St. Sophia Health & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice. One resident had a wound identified on the sacral area with same-day documentation indicating there were no open areas and no treatment orders were obtained (Resident #9). One resident had a skin assessment identifying an open area with measurements, but no additional documentation or treatment orders for three days until the resident was transferred to the hospital for an unrelated change in condition (Resident #1). One resident had a dressing in place to an open area on the left knee with no documentation of a nursing assessment or treatment orders (Resident #8). Two residents had physician orders for skin treatments that were not documented as completed (Residents #6 and #7). The sample size was 10. The census was 161. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was frequently incontinent of bowel and bladder received appropriate incontinence care and services to prevent prolonged exposure to urine when staff applied two adult briefs (incontinence products) following an incontinent episode. The resident's incontinent products became heavily saturated with urine, causing the resident discomfort (Resident #2). The sample size was 10. The census was 161. Review of the facility's Skin Integrity Policy, revised 7/5/24, showed:Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate;Responsibility: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when Certified Nursing Assistant (CNA) F threw a metal fork at the resident after a verbal exchange between them. The resident (Resident #1) was struck in the arm. The sample size was 10. The census was 153. Review of the facility's Abuse and Neglect Policy, last reviewed 1/20/26, showed:Policy: The facility is committed to protecting the residents from abuse, neglect, misappropriation of property, and exploitation by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented their Abuse Prevention Policy by not conducting a thorough investigation as required, when two residents had a physical altercation (Residents #7 and #8). The staff was unsure how many incidents between the two residents had occurred, the date they occurred, and was unsure of any history. The sample size was 10. The census was 153. Review of the facility's Abuse and Neglect Policy, last reviewed 1/20/26, showed:Policy: The facility is committed to protecting the residents from abuse, neglect, misappropriation of property, and exploitation by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to follow physician orders for a resident's Peripherally Inserted Central Catheter (PICC, flexible tube that delivers long term intravenous (IV) treatments through a vein) line (Resident #9). The dressing was ordered to be changed weekly. The date on the dressing was worn off and illegible. The sample size was 10. The census was 153. Review of the facility's Physician Orders Policy, reviewed 9/8/22, showed:-Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, and Director of Nursing (DON).-Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pain received prescribed opioid pain medications as ordered by the physician for four days (Resident #8). The sample size was 10. The census was 153. Review of the facility's Physician Orders Policy, reviewed 9/8/22, showed:-Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, and Director of Nursing (DON).-Procedure: Medications will be ordered from the Pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy if available. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 39 residents (Resident #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41 and #42). The facility census was 160.1. Record review of the facility-maintained Accounts Receivable (A/R) Aging Report, dated [DATE], showed the following residents with personal funds held in the facility operating account. Review showed Resident #42's name did not show on the A/R Report due to the facility refunding $1,834.00 on [DATE], four days prior to running the Accounts Receivable Report on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable nursing practice when facility staff left a pain medication in one resident's room at the bedside (Resident #7). The resident had not been assessed safe to self-administer medications. The medication was the resident's Morphine Sulfate Extended Release (Schedule Class II Opioid pain medication). During a skin assessment observation for the same resident, a white tablet identified as Oxycontin (Schedule Class II Opioid pain medication) was found under the resident, in his/her bed. The resident did not have a physician order for Oxycontin 10 mg. The sample was 14. The census was 160. Review of the facility's Oral Medication Administration Policy, dated 12/2017, included:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated in a dignified manner when staff did not offer a resident (Resident #2) a chance to leave his/her room after his/her roommate (Resident #3) expired at approximately 1:47 A.M. The resident was left in his/her room with the roommate for almost four hours until the funeral home picked up the roommate's remains at approximately 5:09 A.M. The sample was 9. The census was 165. Review of Resident #3's medical record, showed:-A progress note dated [DATE] at 1:47 A.M., Emergency Medical Services (EMS) calls the code and gives a time (of death) 1:47 A.M. EMS departs from the facility;-A progress note, dated [DATE] at 5:09 A.M., funeral home here for the departure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to obtain a repeat weight as requested by the dietician for one resident (Residents #9) after the resident was noted to have significant weight loss. The facility also failed to ensure requested labs from an outside provider were completed and followed up on timely for one resident (Resident #4). The sample was 9. The census was 165.1. Review of Resident #9's medical record, showed diagnoses include diabetes, aphasia (difficulty communicating), dysphagia (difficulty swallowing), dementia, and delusional disorder. