St. Peters Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #1), in a review of eight sampled residents. Staff failed to apply dressings and wraps to the resident's wound on both lower legs and a dressing to the left palm as ordered by the physician. The facility census was 117. Review of the facility policy, Medication and Treatment Orders, revised 07/2016, showed the following:-Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state;-Drugs and biological orders must be recorded on the physician's order sheet in the resident's chart. 1. Review of Resident #1's Physician Order Sheet (POS), dated 06/2026, showed the following:-Apply Ace wrap to right leg only in the morning and remove at night for edema (original order dated 05/10/26); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two residents (Residents #1 and #3), who required staff assistance for activities of daily living (ADLs), in a review of eight sampled residents, the necessary care to maintain good personal hygiene. The facility census was 117. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of eight sampled residents, received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range in motion in the resident's left hand. The resident had a contracture (fixed tightening of muscle, tendons, ligaments, or skin preventing normal movement) to his/her left hand which prevented him/her from opening his/her hand. The resident did not receive restorative nursing services for range of motion to the left hand. The facility census was 117. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions as recommended by the registered dietician and ordered by the physician to prevent weight loss and failed to provide meal encouragement for two residents (Resident #1 and #2), who had a significant weight loss. The facility census was 120. Review of the facility policy for Weight Assessment and Intervention, revised March 2022, showed the following:-The threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month - 5% weight loss is significant and greater than 5% is severe; three months - 7.5% weight loss is significant and greater than 7.5% is severe; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to receive written notice of a room change and ensure residents had the right to share a room with his/her roommate of choice for four residents (Resident #2, Resident #3, Resident #5 and Resident #8) in a sample of 10 residents. The facility initiated room changes for all four residents without providing the resident, family and/or resident representative an explanation in writing of why the move was required. The facility failed to ensure the residents were provided the opportunity to see the new location, meet the new roommate and ask questions about the move. The facility census was 126. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident #1, #4 and #7) of 10 sampled residents received appropriate notice of discharge. The facility census was 126. Review of the undated facility policy for Transfer or Discharge showed the following:-Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record;-When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: the basis of the transfer or discharge; the appropriate notice was provided to the resident and /or legal representative; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff transferred one dependent resident (Resident #10) of ten sampled residents, with a mechanical lift in a safe manner. Instead of lowering the resident slowly to the bed, staff chose to use the lift's emergency release button and dropped the resident quickly to the bed, startling the resident. The facility census was 126. Review of the undated facility policy for Using a Mechanical Lifting Machine showed the following:-The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated two sampled residents (Resident #1 and Resident #2) who had a diagnosis of Alzheimer's and dementia in a sample of 11 residents with dignity and respect. The facility census was 115. On 11/25/25 at 5:00 P.M. the Administrator was notified of the past non-compliance which occurred on 11/11/25 and 11/19/25. On 11/20/25 Family Member A provided the facility with a copy of the video from the ring camera in Resident #1's room, which showed Certified Nurse Aide (CNA A) providing care to the resident in a manner which violated the resident's rights to be treated with dignity and respect. CNA A was an agency aide, and the facility notified the agency on 11/20/25 the aide was not allowed to return to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of two residents (Resident #1 and Resident #2), in a review of 11 sampled residents, who were dependent on staff for transfers and at risk for falls, when staff did not follow the facility policy and use two staff members when transferring the resident with a mechanical lift. The facility census was 115. Review of the facility policy for Mechanical Lift with a revision date of 7/2017 showed the following:-The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device;-At least two nursing assistants are needed to safely move a resident with a mechanical lift. 1. Review of Resident 1's face sheet showed the resident was admitted to the facility on [DATE] had diagnosis of dementia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow current infection control standards for two residents (Resident #1 and Resident #2), in a review of eleven sampled residents when staff failed to perform proper hand hygiene and change gloves to prevent infection during personal care for Resident #1 and Resident #2. The facility census was 115. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to honor resident rights for one sampled resident (Resident #4), in a review of four sampled residents and for three additional residents (Residents #5, #6 and #7), by failing to allow them to choose their own wake up/get-up times. The facility census was 117. Review of the facility policy, Resident Rights, dated 2001, showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to a dignified existence, to be treated with respect, kindness and dignity, self determination, exercise his/her rights as a resident of the facility and be supported by the facility in exercising his/her rights. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure direct care staff utilized Enhanced Barrier Precaution (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multi-drug-resistant organisms (MDROs) when providing care and failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for one sampled resident (Resident #2), who had a gastrostomy tube (G-tube) feeding tube placed surgically into the stomach through the abdominal wall) and for one additional resident (Resident #8), who had a urinary catheter (flexible tube inserted into the bladder to drain urine from the body) in a review of four sampled residents and three additional residents. The facility census was 38. [...]

