St. Peters Rehab and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure staff utilized a gait belt and locked the wheelchair brakes prior to transferring one resident (Resident #4), in a review of 23 sampled residents. Staff did not put a gait belt on the resident when assisting the resident to from the toilet to the wheelchair. Staff did not lock the wheelchair brakes, the wheelchair moved as the resident went to sit in the wheelchair, and the resident fell to the floor. The resident fractured his/her proximal left humerus (the upper end of the upper arm bone, commonly known as a broken shoulder). The facility census was 83. On 06/11/26, the Administrator was notified of the past non-compliance which occurred on 02/23/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation to show the facility used the services of a registered nurse (RN) in the facility for eight consecutive hours a day, seven days a week. The facility census was 83. During an interview on 06/11/26 at 5:37 P.M., the Administrator said the facility did not have a policy addressing RN coverage. Review of the facility assessment, updated on 07/20/25, showed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. Review of the facility provided timecard punches, payroll reports and schedules for Sunday, 04/05/26, showed no RN coverage. Review of the facility provided timecard punches, payroll reports and schedules for Sunday, 04/26/26, showed no RN coverage. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for each nurse aide at least once every 12 months and provide regular in-service education based on the outcome of the reviews. The facility identified six CNAs were employed by the facility for more than a year. Four of six CNAs reviewed did not have the required performance review or documentation of in-servicing education based upon the outcome of the review. The facility census was 83. During an interview on 06/11/26 at 5:37 P.M., the Administrator said the facility did not have a policy to address nurse aide annual performance reviews. Review of the Facility Assessment Tool, dated 07/20/25, showed the following:-Required in-service training for nurse aides. In-service training must address areas of weakness as determined in nurse aides' performance reviews and facility assessment. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff training needs, as identified in the facility assessment and the annual in-servicing calendar, were not met for five of five staff reviewed. The facility failed to maintain documentation staff completed 12 hours of inservice training annually. The facility census was 83. During an interview on 06/11/26 at 5:37 P.M., the Administrator said the facility did not have a policy addressing 12-hours of annual training. Review of the Facility Assessment Tool, dated 07/20/25, showed the following:-Required in-service training must be sufficient to ensure the continuing competencies and be no less than 12 hours per year. Training topics included: -Communication; -Resident Rights and facility responsibilities; -Abuse, neglect and exploitation; -Infection Control; -Culture change; -Dementia care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect and provided care in an environment that promoted and enhancement of their quality of life. Staff did not assist three residents (Residents # 95, #28, and #34) when they requested staff assistance to use the bathroom. Staff stood while assisting one resident (Resident #89) to eat his/her meal. Residents reported unidentified staff yelled or spoke loudly, disrupting residents activities, refused to tell residents their names when requested, and spoke on their personal phone devices while providing care to residents. A sample of 23 residents was selected for review. The facility census was 83. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff consistently provided assistance with showering/bathing and personal hygiene to five residents (Residents #3, #90, #88, #2, and #37), who required assistance with showers/bathing, in a review of 23 sampled residents. The facility census was 83. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper settings were in place for pressure reducing and relieving low air loss (LAL) mattresses (mattress that provided a constant flow of air in the mattress to help prevent pressure ulcers) to prevent the potential for development and worsening of pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or friction) for three residents (Residents #8, #44 and #70) in a review of three residents reviewed for pressure ulcer care. The facility census was 83. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure compliance with the Federal requirement for nurse aide training when the facility made the nurse aides, employed by the facility, pay for the cost of the testing for the nurse aide training program. The facility census was 83. 1. Review of the Code of Federal Regulation, 42 CFR 483.152 Requirements for approval of a nurse aide training and competency evaluation program, showed the following:(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure recommendations from the pre-admission screening and resident review (PASRR, a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) Level II determination and evaluation report were incorporated into the resident's care plan for two residents (Resident #41 and #2), in a review of four residents. The facility census was 83. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to account for and reconcile Ativan (a schedule IV narcotic controlled substance medication for anxiety) maintained in the facility's emergency medication kit. The facility census was 83. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #54), in a review of seven residents observed during medication administration, was free from a significant medication error when staff failed to follow physician orders and applied a topical patch instead of a topical cream for pain control. The facility census was 83. Upon request, the facility did not provide a policy related to following physician orders. Review of the on-line Certified Medication Technician Student manual- Missouri Center for Career Education, dated 05/14/10, showed the following:-The Five Rights of medication administration are foundational guidelines used by Certified Medication Technicians (CMT) to prevent medication errors and ensure resident safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications for two residents (Resident #54 and #11), in a review of 23 sampled residents, were securely stored behind a locked compartment and not left in the resident's room without a physician's order to self-administer or to keep at bedside. The facility census was 83. Review of the facility policy, Storage of Medication, dated 01/2021, showed the