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: Resident has nutritional problem or potential nutritional problem related to multiple comorbidities and age/diagnosis process;-Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed their Enhanced Barrier Precautions (EBP) policy when a staff member assisting with wound care did not wear an item of personal protective equipment (PPE), which was the gown, for one resident (Resident #5). Further review of the medical record, showed the resident was not ordered to be on EBP Precautions despite multiple open areas. The sample was 9. The census was 165. Review of the facility's Enhanced Barrier Precautions policy, last reviewed 5/15/24, showed:-Policy: The facility may expand the use of PPE and refer to the use of gowns and gloves during high-contact care activities that provides opportunities for transfer of multi-drug resistant organisms (MDROs) to hands/clothing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records containing protected health information (PHI) were not accessible to individuals who do not have the right to view the protected health information, for one resident (Resident #23) when staff provided an after-visit summary for Resident #23 to the family of a different resident. The facility census was 159. Review of the Know Your Rights statement, posted at the front entrance of the facility showed resident rights included confidentiality. Medical, personal, social or financial affairs should be considered privileged information. During an interview on 12/31/25 at 1:30 P.M., the family member for Resident #10 said a couple weeks ago on December 17th, the resident's nurse handed him/her the after-visit summary for Resident #23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for two residents sampled (Resident #10 and Resident #12) by not keeping Resident #10's room swept daily and having a bedside table with screws sticking out of the table. The facility staff also left two plates stacked by the air conditioning unit in Resident #12's room over a period of two days. The plates had dried food on them. In addition, the facility failed to ensure a sufficient number of plates were available to provide a homelike environment, providing Styrofoam plates in place of dining plates (Residents #6 and #7). The facility census was 159. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, when the narcotic count sheet for one resident was lost, resulting in 30 narcotic pain pills with no reconciliation (Resident #12). The census was 159. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner to prevent the risk of accidents and injury for one resident who was transferred without using a mechanical lift as ordered and according to the resident's plan of care (Resident #1). The census was 170. Review of the facility's Total Lift Transfer policy, dated 11/28/22, showed the facility will utilize a total lift device on residents who are unable to assist with transfers:-Full Body Lift: A lifting device used to provide safety of the resident/employees during transfers.-Procedure: Measure resident for appropriate sling size according to manufacturer. Position the sling under the resident with the base of the sling at the base of the resident's spine, top of the sling at the top of the head, cross straps prior to hooking the straps of the lift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff working in the facility were licensed to practice in the state of Missouri, when a Licensed Practical Nurse (LPN) on duty, who obtained their nursing license in a different state was working as a LPN in the facility with no Missouri nurses license. This had the potential to affect all residents. The census was 170. Review of the facility's current Human Resources (HR) General Position Information, showed graduated practical nurses (GPN, an individual who had graduated from nursing school to work as an LPN but had not yet passed the nursing boards) may only work for maximum of 90 days following graduation date. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented their Abuse Prevention Policy by not conducting a thorough investigation and report to the state survey agency as required, when two residents had a physical altercation (Residents #24 and #25). The sample was eight. The census was 171. Review of the facility's Abuse Prevention Policy, dated 10/21/22, showed the following:-Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;-Definition: -Abuse: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policy, and notify the physician and the Registered Dietician (RD) of an 11.5-pound (lb) weight loss in 56 days for one resident (Resident #17). The sample was eight. The census was 171. Review of the facility's Weight Variances Policy, dated 3/31/21, showed the following:-Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian. Recommendations from Registered Dietitian to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes; -Residents receiving supplements shall be monitored for acceptance by the Dietary Manager/Nursing Staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff consistently notified physicians when blood glucose/sugar levels (the concentration of glucose in the blood) exceeded the parameters ordered by the physician or the parameters in accordance with the facility's policy. In addition, the facility failed to ensure staff consistently documented blood glucose levels on the Medication Administration Record (MAR) and/or failed to ensure staff documented explanations when they used the codes NA (not administered, see nurses notes), NI (no insulin required) or HD (hold, see nurses notes) on the MAR. The facility identified 48 residents with routine blood glucose monitoring. Of those 48, eight were sampled and problems were found with four (Residents #8, #15, #16 and #17). The census was 170. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had oral care supplies (toothbrush, toothpaste and mouthwash) for their use in their rooms and failed to ensure staff provided oral care to residents. Twenty-three residents were sampled. Of those 23, five were interviewed and three said they did not have oral care supplies and staff did not offer to provide oral care (Residents #18, #8 and #15). The census was 170. Review of the facility Oral Hygiene policy, approved on 4/28/22 and last reviewed on 7/21/22, showed:-Policy: The Facility will provide Oral Hygiene to Residents as directed in the Plan of Care. Oral Care will include cleansing the Oral Cavity and removing Food/Debris; This may reduce Odor, Infection and provide Comfort;-Responsibility: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents referred to the restorative program from the therapy department received the services according to the restorative therapy plan. The facility identified 19 residents receiving restorative services. Four of these residents (Residents #1, #21, #22, and #23) had a restorative exercise plan developed by the therapy department, and they were not receiving services as prescribed by skilled therapy. The facility had a census of 170. Review of the facility's Restorative Nursing Care policy dated 1/1/2014, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary Social Services (SS) by failing to promptly develop a discharge plan and/or seek professional medical and/or psychiatric