Inspectors wroteRefer to event id MPKL12 Based on interview and record review, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances for four sampled residents (Resident #1, #6, #8 and #9) when the family members of the residents requested a meeting with the administrator and department managers and filed grievances and the facility did not follow up or provide a plan for resolution to those grievances. The facility census was 116. Review of the facility policy for Filing Grievances/Complaints dated 4/2017 showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman); [...]

Inspectors wroteRefer to event id MPKL12 Based on interview and record review, the facility failed to provide four residents (Resident #1, #4, #5 and #8) sampled residents, the necessary care and services to maintain his/her highest practicable well-being when staff failed to provide incontinent care for Resident #1 and Resident #8 in a timely manner. Resident #8 had been up in a wheelchair from 7:30 A.M. until 4:45 P.M. without being taken to the bathroom. Resident #1 had been observed incontinent at 11:30 P.M. and was not provided care until 4:00 P.M. Resident #4 and Resident #5 were observed in their beds at 11:30 A.M. and had not been given a noon meal tray or offered any food or fluids until staff got the residents to the dining room for the supper meal at 5:00 P.M. The facility census was 116. Review of the facility policy for Assistance with Meals dated 3/2022 showed the following: [...]

Inspectors wroteRefer to event id MPKL12 Based on observation, interview, and record review, the facility failed to follow the Registered Dietician's recommendation and physician orders for prescribed interventions to address weight loss for five residents (Resident #1, #2, #3, #4, and #6) of 11 sampled residents. The facility also failed to educate staff on the interventions that were put in place and how to identify fortified foods to ensure residents received food ordered by the physician to prevent further weight loss. The facility census was 116. Review of the facility policy for Weight Assessment and Intervention dated 3/2022 showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Residents are weighed upon admission and at intervals established by the interdisciplinary team; [...]

Inspectors wroteRefer to event id MPKL12 Based on observation, interview and record review, the facility failed to ensure resident safety by failure to transfer one resident (Resident #8) as directed in his/her plan of care and failed to follow the facility policy for using a mechanical lift for the transfer. The facility failed to ensure one resident's (Resident #9's) safety when staff left the resident alone on the toilet and fell of 11 sampled residents. The facility census was 116. Review of the undated facility policy for Managing Falls and Fall Risk showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Review of the facility policy for Safe Lifting and Movement of Residents dated 7/2017 showed: the following: [...]

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility failed to ensure the dish machine operated at the correct temperature and equipment and surfaces were kept clean for one of one kitchen. This had the potential to affect 113 of 113 residents who received meals prepared in the facility.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide a dignified dining experience for three of 20 residents (Resident (R) 68, R98, and R88) who resided on the memory care unit by standing to assist to feed R68 and R98; by failing to obtain an alternate meal in a timely manner for R88 when she refused what was served; and by failing to provide continuous dining service for one resident (R102) on the long term care unit of 30 sample residents. This failure had the potential to affect resident dignified dining experiences.