following:-The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications;-The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices, facility policy, and the resident's care plan to prevent the development and spread of infection for one resident (Resident #8), in a review of 23 sampled residents. Staff failed to keep the resident's urinary catheter drainage bag off the floor, failed to wear proper personal protective equipment (PPE) during high-contact resident care activities, and failed to follow hand hygiene procedures when providing personal care to the resident. The facility census was 83. Review of the facility policy, Care of Catheter, revised 10/24/22, showed collection bags (urinary catheter drainage bags) should always avoid contact with the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services necessary to address one resident's (Resident #1's) pressure ulcer treatment of six sampled residents. Resident #1 admitted to the facility on [DATE] with a Stage 4 pressure ulcer of the sacrum (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed. Often includes undermining and tunneling at the base of the spine) and diagnosis of osteomyelitis (a severe infection within the bone). The facility failed to follow physician orders for treatment of the sacral wound and failed to communicate the resident's condition including culture of the wound to consider for treatment. The facility failed to complete a weekly skin assessment per policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1) in a review of 11 sampled residents, remained free from physical abuse when on Certified Nurse Aide (CNA) B aggressively moved the resident in bed, causing the resident to yell out for help, and report CNA B was too rough and hurt him/her. The resident was tearful, upset and said he/she did not want CNA B to come back after the incident. The resident sustained bruising to the right arm as identified on the facility skin assessment dated [DATE]. During an interview on 9/4/25, the resident said he/she was scared of CNA B. The facility census was 78. On 9/10/25 at 2:54 P.M. the administrator was notified of the past noncompliance which occurred on 8/25/25. On 8/25/25 CNA B physically abused Resident #1 while providing his/her care in an aggressive manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to respond and adequately act upon and provide feedback related to resident concerns regarding call light wait times and response from staff from resident council meetings. The facility census was 93. Review of the facility policy for Resident and Family Council with a revision date of 10/24/22 showed the following:-Purpose: to promote the exercise of a resident's right to organize and participate in resident groups at the facility;-Policy: The purpose of the Resident and/or Family council is to provide a forum for discussion of resident's concerns; input in the operation of the facility;-Responsibilities of the Resident and/or Family council: providing feedback in the development of policies and procedures governing the operation of the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their fall management policy and response to falls policy for one resident (Resident #9) of 12 sampled residents, who sustained falls. Resident #9 had two falls with no documentation including assessments or notifications at the time of the falls. The resident fell out of bed on 7/27/25 onto the floor and crawled to the bathroom to turn on the call light to alert staff. Staff did not respond to the call light for 45 to 60 minutes. When staff did respond, staff completed no assessment for injuries or documentation of the fall. The care plan was not updated with meaningful interventions based on the cause of the resident's falls sustained on 7/17/25 and 7/27/25. The facility census was 93. Review of the facility policy for Fall Management Program with a revision date of 10/24/22 showed the following:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed appropriate hand hygiene and changed gloves during the provision of care for one resident (Residents #2), and failed to follow the facility policy for Enhanced Barrier Precautions (EBP) for four residents (Residents #1, #2, #3, and #4), in a review of nine sampled residents. Staff failed to utilize Personal Protective Equipment (PPE) while providing high-contact care activities or wound care. The facility had identified 16 residents with wounds, six residents with indwelling catheters (a sterile tube inserted into the bladder to drain the bladder of urine) and three residents receiving Enteral tube feedings (a tube placed in the stomach to provide nutrition). The facility census was 81. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oversight and prevent injury for one resident (Resident #2), in a review of 18 sampled residents, when staff left the resident unattended in the shower room, resulting in the resident falling and sustaining a fracture. The facility census was 87. On 11/27/24 at 4:15 P.M., the administrator was notified of the past noncompliance which occurred on 10/12/24. On 10/12/24, the administrator became aware of the violation of resident safety when Resident #2 was left alone in the shower room by staff. Resident #2's care plan directed he/she required one staff assist for bathing, hygiene and dressing. Resident #2 attempted to dress him/herself and had a fall that resulted in a right hip fracture. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to call lights in a timely manner for three residents (Resident #12, #3 and #8), in a review of 18 sampled residents. The facility census was 87. Review of the facility's policy, Communication - Call System, revised 10/24/22, showed the following: -The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities; -Nursing staff will answer call lights promptly; -Call lights located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly. 1. Review of Resident #12's admission record showed the resident's diagnoses included dementia, arthritis, muscle weakness, cognitive communication deficit, and other abnormalities of gait and mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to clarify and obtain physician orders for two residents (Resident #1 and #2), in a review of 18 sampled residents, who sustained fractures and had surgery to repair, for assessment and treatment of each residents' surgical incisions when they admitted to the facility from the hospital. The facility failed to complete neurological checks per facility policy following a fall for one resident (Residents #2), in a review of 18 sampled residents. The facility census was 87. Review of the facility's policy, Physician Orders, revised October 24, 2022, showed the following: -Purpose: This will ensure that all physician orders are complete and accurate; [...]

