive.) 1. Record review of Resident #19's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility), dated 1/17/23, showed the following: -admission date of 4/19/18; -Diagnoses included of reduced mobility, history of UTIs (urinary tract infections), anxiety, and depression; [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, for seven residents (Resident #14, #25, #29, #35, #51, #88, and #161). The facility census was 109. Record review of the facility policy, titled Emergency Transfer Procedures, dated 10/07/2021, showed the following: -The family or responsible party will be notified of the transfer to the hospital by the nursing shift supervisor or designee; -A transfer form is used to accompany the resident to include medication information pertinent to the transfer, such as diagnosis, medications, diet, insurance information, responsible party, and a brief description of the resident's medical problem; -Document accordingly under nursing/progress notes. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative in writing of the bed hold policy when transferring residents to the hospital for seven residents (Resident #14, #25, #29, #25, #51, #88, and #161). The facility census was 109. Record review of the facility policy titled Resident Bed Hold, dated 11/15/2022, showed the following: -The facility will provide written information to the resident and/or the resident/representative regarding the bed hold policy prior to transferring a resident to the hospital or therapeutic leave as required by state and federal guidelines. 1. Record review of Resident #25's face sheet (brief information sheet about the resident) showed the following: -admission date of 5/17/2021; [...]

Inspectors wroteBased on interview and record review, the facility failed to revise and update the comprehensive care plans for five resident (Resident #7, #25, #61, #66, and #88). The facility census was 109 Record review of the facility policy titled Comprehensive Person-Centered Care Plan, dated 10/23/2019, showed the following: -Each resident will have a person centered care plan to identify problems, needs strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; -The comprehensive person centered care plan contains services provided, preferences, abilities, and goals for admission, desired outcomes, and care level guidelines; 1. Record review of Resident #7's face sheet showed the following: -admission date of 7/27/2018; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made five errors out of 26 opportunities resulting in an error rate of 19.2% error rate when staff failed to administer the correct amount of medication for one residents (Resident #43), when staff failed to ensure four residents (Resident #7, #35, #39, and #88) had a meal intake within 30 minutes of insulin administration, and when staff failed to administer insulin correctly for the four residents (Resident #7, #35, #39, and #88). The facility census was 109. Record review of the facility policy, titled Injectable Medication Administration, dated August 2018, showed the following: -Check order on the medication administration record to see that an injection is currently ordered or due; -Prepare the resident; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents were free of significant medication errors when staff failed to ensure four residents (Resident #7, #35, #39, and #88) had a meal intake within 30 minutes of insulin administration and failed to ensure staff administered the full dose of insulin to the four residents by not the holding insulin dose for 6 to 10 seconds at the site of administration as recommended by the manufacturer. The facility census was 109. Record review of the facility policy, titled Injectable Medication Administration, dated August 2018, showed the following: -Check order on the medication administration record to see that an injection is currently ordered or due; -Prepare the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants, when staff failed to use appropriate hand hygiene after performing wound care for one resident (Resident #7), failed to use appropriate hand hygiene after performing incontinent care for three residents (Resident #7, Resident #33, and Resident #213), failed to use appropriate hand hygiene after performing glucometer (a machine used to check blood sugar) checks for two residents (Resident #29 and Resident # 262), and failed to use appropriate hand hygiene after performing glucometer checks and insulin injections for four residents, (Resident #7, Resident #35, Resident #39, and Resident #88). The facility also failed to properly clean/disinfect the shared glucometer between uses/residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine to three residents (Resident #19, #35, and #44) following admission to the facility. Staff also failed to provide information and education to the residents or the residents' representatives of the risks and benefits of the pneumococcal vaccine. The facility census was 109. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for adults, dated 4/01/2022, showed the following recommendations: -Two pneumococcal vaccines are recommended for adults 65 years or older; -CDC recommends vaccination with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people two through [AGE] years old with certain medical conditions, including chronic (ongoing) conditions; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the interdisciplinary team approved all self-administration of medication, obtained orders for the self-administration of medication and care planned the self-administration for one resident (Resident #78) with a medication at bedside The facility census was 109. Record review of the facility policy titled Medication Administration - General Guidelines:, dated December 2017, showed the following information: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Five rights - right resident, right drug, right dose, right route, and right time, are applied for each medication being administered; -The medication administration record (MAR) is always employed during medication administration; [...]