Inspectors wroteBased on interview and record review, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances for four sampled residents (Resident #1, #6, #8 and #9) when the family members of the residents requested a meeting with the administrator and department managers and filed grievances and the facility did not follow up or provide a plan for resolution to those grievances. The facility census was 116. Review of the facility policy for Filing Grievances/Complaints dated 4/2017 showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide four residents (Resident #1, #4, #5 and #8) sampled residents, the necessary care and services to maintain his/her highest practicable well-being when staff failed to provide incontinent care for Resident #1 and Resident #8 in a timely manner. Resident #8 had been up in a wheelchair from 7:30 A.M. until 4:45 P.M. without being taken to the bathroom. Resident #1 had been observed incontinent at 11:30 P.M. and was not provided care until 4:00 P.M. Resident #4 and Resident #5 were observed in their beds at 11:30 A.M. and had not been given a noon meal tray or offered any food or fluids until staff got the residents to the dining room for the supper meal at 5:00 P.M. The facility census was 116. Review of the facility policy for Assistance with Meals dated 3/2022 showed the following: [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to implement weight loss interventions and/or provide meal encouragement for one of eight residents (Resident (R) 95) reviewed for nutrition of 30 sample residents. This had the potential to cause further weight loss.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the facility's dumpster area was kept cleaned and the container lids were kept closed when not in use for 115 census residents. This had the potential to attract rodents and other pests that could enter the facility.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge return anticipated (DCRA) Minimum Data Set (MDS) assessment was submitted timely for processing for one of one resident (Resident (R) 6) reviewed out of 30 sample residents. This failure had the potential to adversely affect care planning and care provision or payment to other facilities for any resident that may not have had a discharge assessment transmitted.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for two of six residents (Resident (R) 61 and R94) reviewed for psychoactive medication use of 30 sample residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of psychoactive medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety by failure to transfer one resident (Resident #8) as directed in his/her plan of care and failed to follow the facility policy for using a mechanical lift for the transfer. The facility failed to ensure one resident's (Resident #9's) safety when staff left the resident alone on the toilet and fell of 11 sampled residents. The facility census was 116. Review of the undated facility policy for Managing Falls and Fall Risk showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Review of the facility policy for Safe Lifting and Movement of Residents dated 7/2017 showed: the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide toileting assistance when requested, which created the potential for discomfort and distress to one of 20 residents (Resident (R) 47) and failed to ensure an order was in place for catheters for one of four residents (R70) reviewed for catheters of 30 sample residents. This failure had the potential to cause discomfort and reoccurring urinary tract infections or other complications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure there were documented indications for use of and that psychotropic medication efficacy was monitored for two of six residents (Resident (R) 61 and R94) reviewed for unnecessary medications or antipsychotic medication use of 30 sample residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure food preferences were obtained and honored for one of one resident (Resident (R) 54) reviewed for food preferences of 30 sample residents. This failure had the potential to cause R54 not to maintain proper nutrition.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure three of three residents (Resident (R) 6, R16, and R54) reviewed for discharge to the hospital were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer, out of 30 sample residents. This failure has the potential to affect the residents by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure one of three residents (Resident (R) 6) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information of 30 sample residents. This failure had the potential to contribute to possible denial of re-admission and loss of the residents' home following a hospitalization for residents transferred to the hospital.

Inspectors wroteRefer to event id 50SJ13 Based on observation, interview, and record review, the facility failed to serve food to the residents at an appetizing temperature. Residents who ate meals in their rooms said the food was cold when served most of the time. The facility census was 115.

Inspectors wroteRefer to event id 50SJ13 Based on interview and record review, the facility failed to inform five residents (Residents #5, #13, #14, #15, and #16) or their representatives, in a review of 16 sampled residents, of respiratory therapy services they may be charged for which were not covered under Medicare/Medicaid or by the facility's per diem rate, prior to receiving those services, when the facility charged the residents for respiratory therapy services. The facility census was 115.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident (Resident #3) received an antibiotic and a probiotic to treat a urinary tract infection (UTI) as ordered by the physician. The assistant director of nursing (ADON) received a verbal order from the resident's physician on 8/2/24 for Florastor (probiotic) that was never entered on the resident's medication administration record to administer and on 8/7/24 she received another verbal order to discontinue Macrobid (antibiotic) and start Cipro (antibiotic). She discontinued one antibiotic but did not enter the order in the resident's electronic medication administration record for the new antibiotic. This resulted in the resident being hospitalized for his/her continued untreated symptoms from the UTI. The facility census was 117. [...]

Inspectors wroteBased on observation and interview, the facility failed to comply with state laws and designate a person as an administrator currently licensed in the state as a nursing home administrator. This had the potential to affect all facility residents. The facility census was 117. Review of the facility policy, Administrator, dated 3/2021, showed the following: -A licensed administrator is responsible for the day to day functions of the facility; -The governing board of this facility has appointed an administrator who is duly licensed in accordance with current federal and state requirements; -Should an administrator license expire, the facility has 10 days to have a fully licensed administrator step into the position; -In the absence of the administrator, the assistant administrator or director of nursing services was authorized to act in the administrator's behalf. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals, who was qualified by completing specialized training in infection prevention and control, as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The facility census was 117. Review of the facility policy, Infection Prevention and Control Program, dated 12/2023, showed the following: -An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu, reviewed by the Registered Dietician, was followed and items listed on the menu served to the residents. The facility also failed to serve the correct serving sizes per the menu. The facility's census was 117. Review of the facility policy Food and Nutrition Services, dated 10/2017, showed the following: -Each resident is provided a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue an appropriate discharge notice to one resident (Resident #4) of nine sampled residents. The facility failed to document an appropriate location to which the resident would be discharged , failed to ensure the physician documented in the resident's medical record the specific needs the facility could not meet, and failed to provide the explanation of the right to appeal to the state (the name, address and phone number of the state entity which receives appeal hearing requests). The facility census was 117. Review of the facility policy Discharge Summary and Plan, dated 12/2022, showed the following: -Every resident is evaluated for his/her discharge needs and has an individualized post discharge plan; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the water faucet in the food preparation area in the kitchen. The faucet would not turn off and water ran continuously at approximately half flow. The facility census was 117. Review of the facility policy Maintenance Service, dated 12/2009, showed the following: -The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel included but were not limited to maintaining the plumbing fixtures. Review of the facility Maintenance Request Log, dated 7/1/24, showed the following: -The Dietary Manager put in a work request for a sink in the prep area that was leaking; -The Maintenance Director marked the status of the leaking sink as done. [...]