Inspectors wroteSee event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/12/24. Based on observation, interview, and record review, the facility failed to provide adequate staffing and oversight to ensure residents that required staff assistance were showered, clean, hair maintained, shaving completed, nails trimmed and call lights answered for eight residents, in a review of 25 sampled residents. The facility failed to ensure sufficient staff to provide regular baths or showers and meet hygiene needs for two residents (Resident #32 and Resident #310) and did not respond to resident call lights in a timely manner for eight residents (Resident #304, #2, #310, #306, #4, #20, #307 and #313) , resulting in the resident's toileting needs not being met and episodes of incontinence or resident's being left soiled for extended times. [...]

Inspectors wroteSee event ID 6GI312 Based on observation, record review, and interview, the facility failed to provide a safe, clean and comfortable environment by failing to ensure resident rooms and living spaces were clean and in good repair. The facility census was 81.

Inspectors wroteSee event ID 6GI312 Based on observation, interview, and record review, the facility failed to follow physician orders for three residents (Resident #305, #20 and #224) in a review of three sampled resident reviewed. Resident #305 did not receive his/her insulin (injection of hormone that regulates blood sugar) which resulted in the resident's blood sugar exceeding the parameters set by the physician as acceptable. The facility staff failed to identify the missed dose of insulin or document proper notification of the physician, or continued assessment of the resident with a blood sugar of 499. The facility also failed to provide medications as ordered by the physician and did not contact the physician for further direction when orders could not be followed. The facility census was 81.

Inspectors wroteSee event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiency dated 4/12/24. Based on observation, interview and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 81.

Inspectors wroteSee event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/12/24. Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #32 and Resident #310), of 25 sampled residents, who required assistance with activities of daily living (ADL) received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 81.

Inspectors wroteSee event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/12/24. Based on observation, interview, and record review, the facility failed to ensure interventions to address weight loss, including physician ordered supplements were provided and registered dietician (RD) recommendations followed to prevent further weight loss for two residents (Resident #30 and #32), in a review of 25 sampled residents. The facility failed to ensure the residents received the necessary services and assistance to maintain their nutritional status and to prevent weight loss. The facility census was 81.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure two of 28 sampled residents (Resident (R)16 and R20) were free from abuse and neglect. On 4/7/24, Certified Nurse Aide (CNA) 7 refused to assist R16 out of bed, resulting in the resident laying in bed until the next shift arrived. On 4/8/24, R16 used her call light on the night shift to request help for repositioning. R16 continued to use her call light for assistance because no one came. R16 reported two agency staff members came into her room and said she was calling too much. When she informed the staff members that she would continue to call until someone helped her, one of the staff yanked the call light out of her hand, threw it on the floor, and told her that she would be sorry if she continued to call. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure allegations of neglect were reported to supervisors and/or the facility's Abuse Coordinator for two of 28 sampled residents (Resident (R)16 and R20). R16 reported allegations of neglect involving Certified Nurse Aide (CNA) 7 to Licensed Practical Nurse (LPN) 1. LPN1 did not report the allegations to the on-call nursing supervisor, Director of Nursing (DON), or Administrator, who was the facility's Abuse Coordinator. R20 reported allegations of neglect to (Nurse Aide) NA1. NA1 did not report the allegations to her supervisor or the facility's Abuse Coordinator. The facility census was 82. The administrator was notified on 04/09/24 at 7:47 PM of the Immediate Jeopardy, which began on 04/07/24.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide pain management for one of four sampled residents (Resident (R) 20) reviewed for pain out of a total sample of 28 residents. R20 was without pain medication for three days. R20's pain was not assessed, the Director of Nursing (DON) was not notified, and non-pharmacological interventions to help relieve the resident's pain during the three-day period were not attempted. This failure resulted in actual harm for R20. The facility census was 82.