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 adequately clean resident bathroom floors, repair, and maintain the bathrooms's of two residents (Resident #83 and #263). The facility census was 109. Record review showed the facility did not provide a policy related to cleaning and upkeep of the facility. 1. Observations on 1/27/23, at 1:57 P.M., showed tile on the floor of Resident #83's bathroom had been removed and the black area beneath was visible throughout. The walls of the bathroom were torn up and partially repaired with drywall putty/spackle. During an interview on 1/27/23, at 2:00 PM, the resident said the state of the bathroom bothered him/her. It was ugly, only partially repaired, and appeared dirty. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff when one staff member (Certified Nurse Aide (CNA) I) cursed at one resident (Resident #14). The facility census was 109. Record review of the facility policy titled Abuse Prevention, dated 4/28/21, showed the following: -The facility is committed to protecting the residents from abuse by anyone; -Identify, correct, and intervene in situations in which abuse and/or neglect if more likely to occur; -It is the responsibility of all staff to provide a safe environment for the residents. 1. Record review of the Resident #14's face sheet showed the following information: -admission date of 11/3/12; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services) when one resident (Resident #14) and one staff member reported an allegation of abuse against a staff member (Certified Nurse Aide (CNA I) to nurse who did not report to management or DHSS. The facility census was 109. Record review of the facility's protocol titled, Abuse Prevention, dated 4/28/21, showed the following information: -Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an a timely written investigation of an allegation of possible employee-to-resident abuse when one staff member and one resident (Resident #14) reported allegations of abuse again one staff member (Certified Nurse Aide (CNA) I) to a nurse. The facility census was 109. Record review of the facility policy titled Abuse Prevention, dated 4/28/21, included the following: -Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse; -Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigate, documented, and report to the physician, families, and/or representatives, and as required by state guidelines; [...]

Inspectors wroteBased on record review and interview the facility failed to electronically transmit encoded, accurate, and complete a Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff) to the Center for Medicare & Medicaid Services (CMS) System within 14 days after a facility completed a resident's discharge for one resident (Resident #71). The facility census was 109. 1. Record review of Resident #71's face sheet showed the following information: -admission date of 5/20/22; -Diagnoses included metabolic encephalopathy (problem in the brain, caused by a chemical imbalance in the blood), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), history of falling, cognitive communication deficit, and generalized weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all assessments were accurate when staff failed to identity dialysis received by one resident (Resident #29) on his/her Minimum Data Set (MDS - a federally mandate assessment tool completed by facility staff). The facility census was 109. Record review of the facility-provided policy MDS 3.0, revised 10/1/19, showed the following: -The MDS Coordinator, in conjunction with the Interdisciplinary Team (IDT), is expected to complete assessments using the MDS 3.0 Resident Assessment Instrument (RAI) specified by the state in compliance with the MDS 3.0 RAI User's Manual guidelines; -Everyone completing a portion of the assessment must sign and certify the accuracy of the portion of the assessment he/she completed; [...]