Inspectors wroteRefer to 50SJ12. Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. by fax and directly to the facility's electronic medical record system and the facility failed to administer pain medication or alternate interventions for the resident's pain. [...]

Inspectors wroteRefer to 50SJ12. Based on observation, interview, and record review, the facility failed to identify weight loss, notify the physician and dietician of further weight loss, implement interventions, or evaluate effectiveness of the interventions for three residents (Resident #2, #3, and #4) out of four sampled residents who had significant weight loss. Resident #2 had a 5.9% weight loss in five months; Resident #3 had a 9.3 % weight loss in 3 months and Resident #4 had a 17% weight loss in seven months. The facility failed to notify the physician or the registered dietician of the weight loss. The facility failed to implement and communicate the interventions that the Registered Dietician had put in place for Resident #4 to help prevent further weight loss. The facility census was 117.

Inspectors wroteRefer to 50SJ12. Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions. The staff failed to ensure the kitchen floors were free from food, debris and rodent feces, failed to ensure surfaces of equipment in the kitchen were free from rodent feces, failed to label and date food when opened, failed to appropriately store food, and failed to discard food items that were compromised including ice cream and apples. The facility census was 117.

Inspectors wroteRefer to 50SJ12. Based on observation and interview, the facility failed to maintain an effective pest control program to control the presence of rodents in the kitchen. The facility census was 117.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate services to attain the highest practical well-being for one resident (Resident #2), with a diagnosis of dementia, in a review of four sampled residents. Facility staff identified the resident had behaviors affecting the resident and other residents, however, did not evaluate and implement further approaches to address the resident's care needs related to his/her diagnosis of dementia. Resident #2 had an increase in behaviors which resulted in the administration of anti-anxiety IM (intramuscular) medication and psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) without trying alternative interventions first. [...]