Inspectors wroteBased on interview, policy review, and job description review, the facility failed to ensure there was a qualified Activity Director (AD) to oversee the activity program. This created the potential for the activity program to not be administered effectively and to not meet the needs, interests, and preferences of all 82 residents who resided in the facility. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, facility policy review, and staffing schedule review, the facility failed to ensure there was adequate competent nursing department staffing, in adequate numbers to meet the needs of five of 28 sampled residents (Resident (R) 20, R13, R14, R4, and R16) and six supplemental residents (R5, R70, R6, R118, R224, and R41). Residents did not receive medications; did not have their call lights answered timely and/or they had unmet needs; activities of daily living (ADLs) were not provided for residents requiring assistance; and residents were not provided ice water in their rooms or sufficient beverages. Weekend staffing and agency staff were common problems expressed by the residents. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nourishment refrigerators free from grime and food residue on the inside and that temperatures were checked. These failures had the potential to affect all 82 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Infection Prevention and Control Program (IPCP) was overseen by an Infection Preventionist (IP) who had completed specialized training in infection prevention and control (IPC). This had the potential to affect 82 of 82 residents who resided at the facility. The facility census was 82.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the wireless call light system to ensure staff carried pagers to alert them to residents' calls for staff assistance as required by the exception granted to the facility for seven residents (Resident #301, #306, #4, #20, #307, #14 and #300) of 25 sampled residents. Review of the call light response time log, showed staff did not respond to call lights timely, with residents experiencing extensive wait times of over an hour on each resident hall. This had the potential to affect all residents. The facility census was 81. Review of a letter from the Department of Health and Senior Services to the facility, granting the exception for the use of a wireless nurse call system, dated 9/20/22, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bariatric incontinent briefs in ample supply to meet residents' needs for three of three sampled residents (Resident (R) 4, R14, and R20) reviewed for accommodation of needs. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure grievances raised by the resident council were addressed and attempts were made to resolve the grievances for six of six residents who attended the resident council group interview (Resident (R) 5, R70, R18, R224, R41, and R20). Ongoing concerns included: call lights, staff not introducing themselves, staff not responding to residents' needs, staff talking on their phones, and food palatability issues. The facility census was 82.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents and/or their representative received written information about and assistance with formulating advance directives for three of three residents reviewed for advance directives (Resident (R) 4, R16, and R14) out of 28 sampled residents. The facility census was 82.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe, clean and comfortable environment by failing to ensure resident rooms and living spaces were clean and in good repair. The facility census was 81. Review of the facility policy, Resident Rooms and Environment, dated 10/24/22, showed the following: -The facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff will provide residents with a pleasant environment; -Facility staff aim to create a personalized, homelike atmosphere, paying close attention to cleanliness, odor and pleasant, neutral scents. 1. Observation on 6/17/24 at 10:30 A.M., upon entrance to the facility, showed a strong urine odor in the main dining room where several residents sat at tables, visiting and watching television. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for three residents (Resident #305, #20 and #224) in a review of three sampled resident reviewed. Resident #305 did not receive his/her insulin (injection of hormone that regulates blood sugar) which resulted in the resident's blood sugar exceeding the parameters set by the physician as acceptable. The facility staff failed to identify the missed dose of insulin or document proper notification of the physician, or continued assessment of the resident with a blood sugar of 499. The facility also failed to provide medications as ordered by the physician and did not contact the physician for further direction when orders could not be followed. The facility census was 81. Review of the facility policy, Physician Orders, dated 10/24/22, showed the following: [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure sufficient activities were provided to one of 28 sample residents (Resident (R) 20) and all five of five supplemental residents (R70, R5, R18, R51, R224, and R41). Failures included not offering activities on the weekends or offering outings. Activity participation was not documented; quarterly activity progress was not completed; and a care plan was not developed for R51 as directed by the facility's policy. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to offer/provide adequate fluids such as ice water and other beverages to two of 28 sampled residents (Resident (R)13 and R20) and to four of five supplemental residents ( R70, R18, R41, R224) attending the resident council group interview. An initial nutritional assessment was not completed by the Registered Dietitian for R13; R13 was not offered and was not documented as consuming adequate fluids. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for Resident (R) 14 were made out of 25 opportunities. The medication error rate was 8 percent. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure condiments were offered and served with food for three of 28 sampled residents (Resident (R) 174, R13, and R41). The facility census was 82. Findings Include: Review of the facility's policy titled, Dietary Department- General revised 10/24/22, revealed The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. The primary objectives of the dietary department include Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. 1. During the initial tour on 04/08/24 at 10:45 AM, an interview was conducted with R174. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure three of 28 sampled residents (Resident (R) 30, R28, and R63) received services in a manner that promoted their dignity and enhanced their quality of life. R30 was observed as unshaven with long stubble facial hair and wearing clothing covered with food spills, residue, and crumbs. R28 and R63 required assistance with eating and facility staff were observed standing over them while assisting them. The facility census was 82.