Inspectors wrote2. Record review of Resident #35's face sheet showed the following: -admission date of 9/1/22; -Diagnoses included functional quadriplegia (refers to complete immobility due to severe physical disability or frailty without injury to the spinal cord), neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems); cystostomy status (surgical creation of an opening into the bladder); and retention of urine (condition in which urine cannot empty from the bladder). Record review of the resident's physician order sheet (POS), current as of 2/3/23, showed the following: -An order, dated 9/3/22, for indwelling catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care every shift related to neuromuscular dysfunction of the bladder and retention of urine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) to maintain good grooming when staff failed to provide routine showers to two dependent residents (Resident #21 and #32). The facility census was 109. Record review of the facility policy titled, ADL Care Bathing, last reviewed on 7/21/22, 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. (The policy did not address how many showers per week residents should receive.) 1. Record review of Resident #32's quarterly Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 1/10/23, showed the following: -admission date of 4/16/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary care to promote healing and prevent possible infection of wounds when staff failed to update the care plan regarding treatment and failed to perform hand hygiene during wound care for one resident's (Resident #7) pressure ulcer (injuries to the skin and underlying tissue primarily caused by pressure on the skin). The facility census was 109. Record review of the facility policy, titled Wound Management, dated 11/15/2022, showed the following: -The facility will provide evidence based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders; -Wound dressings will be applied in accordance with manufacturer's directions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a physician order for use of oxygen, failed to care plan the use of oxygen, and failed to document use of oxygen on the Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) for one resident (Resident #71). The facility census was 109. Record review of the facility policy titled Oxygen Administration and Storage, dated 1/1/2014, showed the following information: -It is the nurse's responsibility to provide emergency administration of oxygen when it is necessary the care of the resident; -The nurse will then call the physician as soon as reasonable to obtain a physician order; -Staff should verify the physician's order for oxygen prior to oxygen administration except in the case of emergencies. 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 obtain orders related to dialysis services for one resident (Resident #29) and when the facility failed to have a contract with a dialysis provider for two residents (Resident #29 and #32) currently receiving dialysis services. The facility census was 109. Record review of the facility policy titled Dialysis Communication Transfer, dated 10/7/21, showed the following information: -A dialysis communication transfer form is completed each time a resident received outpatient dialysis. This ensured enhanced communication between the two facilities; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to post staff hours and census in a prominent place easily accessible to all residents and visitors. The facility census was 109. Record review showed the facility did not provide a policy related to nurse staff hours. 1. Observation on 1/23/23, at 1:43 P.M., showed no staffing census hours located in the facility. Observation on 1/24/23, at 12:24 P.M., showed no staffing census hours located in the facility. Observation on 1/26/23, at 9:23 A.M., showed nurse staff census hours located near the front entrance towards the left side going towards the 500 hall. The posting was in a picture frame type box on an orange piece of paper. The posting was at approximately 5 feet 5 inches from the floor. A resident in a wheelchair would have trouble viewing the information. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to post the abuse and neglect hotline number in a manner that residents and family could easily access it when the number was posted in an elevated position not easily seen from a wheelchair and in small print. The facility census was 109. Record review of the facility policy titled Abuse Prevention, dated 4/28/2021, showed the policy did not address where and how the abuse and neglect hotline number should be posted. 1. Observations on 1/26/2023, at 1:44 P.M., and on 2/2/2023, at 8:05 A.M., showed the following: -The abuse/neglect hotline number posted just to the left down hallway from main entrance, approximately four feet high, with small print. The print would be difficult for a resident or family member with poor eyesight to read. [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to ensure food was palatable, attractive, and served at an appropriate temperature at the time the food was delivered to residents. The facility staff failed to ensure the nutritive value of all foods was maintained when staff failed to follow prepare pureed food according to the corresponding puree food instructions. The facility census was 106. 1. Record review of the facility's policy titled, Meal Service-Temperatures, dated 4/1/16 and revised 2/23/17, showed the following: -Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis; -Temperatures shall be taken once food it placed on the steam table prior to the start of meal service; -Temperatures shall be taken at the end of the meal service to ensure temperature maintenance throughout service; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure a sanitary environment when the kitchen had two areas with standing water observed on multiple days. The facility census was 106. 