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food under sanitary conditions. The staff failed to ensure the kitchen floors were free from food, debris and rodent feces, failed to ensure surfaces of equipment in the kitchen were free from rodent feces, failed to label and date food when opened, failed to appropriately store food, and failed to discard food items that were compromised including ice cream and apples. The facility census was 117. Review of the facility policy for Sanitization dated 11/2022 showed: -The food service area is maintained in a clean and sanitary manner; -All kitchen, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. There was no policy provided regarding dating and labeling of foods or food storage. Review of the undated facility policy for Pest Control showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform five residents (Residents #5, #13, #14, #15, and #16) or their representatives, in a review of 16 sampled residents, of respiratory therapy services they may be charged for which were not covered under Medicare/Medicaid or by the facility's per diem rate, prior to receiving those services, when the facility charged the residents for respiratory therapy services. The facility census was 115. The facility did not provide a policy for the respiratory therapy department or to outline the responsibilities of the respiratory therapist. 1. Review Resident #5's face sheet showed the resident's payer source was private pay and Medicare Part B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided five residents (Residents #1, #2, #3, #4, and #7), who were unable to perform their own activities of daily living, in a review of 13 sampled residents, the necessary care and services to maintain good oral hygiene. The facility census was 113. Review of the facility policy for Activities of Daily Living (ADL) dated revised on 3/2018 showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); -Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 8/21/24. Based on observation, interview, and record review, the facility failed to ensure the planned menu, reviewed by the Dietary Consultant, was followed and items listed on the menu were served to the residents. The facility also failed to serve the correct serving sizes per the facility diet spreadsheet. The facility's census was 115. Review of the facility untitled policy, dated 2023, showed the following: -Food will be served according to the posted menu. If the menu changes residents will be notified as reasonably able; -Each wait staff should serve one table completely before starting to serve the next table. 1. Review of the menu dated 9/23/24 showed the noon meal included: -Tossed salad with dressing; -Baked glazed ham; -One half of a baked sweet potato; -Green bean casserole; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food to the residents at an appetizing temperature. Residents who ate meals in their rooms said the food was cold when served most of the time. The facility census was 115. The facility did not provide a policy for food temperatures upon request. Review of the dietary cook job description, dated 10/2016, showed the following: -The cook was responsible to record food temperatures for each meal; -The cook was to manage and operate the kitchen in the absence of the dietary supervisor. Review of the facility policy Tray Line Food Temperatures, showed the following: -Hot foods should be 135 degrees Fahrenheit or greater; -Cold Foods should be 41 degrees Fahrenheit or less: -Each day had three columns to take food temperatures (before, during, and after each meal served). 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a policy for Enhanced Barrier Precautions (EBP-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi drug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) and failed to ensure staff's adherence to use of personal protective equipment (PPE) for four of thirteen residents (Resident #8, #9, #10, and #11) who met criteria to be on enhanced precaution isolations. The census was 113. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program to control the presence of rodents in the kitchen. The facility census was 117. Review of the facility's undated policy for Pest Control showed the following: -Our facility shall maintain an effective pest control program; -This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; -Garbage and trash are not permitted to accumulate and are removed from the facility daily. 1. Observation on 7/23/24 at 2:14 P.M., in the main kitchen showed the following: -A stainless steel preparation table in the kitchen in front of the steam table with numerous black pellets that resembled rodent feces on the bottom rack of the table. Staff used the table to store and prepare food; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for three resident (Resident #2, Resident #4 and Resident #10) of 13 sampled residents when staff failed to ensure medications were not left in resident rooms, and residents had an order to keep medications at bedside. The facility census was 113. The facility did not provide a policy for medications at the resident's bedside. 1. Review of resident #2 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/22/24 showed: -Able to make self understood and able to understand others, difficulty with some decision making; -Requires staff assistance with Activities of Daily Living (ADL's); -Diagnoses of heart disease, hypertension, diabetes, stroke, dementia and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate services to attain the highest practical well-being for one resident (Resident #2), with a diagnosis of dementia, in a review of four sampled residents. Facility staff identified the resident had behaviors affecting the resident and other residents, however, did not evaluate and implement further approaches to address the resident's care needs related to his/her diagnosis of dementia. Resident #2 had an increase in behaviors which resulted in the administration of anti-anxiety IM (intramuscular) medication and psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) without trying alternative interventions first. [...]

Inspectors wroteBased on observation and interview, the facility failed to comply with state laws and designate a person as an administrator currently licensed in the state as a nursing home administrator. This had the potential to affect all facility residents. The facility census was 118. The facility did not provide a policy for the requirements of the facility administrator. Observation on 3/28/24 at 8:55 A.M. of the facility lobby and hallway leading to the administrator's office showed the following: -The facility license to operate as a long term care facility and different associations memberships; -No current administrator's license. During an interview on 3/28/24 at 8:55 A.M. the acting administrator said the following: -He had been at the facility for about a week acting as the administrator; -He did not hold a license to be an administrator in the state of Missouri; [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 115 residents who resided in the facility and were able to consume meals. Concerns included: proper dating and labeling of all food items, providing proper training to all staff handling food, and proper serving temperatures were maintained when food was served to residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to obtain a physician's order to include the type and size of the indwelling catheter, and criteria for changing the indwelling catheter for one of two residents (Resident (R) 104) reviewed for urinary catheters in a total sample of 33 residents. This failure has the risk for complications, such as urinary trauma or infection, for any resident with an indwelling urinary catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent accidents for one resident (Resident #12) in a review of 26 sampled residents and for one discharged resident (Resident #405). The facility census was 117. 1. Review of the facility policy Fall Program undated, showed : Identification of a fall risk is the first step in prevention of a fall. Upon getting a referral to our center, the admission coordinator will be gathering any prior fall information available. This information will be considered during the bed management/placement process. The admissions coordinator will alert the receiving nurse if there is a known fall risk. The admissions coordinator will identify the chart with a yellow sticker. The name label on the door will be printed with yellow label tape. [...]