Inspectors wroteBased on interview, record review, and policy review, the facility failed ensure residents retained their right to exercise their rights for one of 28 sampled residents (Resident (R) 73). The facility did not provide R73 the opportunity to make their own decision regarding whom they wanted to contact and if they wanted to use a cell phone sent to them to communicate. The facility opened the resident's mail containing a cell phone, read a note inside the package intended for the resident, and contacted (Family Member (F) 73. FM 73 told the facility to not give the phone to the resident, even though the resident had not been adjudged incompetent by the court and legally retained his rights as a United States citizen. The facility census was 82.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to invite two of 28 sampled residents (Resident (R) 11 and R4) to participate in their care plan meetings. Both residents had been assessed as cognitively intact and expressed they would like to attend their own care plan meetings. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 43) reviewed for room change out of a total sample of 28 residents were provided with written notice of room change, including the reason for the change, prior to the facility-initiated room change occurring. The facility census was 82.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to complete an investigation for one of one resident reviewed for grievances (Resident (R) 33) out of 28 sampled residents. The facility failed to inform R33 of the outcome of an investigation into his/her missing brooch. The facility census was 82.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure residents were provided with a bed hold notice within 24 hours of emergent transfer to the hospital for one of three residents (Resident (R) 30) reviewed for hospitalizations out of a total sample of 28. This failure placed R30 and/or his Responsible Party at risk of not knowing to request a bed hold to be able to return to the facility. The facility census was 82.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for one of seven residents reviewed for ADLs (Resident (R) 176) out of 28 total sampled residents. R176, who was totally dependent on staff for ADLs, and was admitted on [DATE], did not receive a shower until 4/10/24. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #16 was offered a smoking apron to prevent accidents while smoking, per her care plan. Additionally, the facility failed to care plan what staff should do if the resident refused the smoking apron and failed to ensure all staff were aware of the resident's assessed need for the smoking apron for safety. This affected one of two sampled residents reviewed for smoking out of a sample of 28 residents. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and review of facility's policy, the facility failed to ensure residents' indwelling catheters were properly positioned and secured to promote adequate drainage and prevent reoccurring urinary tract infections for one of two residents (Resident (R) 173) reviewed for catheters out of a total sample of 28 residents. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and review of facility's policy, the facility failed to maintain oxygen therapy equipment for one of three residents reviewed for oxygen (Resident (R) 46) out of a total sample of 28 residents. R46's oxygen tubing and humidifier bottle were not changed and not dated. Additionally, the oxygen concentrator filter had a heavy accumulation of gray dust debris. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, policy review and job description review, the facility failed to provide medically-related social services to ensure residents maintained their highest practicable wellbeing for three out of 28 sampled residents (R73, R43, and R11). R43 was not provided with a room change notice prior to a room change, had only one set of clothing to wear for a week following the room change. R73 was not given the opportunity to make his own decisions regarding the possession of his phone; the SSD followed the Power of Attorney's wishes without determining what R73 wanted. R11 was not invited to his care plan meeting; the resident's family was invited and the meeting was scheduled around the family's availability. The Social Service Director was the only social services employee and she was routinely assigned to provide direct care service tasks. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide medications, as ordered by the physician, to meet the residents' needs for two of five sampled residents (Resident (R) 20 and R4) whose medications were reviewed. The facility census was 82.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure one of five medication carts and one of two treatment carts were locked and secured on two of five resident halls. Additionally, the facility failed to ensure medication refrigerator temperature logs were maintained in one of two medication rooms. The facility census was 82.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 23 sampled residents (Resident #1) with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (disorder in which a person experiences a combination of symptoms such as hallucinations or delusions and mood disorder symptoms such as depression or mania); paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and often the person feels distrustful and suspicious of others), received appropriate treatment and services when staff failed to develop interventions to address the resident's behaviors. Staff were aware of Resident #1's history of behaviors and were aware the resident was known to steal, make accusations, intimidate, and curse at other residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of practice for 14 of 23 sampled residents (Resident #5, #6, #7, #8, #9, #11, #13, #14, #15, #16, #18, 19 #20, and #21) when staff failed to administer all medications as ordered and in a timely manner. Facility staff failed to document when a narcotic was administered on the medication administration record (MAR) for one resident (Resident #10) who had a G-tube (a tube inserted through the belly that brings nutrients directly to the stomach), and failed to routinely document narcotic administration, assess and document the pain level for an as needed (PRN) narcotic for one resident (Resident #12) after facility staff signed out narcotics on the individual narcotic record. [...]

Inspectors wroteDocument under event id WVYK12 Based on observation, interview, and record review, the facility failed to ensure resident and staff testing for COVID-19 (coronavirus disease, caused by the SARS-CoV-2 virus) was completed according to facility policy for COVID-19 during an outbreak. The facility failed to ensure staff changed gloves and washed hands as indicated during the provision of care for three residents (Residents #2, #9 and #13) in a review of 16 sampled residents. The facility failed to ensure use of proper personal protective equipment (PPE) when staff entered COVID-19 positive rooms and failed to discard of trash from isolation rooms appropriately. The facility census was 86. 1. Review of the facility policy, Coronavirus Disease (COVID-19) - Testing Residents, dated May 2023, showed the following: [...]

Inspectors wroteDocument under event id WVYK12 Based on observation, interview and record review, the facility failed to provide reasonable accommodations of needs for four residents (Resident #4, #12, #14 and #15) in a review of 16 sampled residents, when staff failed to identify the needs of two visually impaired residents (Resident #4 and #12), and did not provide water routinely for Resident #14 and #15. The facility census was 86. Review of the facility policy, Accommodation of Needs, revised January 2020, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being; -The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; [...]

Inspectors wroteDocument under event id WVYK12 Based on observation, interview and record review the facility failed to update a plan of care consistent with resident specific conditions, needs and risks for three residents (Resident #2, #4 and #13) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Using the Care Plan, revised August 2006, showed the following: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station; -The Nurse Supervisor uses the care plan to complete the certified nurse assistant (CNA's) daily/weekly work assignment sheets and/or flow sheets; [...]

Inspectors wroteDocument under event id WVYK12 Based on observation, interview and record review, the facility failed to ensure staff provided five residents (Resident #6, #3 #12, #10 and #4) of 16 sampled residents, that were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 86. Review of the facility policy Activities of Daily Living (ADLs), Supporting, dated March 2018, showed the following; -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; [...]

Inspectors wroteDocument under event id WVYK12 Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of four residents, in a review of 16 sampled residents, when they failed to provide regular baths or showers and did not respond to resident call lights in a timely manner for four residents (Resident #4, #9, #3 and #10) resulting in the resident's toileting needs not being met and episodes of incontinence. The facility census was 86. Review of the facility policy, Answering the Call Light, dated March 2021, showed the following: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs; -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident; -Some residents may not be able to use their call light. [...]