1. Observation on 11/18/19, at 12:57 P.M., showed standing water covering an area approximately three to five feet wide underneath the cup storage racks in the kitchen. Observation on 11/22/19, at 8:56 A.M., showed standing liquid underneath the cup storage racks in the kitchen. The liquid was a light brown color. Observation on 11/22/19, at 9:00 A.M., showed standing water underneath a food preparation table near the reach in fridge along the back wall in the kitchen. Observation on 11/22/19, at 10:20 A.M., showed standing liquid underneath the cup storage racks in the kitchen. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff treated residents with dignity and respect when they did not provide dignity bags for two residents (Residents #33 and #66) with indwelling catheters (tubing placed internally to drain the bladder) and when staff failed to assist four residents (Residents #27, #35, #64, and #96) to dress in a dignified manner for dinner. A sample of 23 residents was selected for review; the facility census was 106. 1. Record review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/4/19, showed the following information: -re-admitted to the facility from a hospital on 4/29/15; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for four residents (Resident #17, #30, #76, and #83), and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for four residents (Resident #17, #30, #76, and #83). A sample of 23 residents was selected for review out of a facility with a census of 106. 1. Record review of Resident #76's Skilled Nursing Facility (SNF) progress notes did not showed staff did not make an entry for a transfer to the hospital on [DATE] or any progress note leading up to the transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and/or meal assistance for three residents (Residents #33, #35, and #64) who were identified as needing assistance with meals. A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/4/19, showed the following information: -re-admitted to the facility from a hospital on 4/29/15; -Diagnoses included Type II diabetes mellitus, dementia, and Parkinson's disease (slowly progressive , degenerative, neurological disorder characterized by resting tremor, muscle rigidity and weakness), anxiety and depression; -Moderately impaired cognition; -Required extensive assistance for eating; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff and residents stored smoking supplies in a safe manner for four residents (Resident #17, #19, #69 and #83) selected for review out of a sample of 23 residents in a facility with a census of 106. Record review of the facility's smoking policy, dated 2/1/16, showed the following information: -Prior to, or upon admission, and as needed, residents and resident representatives shall be informed about any limitations on smoking, including designated smoking areas, and the extent the facility can accommodate their smoking or nonsmoking preferences; -All residents/resident representatives shall receive a copy of the smoking policy; -The facility will establish designated times to provide smoking times to residents requiring assistance and/or supervision; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff to meet the needs of the residents when call lights were not answered in a timely manner for residents. The facility census was 106. 1. Record review of the facility's resident council minutes, dated 9/12/19, showed the following information: -The residents said there is an issue with the facility not having enough staff; -The residents' call lights are not being answered in a timely manner. 2. During an interview on 11/18/19, at 12:30 P.M., Resident #120 said the facility needs more aides. It takes 30 to 40 minutes for staff to answer call lights. He/she has had to wait to use the bathroom, but has not had any accidents from it. 3. During an interview on 11/18/19, at 12:30 P.M., Resident #125 said staff are slow to answer call lights. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct glucose meter control testing per nursing standards of practice which could affect insulin administration in a facility with a census of 106. Record review of the facility's policy, dated December 2015, titled Glucose Meter Control Testing, showed the following information: -Check dates on control bottle label and test strip via label (date when opened, good for 90 days); -Do not use control if three months past opened date or after expiration printed date on control bottle label; -Do not use test strips if 120 days past written opened date or after expiration date printed on test strip vial label; -Swirl or invert control bottle gently to mix control, do not shake; -Open test strip vial by pushing under lip of the vial cap, remove one test strip. Close vial immediately; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure foods were held at an appropriate temperature to inhibit the growth of pathogens that can cause foodborne illness. The facility census was 106. Record review of the facility policy titled, Meal Service-Temperatures, dated 4/1/16 and revised 2/23/17, showed the following: -Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis; -Temperatures shall be taken once food it placed on the steam table prior to the start of meal service; -Temperatures shall be taken at the end of the meal service to ensure temperature maintenance throughout service; -Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable holding and/or service temperatures; [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to document complete information in the resident's medical record regarding a significant change in condition and transfer to the hospital for one resident (Resident #76); information pertaining to the rationale and placement of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #33); and information regarding an episode of emergency dialysis (process of removing the excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) for one resident (Resident #67). A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of the mayoclinic.org website, showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) within the required two hours timeframe when staff received an