Inspectors wroteBased on interview and record review, the facility failed to credit all interest earned on residents' funds to the 49 residents the facility held resident funds for. Further review showed the facility failed to prevent one resident (Resident #101) from overspending his/her account and using other resident monies. The facility census was 117. Review of the facility Bookkeeping Manual, section: for resident trust, subject: interest allocation, dated 08/07, showed interest earned must be credited to each resident's account. Review of the facility Bookkeeping Manual, section: for resident trust, subject: resident trust fund balances, dated 08/07 and revised 10/10, showed the following: -It was recommended a report be printed each day to be able to determine the level of funds a resident had available; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain closets in good repair, maintain the memory care free of a mold-like substance, and maintain a toilet in good repair. The census was 117. 1. Observation on 8/14/19 at 1:07 P.M., showed the toilet seat in the bathroom in resident room [ROOM NUMBER] was held on by only one bolt and was very loose. During interview on 8/14/19 at 1:07 P.M., Resident #409 said he/she has told the facility about the loose toilet seat. It has been that way for two to three weeks. The toilet seat pinched him/her every time he/she sat on it. Observations on 8/14/19 between 9:25 A.M. and 3:32 P.M., showed the following: -In resident room [ROOM NUMBER], four patches of unmatched paint on the wall. The areas were approximately 1 foot by 3 inches, 1 foot by 8 inches, 1 foot by 6 inches, and 1 foot by 1.5 feet; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for four of 26 sampled residents (Resident #4, #30, #25, and #107) and for three additional residents (Resident #7, #9, and #6) . The facility census was 117. During an interview on 8/16/19 at 5:46 P.M., the MDS coordinator said the facility followed the RAI process for completion of resident's quarterly assessments. Record review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument User's Manual MDS 3.0, dated October 2018, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice and physician orders for one resident (Resident #262) in a review of 26 sampled residents, one additional resident (Resident #14) and one discharged resident (Resident #406). The facility failed to provide and administer one resident's (Resident #262) physician ordered medications on admission to the facility, and failed to ensure one resident (Resident #406), was provided the physician ordered diet. The facility also failed to ensure staff held pressure on the lacrimal duct after administering medicated eye drops and obtain an apical (a pulse taken at the area of the apex of the heart at the point of maximum impulse) pulse prior to administering Digoxin (medication used to treat heart failure and heart rhythm problems) for one resident (Resident #14). The facility census was 117. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure medications that could not be returned to the pharmacy were destroyed in a timely manner per facility policy. The facility census was 117. 1. Review of the facility policy Medication Destruction For Non-Controlled Medications revised [DATE] showed the following: Policy: -Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, or are donated are destroyed; Procedures: A. Unused, unwanted, discontinued, expired and non-returnable medications should be removed from their storage area and secured until destroyed. These medications may be stored in the medication room in a designated area until destroyed. Destruction should be done within 14 days; C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow two of 26 sampled residents (Resident #4 and #12), the right to make choices about aspects of his or her life in the facility that were significant to the resident. The facility census was 117. Review of the facility policy admission Criteria dated 3/19 showed the objectives of the facility admission criteria policy included to review with the resident, and /or his/her representative, the facility's policies and procedures relating to resident rights and resident care. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, dated 6/13/18, showed the following: -The resident's cognition was intact; -It was very important for him/her to choose between a tub bath, shower, bed bath, or sponge bath; [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the state agency within two hours of the incident or when an allegation was made for one resident (Resident #212) who made an allegation of sexual abuse in a review of 26 sampled residents. The facility census was 117. Review of the facility policy Abuse, last revised 12/11/17, showed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Abuse will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center. The center administrator is responsible for assuring patient safety, including freedom from risk of abuse or neglect, holds the highest priority. Sexual Abuse: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete comprehensive assessments timely for one sampled resident (Residents #3) in a review of 26 sampled residents and for one additional resident (Resident #5). The facility census was 117. Review of the facility policy, dated 2001 and last revised 7/17, MDS Completion and Submission Timeframes showed: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing system as soon as possible in accordance with current federal and state regulations. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, maintain, and update a plan of care consistent with residents' specific conditions, needs, and risks based on their comprehensive assessment for two residents (Resident #61 and #3), in a review of 26 sampled residents. The facility census was 117. Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 12/16 showed: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident' s physical, psychosocial and functional needs is developed and implemented for each resident. 1. The Interdisciplinary Team (IDT), in injunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, Completion Date (Z0500B) was no later than 14 days after the Assessment Reference Date (ARD) (A2300) for four additional residents (Resident #11, #51, #10 and #405). The facility census was 117. Review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, showed the following: -Z0500B description: MDS Completion Date: Date of the RN assessment coordinator's signature, indicating that the MDS is complete; -In accordance with the requirements at 42 CFR 483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: [...]