Inspectors wroteDocument under event ID WVYK12 Based on observation and interview, the facility failed to ensure food was served at a safe appetizing temperature. This affected five residents (Residents #4, #7, #9, #10 and #16) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Assistance with Meals, dated March 2022, showed the following: -For residents confined to bed, the food services department will deliver food carts to appropriate areas, nursing staff will prepare residents for eating and the nursing staff and/or feeding assistants will take food trays into residents' rooms; -Hot foods shall be held at a temperature of 135 degrees F or above until served. Cold foods shall be held at 41 degrees F or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident and staff testing for COVID-19 (coronavirus disease, caused by the SARS-CoV-2 virus) was completed according to facility policy for COVID-19 during an outbreak. The facility failed to ensure staff changed gloves and washed hands as indicated during the provision of care for three residents (Residents #2, #9 and #13) in a review of 16 sampled residents. The facility failed to ensure use of proper personal protective equipment (PPE) when staff entered COVID-19 positive rooms and failed to discard of trash from isolation rooms appropriately. The facility census was 86. 1. Review of the facility policy, Coronavirus Disease (COVID-19) - Testing Residents, dated May 2023, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of needs for four residents (Resident #4, #12, #14 and #15) in a review of 16 sampled residents, when staff failed to identify the needs of two visually impaired residents (Resident #4 and #12), and did not provide water routinely for Resident #14 and #15. The facility census was 86. Review of the facility policy, Accommodation of Needs, revised January 2020, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being; -The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to update a plan of care consistent with resident specific conditions, needs and risks for three residents (Resident #2, #4 and #13) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Using the Care Plan, revised August 2006, showed the following: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station; -The Nurse Supervisor uses the care plan to complete the certified nurse assistant (CNA's) daily/weekly work assignment sheets and/or flow sheets; [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, see the Statement of Deficiency dated 11/15/23. Based on interview and record review, the facility failed to follow professional standards of practice for 13 of 23 sampled residents (Resident #1, #3, #6, #7, #8, #10, #12, #14, #16, #17, #18, #19, and #20), when staff failed to administer medications as ordered by the physician. The facility failed to ensure one resident (Resident #20) received the correct medications when staff administered another resident's (Resident #10) morning medications. The facility also failed to ensure staff administered prescribed controlled substance medications to three residents (Resident #6, #10, and #8). The facility census was 74. Review of the facility policy Administering Medications, dated April 2019, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish restorative nursing programs that included specific goals and objectives that included the frequency the program was to be provided and failed to ensure staff provided restorative nursing therapy for three residents (Residents #4, #8 and #18), in a review of 18 sampled residents, who were unable to perform their own activities of daily living (ADLs) due to disease processes that affected their daily routines. The facility census was 71. Review of the facility policy, Restorative Nursing Services, dated July 2017, showed the following: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided five residents (Resident #6, #3 #12, #10 and #4) of 16 sampled residents, that were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 86. Review of the facility policy Activities of Daily Living (ADLs), Supporting, dated March 2018, showed the following; -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for six residents (Residents #2, #12, #1, #15, #11 and #14), in a review of 18 sampled residents, when family members had to assist with the residents' personal care needs and pass meal trays. Staff took 30 minutes or longer to answer resident call lights. Staff were unable to assist residents out of bed who required assistance of two staff with a mechanical lift. The facility also failed to provide sufficient staff for residents to receive restorative nursing services due to the restorative Certified Nurse Aide (CNA) being pulled from his/her duties to work the floor and helping with shipments on Fridays. The facility census was 71. Review of the facility Staffing policy, dated October 2017, showed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing assistants (NAs) demonstrated competency in skills and techniques necessary to care for the residents. Those competencies included transfers, charting, equipment and safety, infection control, bathing, hygiene, perineal care, care plans, and reporting incidents. The failure involved 20 NAs who provided direct resident care, with start dates of 4/4/23 through 8/22/23. The facility census was 71. Review of the facility Staffing policy, dated October 2017, showed the following: -The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment; -Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at a safe appetizing temperature. This affected five residents (Residents #4, #7, #9, #10 and #16) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Assistance with Meals, dated March 2022, showed the following: -For residents confined to bed, the food services department will deliver food carts to appropriate areas, nursing staff will prepare residents for eating and the nursing staff and/or feeding assistants will take food trays into residents' rooms; -Hot foods shall be held at a temperature of 135 degrees F or above until served. Cold foods shall be held at 41 degrees F or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement; [...]