allegation of one resident (Resident #33) hitting another resident. The facility census was 106. Record review of a facility policy titled, Abuse Prevention, showed the following information: -Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of a resident property are reported immediately, but not later than two hours after the allegations made, if the events that cause the allegation involve abuse or result in serious bodily injury; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive discharge summary for one resident (Resident #105) who discharged to the community. Three residents were reviewed for discharge. The facility census was 106. Record review of a facility's policy entitled Discharge Planning Process (April 2017), showed the following information: -Purpose: Development and implementation of a discharge plan for residents interested in being discharged to facilitate safe transitions from the nursing center back to the community; -Evaluate the resident's discharge potential and needs; -Develop a discharge plan as part of the comprehensive care plan which includes: [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess, monitor, treat, and document a change of condition for one resident (Resident #76) out of a sample selection of 23 residents in a facility with a census of 106. Record review of the mayoclinic.org website, showed the following information: -Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones; -The condition develops when the body cannot produce enough insulin. Insulin normally plays a key role in helping glucose, a major source of energy for muscles and other tissues; -Without enough insulin, the body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to DKA if untreated; -DKA signs and symptoms often develop quickly, sometimes within 24 hours; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure staff provided wound treatment for pressure ulcers consistent with professional standards of practice, to promote healing and prevent infection, and failed to consistently monitor the status of pressure ulcers for two residents (Residents #9 and #74). A sample of 23 residents was selected for review in a facility of 106. Record review of the facility's policy entitled Wound Care/Treatment Guidelines (revised 2009), showed the following information: -At weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description; -Documentation of the treatment should be done immediately after the treatment; -The care plan should reflect the current status of the wound and appropriate goals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders and care plan the use and care of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #33). A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/4/19, showed the following information: -re-admitted to the facility from a hospital on 4/29/15; -Diagnoses included history of urinary tract infections (UTIs); -Moderately impaired cognition; -Total dependence on staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Required extensive assistance for eating; -Occasionally incontinent of bowel and bladder; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure one resident (Resident #67) had a physician's order indicating where and when the resident was to go to dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) treatment. A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of Resident #67's face sheet (gives basic profile information) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included end stage renal disease (Stage 5). Record review of the resident's Care Plan, initiated on 9/30/19 and current as of 11/26/19, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a side rail gap assessment, to obtain a risk/benefit review, document alternatives attempted prior to use, document ongoing assessments, and/or failed to obtain informed consent for the use of side rails prior to use for two residents (Resident #69 and #17) out of a sample of 23 residents in a facility with a census of 106. 1. Record review of Resident #69's care plan, revised date 1/22/19, showed the following information: -Potential for impairment to skin integrity related to wheelchair use, incontinence of urine and bowel, and assistance with transfers and toileting; -The care plan did not address the use of a side rail. Record review of the resident's safety device audit assessment tool, dated 2/4/19, showed the following information: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff administered medications with an error rate of less than 5%. Facility staff made two errors out of 27 opportunities for error, affecting two residents (Resident #65 and #76), resulting in an error rate of 7.4%. The facility census was 106. Record review of the facility's policy entitled Medication Administration: Subcutaneous Insulin (2007) showed to administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. 1. Record review of Mosby's 2017 Nursing Drug Reference (30th ed.), showed Humalog (insulin lispro) is a rapid acting insulin and should be administered within 15 minutes before beginning a meal. The onset is 15-30 minutes with its peak at ½ to 1 ½ hours. Record review of Resident #65's current physician order sheet (POS) showed the following information: [...]

Inspectors wroteBased on record review, and interview, staff did not document the results of the first step of a tuberculosis (TB) test in millimeters (mm) of induration on admission and did not complete the second step or a screening in lieu of the second step during a shortage of test solution for one resident (Resident #37). A sample of 23 resident was selected for review in a facility with a census of 106. Record review of the facility's policy entitled Infection Prevention Manual for Long Term Care, Section 9: Tuberculosis showed the following information: -All first time residents will be screened for infection with tubercle bacilli (TB) on admission, see the form Immunization and TB skin Testing Record; -Review of the form showed a space labeled results in mm/date; -Skin testing will employ the two-step procedure; [...]