Inspectors wrote23. Review of Resident #24's annual MDS, dated [DATE], showed the following: -Cognition intact; -Required physical assistance from two staff for transfers; -Required physical assistance from one staff for toilet use, personal hygiene and bathing. Review of the facility's call light log showed the following: -On 4/02/22, the resident activated the call light at 6:06 P.M. Staff answered the call light 83 minutes later; -On 4/03/22, the resident activated the call light at 10:00 P.M. The call light timed out at 99 minutes; -On 4/04/22, the resident activated the call light at 5:42 A.M. Staff answered the call light 58 later. During interviews on 4/03/22 at 3:29 P.M. and on 4/4/22 at 9:55 A.M., the resident said the following: -He/She has to have help with ADLs and depends on staff to provide his/her care; -It can take staff an hour or more to answer his/her call light; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage, other than the Director of Nursing (DON), eight consecutive hours per day seven days per week when the average daily census was greater than 60 residents. The facility census was 71. Review of the facility policy titled, Staffing, revised October 2017 showed the following: -Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment; -Policy Interpretation and Implementation: 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the freezers, refrigerators, and the dishwasher were free of debris buildup, failed to ensure the floors around the refrigerator units were clean, and the floor under the clean plate cart was free of standing water. The facility census was 71. Review of Cleaning Rotation policy, dated 2016, showed the following: -Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; -Items cleaned after each use: can opener, small food preparation, slicer, kettles and utensils, mixers, cutting boards, worktables and counters, beverage table, coffee urns, pots and pans, dishes, dining room table and chairs; -Items cleaned daily: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six residents (Resident #9, #12, #16, #29, #54 and #61) in a review of 20 sampled residents and four additional residents (Resident #43, #30, #68 and #78) were treated in a manner to maintain dignity and respect. Resident #54's urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bag was on the floor by the resident's bed and not covered or placed in a dignity bag or with a cover, exposing the bag and urine from the resident's open door. Further observation showed residents were served meals in Styrofoam containers, Styrofoam beverage glasses and with plastic silverware during the survey process. Residents complained that the Styrofoam and plastic use made foods cool quicker and were difficult to use and not homelike. [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to concerns raised by multiple residents attending the resident council meetings. The facility failed to adequately act upon and provide feedback to the residents regarding their concerns. The facility census was 71. Review of the facility Resident Council policy revised 2/2021 showed the following: Policy Statement: The facility supports residents' rights to organize and participate in the resident council; 1. The purpose of the resident council is to provide a forum for: a. residents, families and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff; d. disseminating information and gathering feedback from interested residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable environment by failing to ensure residents' rooms and living spaces were clean and in good repair. The facility census was 71. 1. Observation on 04/04/22 between 10:15 A.M. and 4:45 P.M. during the life safety code tour of the facility showed the following: -In resident room [ROOM NUMBER], there was a ¾ inch black ring around the entire base of the toilet; -In resident room [ROOM NUMBER], the hose beside the toilet was leaking water into a trash can; -In resident room [ROOM NUMBER], there were several scuff marks on the wall behind both beds; -In resident room [ROOM NUMBER], there were several scuff marks on the wall behind bed two; -In resident room [ROOM NUMBER], there was a ¼ inch black ring around the entire base of the toilet; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care for four residents (Resident #29, #61 and #64) in a review of 20 sampled residents. The facility census was 71. Review of the facility policy, Comprehensive Person-Centered Care Plans, revised December 2016, showed the following: -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; 8. The comprehensive, person-centered care play will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for three residents (Resident #16, #39, and #54), in a review of 20 sampled residents. The facility census was 71. Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to met the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided bathing and hygiene needs for three residents (Residents #57, #61, and #64), who were unable to perform their own activities of daily living (ADLs), in a review of 20 sampled residents. The facility census was 71. Review of the facility policy, Supporting Activities of Daily Living (ADLs), revised March 2018, showed the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out 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 wroteBased on interview and record review, the facility failed to implement their policy addressing cardiopulmonary resuscitation (CPR) requirements for staff. The facility failed to ensure there was an adequate number of staff present at all times who were properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency services arrived. The facility had no system to ensure staff were certified in CPR for Healthcare Providers to include a hands-on and in-person skills assessment. The facility failed to ensure they had a system to monitor the medical record to ensure it accurately and consistently indicated the resident's code status for two residents (Resident #39 and Resident #60), in a review of 20 sampled residents and for two additional residents (Resident #43 and Resident #73 ). The facility census was 71. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent the development and promote healing of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for four residents (Residents #12, #26, #54, and #64), in a review of 20 sampled residents. The facility failed to implement a system to ensure low air loss mattresses, utilized for two residents with pressure ulcers (Residents #12 and #54), were maintained on the correct weight setting to promote healing, and failed to timely reposition two residents (Residents #26 and #64), who were identified as a risk for pressure ulcers, as directed per facility policy to prevent the potential development of pressure ulcers. The facility census was 71. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to assist three residents (Resident #12, #24, and #26) in a review of 20 sampled residents, with mobility and/or limited range of motion, to attain or maintain their highest level of functioning when the restorative aide was pulled to fill certified nursing assistant (CNA) duties. The facility census is 71. Review of the facility policy titled, Restorative Nursing Services, revised July 2017, showed the following: -Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Policy Interpretation and Implementation: 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services ( e.g., physical, occupational or speech therapies); 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfer) transfers for one resident (Resident #39) of 20 sampled residents and one additional resident (Resident #8). Staff used Resident #39's pant waist and underarm during transfers and staff transferred Resident #8 with assist of one when the resident's knees were bent and he/she was unable to fully bear weight. The facility census was 71. Review of the facility policy Safe Lifting and Movement of Residents revised July 2017 showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to life and move residents; 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule III through IV controlled substance medication, were reconciled by at least two qualified staff to ensure accountability. Further review showed the Director of Nursing (DON) was storing alprazolam, a schedule IV narcotic controlled substance, in his office with no accountability. The facility census was 71. Review of the facility policy, Storage of Medications, revised April 2019, showed access to controlled medications was limited to authorized personnel. Personnel access to controlled medications \was recorded. Review of a facility policy, titled Controlled Substances, revised April 2019, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's, (Resident #9) Schedule IV narcotic controlled substance anxiety medication was kept in a locked compartment and accounted for when the medication was removed from the resident's room and stored in the Director of Nursing's (DON)'s office. Observation showed the facility failed to keep medication carts locked or attended in open areas accessible to residents and staff prepared and left medications in a resident's room. The facility also failed to remove expired medication from the 100/200 unit medication room. The facility census was 71. Review of the facility policy, Storage of Medications, revised April 2019, showed the following: -Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner; -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility census was 71. Review of the facility's Food and Nutrition Services policy, revised April 2019, showed the following: -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature; -If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued; -Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than two hours will be discarded. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer residents a daily bedtime snack. The facility census was 71. Review of the facility's policy, Serving Snacks (Between Meal and Bedtime), revised September 2010), showed the following: -The purpose of this procedure is to provide the resident with adequate nutrition; -Review the resident's care plan and provide for any special needs of the resident; -Place the snack on the over bed table or serving area; -Assist the resident as necessary; -Record the date and time the snack was served; -If the resident refused the snack, the reason(s) why and the intervention taken; -Report any problems or complaints made by the resident related to the snack. 1. During group interview on 4/5/22 at 11:15 A.M. five of five residents said they do not get snacks at bedtime. No one comes to offer bedtime snacks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infectious causing contaminants for one resident (Resident #57) in a review of 20 sampled residents and two additional residents (Resident #45 and #78). Further observation showed the facility failed to prevent contamination of a nasal cannula (a plastic tube device for delivering oxygen by way of two small prongs that are inserted into the nares) for one resident (Resident #54). The facility failed to ensure two staff exempted from receiving COVID (Coronavirus) vaccines (Nurse Aide (NA) M and NA O), wore N95 respirators as required. The facility census was 71. Review of the facility policy, Handwashing/Hand Hygiene, revised 2001, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to vaccinate eligible residents with the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for five residents (Residents #12, #16, #24,#37, and #54,) in a review of 20 sampled residents. The facility census was 71. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time Table for Adults, dated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for: *Adults [AGE] years old and older; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete inspections of bed frames, mattresses, bed rails and assist bars as part of a regular maintenance program to identify areas of possible entrapment for two residents (Resident #55 and #61) in a review of 20 sampled residents and for one additional resident (Resident #30). The facility census was 71. Review of the facility's Proper Use of Side Rails or Assist Bars Policy, dated December 2016, showed the following: -Purpose: The purposes of these guidelines are to ensure the safe use of side rails or assist bars as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; - An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the wireless call light system to ensure staff carried functioning pagers to alert them to residents' calls for staff assistance. Review of the call light response time log showed staff did not respond to call lights timely with resident's experiencing extensive wait times for staff. The facility census was 71. Review of a facility, undated, policy titled Wireless Nurse Call System, showed the following: -Purpose: The Wireless Nurse Call system is utilized to ensure residents have the ability to alert staff of their needs and staff respond in a timely manner; -Policy: Charge nurses are responsible for handing out pagers at the beginning of the shift and collecting at the end of the shift. Any extra pagers and replacement batteries are to be kept at the nurses station; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one resident (Resident #11), in a review of 20 sampled residents. The facility failed to ensure the resident had an ordered sleep study. The facility census was 71. 1. Review of Resident #11's face sheet showed the following: He/She was admitted to the facility on [DATE]; -Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all unvaccinated staff took necessary precautions to help mitigate the spread of COVID-19 as required by the facility by wearing an N95 or NIOSH (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask and completing COVID testing twice weekly per facility expectation. The facility census was 70. Record review of an undated facility policy, titled COVID-19 Vaccine Policy, showed the following: -Purpose: -In the interest of providing a safe workplace, the facility has adopted this policy to minimize the risk of exposure and possible transmission of SarsCov-2 (COVID-19) among our employees and their families, our residents, and the community. [...]

Inspectors wroteBased on interview and record review, the facility failed to deposit residents' personal funds in excess of $50.00 into an interest bearing account and to credit interest earned to the residents' personal funds for two residents (Resident #26 and #35). The facility census was 71. 1. Record review of the facility provided bank statements for an account holding resident funds for the period of 11/30/21 through 03/31/22 showed the following: -Statement date of 11/19/21 with a balance of $1195.00 with no accrued interest; -Statement date of 12/20/21 with a balance of $2295.00 with no accrued interest; -Statement date of 1/20/22 with a balance of $3460.00 with no accrued interest; -Statement date of 2/20/22 with a balance of $4625.00 with no accrued interest; -Statement date of 3/20/22 with a balance of $2989.00 with no accrued interest. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative for two residents (Resident #29 and #61), in a review of 20 sampled residents, when the facility initiated a transfer to the hospital. The facility census was 71. Review of the facility's policy, Bed-Holds and Returns, revised March 2017, showed the following: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy; -The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the facility; [...]