evaluation(s) to determine if one resident had the right to discharge to the community with or without a place to reside, discharge against medical advice (AMA), or if the facility should seek legal advice about legal guardianship for the resident. The resident, who was homeless, but his/her own legal representative, was admitted to a local hospital on 4/13/25, for a medical condition and was then discharged to the facility on 4/30/25. The resident's diagnoses included bipolar disorder (characterized by periods of depression and periods of abnormally elevated mood) and anxiety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot water at fixtures accessible to residents located in resident rooms on the 200 hall is maintained between the regulatory temperature range of 105 degrees Fahrenheit (F) and 120 degrees F. The deficient practice had the potential to affect 44 residents residing on 200 hall. The census was 175. Review of the facility's water temperature regulation for residential programs policy, revised 1/29/13, showed:-The comfort and preferences of the individual are balanced with the abilities and safety of the individual. This is outlined in the individual's plan;-1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized comprehensive care plans to address specific needs of the residents for four sampled residents. (Resident #1, Resident #2, Resident #7 and Resident #8). The census was 175. Review of the facility's Comprehensive Person-Centered Care Plan policy, last reviewed 10/23/19:-Policy: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care;-Definitions: -Interdisciplinary Team (IDT): All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; -Baseline Care Plan: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate interventions for falls for one resident (Resident #6) who had no fall mats next to the resident's bed. The facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when the facility failed to accurately complete post (after) fall 72 hour monitoring report (neurological (neuro) evaluation - pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received dialysis (the process of filtering the blood for individuals with kidney failure) services had current dialysis orders that included the location for the dialysis services for one resident (Resident #2), the days of week the resident would go to dialysis and what the dialysis chair time was for two residents (Resident #2 and Resident #8). The facility also failed to ensure the dialysis services had been addressed on the resident's individual care plan for chair time for three residents (Resident #2, Resident #8 and Resident #7). Additionally, the facility failed to contact and document the notification to the physician and resident representative (RR) when the resident refused dialysis or when the dialysis treatment ended early for three of three residents (Resident #2, #7 and #8). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences when staff denied access to the adjoining bathroom for two residents (Residents #6 and #17). Staff removed the bathroom doorknobs on two-bathroom doors of the adjoining bathroom to prevent the two residents from having access to the toilet. Staff did not know which resident may have clogged the bathroom toilets. This required the residents to ask staff to unlock the main bathroom on the hall when they needed to void of urine or have a bowel movement. The sample was 18. The census was 160. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/25, showed: -Moderate cognitive impairment; -Wheelchair; -Toilet hygiene: [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment when staff did not clean and maintain sanitary conditions in an adjoining resident bathroom for two residents (Resident #6 and Resident #17). The sample was 17. The census was 160. Review of the facility's Safe Homelike Environment policy, last reviewed 4/28/22, showed: -Policy: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk; -Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #45), assessed to be at risk for aspiration, was served pureed meat and thickened liquids in accordance with physician's orders. The resident recently returned from a hospitalization after aspirating at the facility, resulting in aspiration pneumonia (an infection caused by inhaling something other than air into your lungs) for which he/she received intravenous antibiotics. The facility staff failed to monitor the resident in the dining room, as assessed in the Minimum Data Set (MDS), which showed the resident required supervision and touching assistance for eating. Observation showed the resident chewing on a milk-soaked paper napkin without staff intervention, which could have resulted in choking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure eight of 33 sampled residents were provided a homelike environment by failing to ensure resident toilets were clean (Residents #8 and #119), resident rooms had clean floors (Residents #8, #119, #38, #62, and #15), soap dispensers in resident rooms were full (Residents #20 and #140) and residents had clean bedding (Resident #119). The facility also failed to ensure residents' furniture and medical equipment were in working order and clean (Residents #62, #105, and #15), and that the 400 hallway dining room had clean floors. The census was 166. Review of the facility's safe homelike environment policy, dated 4/28/22, showed: -Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided to four of 33 sampled residents. The facility failed to ensure one resident was free from unwanted facial hair (Resident #22), failed to ensure one resident had clean hands and hair (Resident #32), failed to ensure one resident had clean hair and nails (Resident #62), and failed to ensure two residents had clean clothing to wear (Residents #62 and #71). The sample was 33. The census was 166. Review of the facility's nail care policy, dated 7/21/22, showed: -Policy: The purpose of nail care is to clean the nails, trim nails, and prevent infection; -Key points: Nails may be cleaned during bathing. Nail care includes daily cleaning and regular trimming. Review of the facility's ADL care bathing policy, dated 7/21/22, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice, in two of two facility medication rooms and in two of three medication administration carts. The facility census was 166. Review of the facility's Medication Storage in the Facility policy, revised 11/2018, showed: -Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen floors, bulk bins, and appliances were free from food and trash debris. The facility failed to ensure the ceiling above a meal preparation station was free from dust build up, and failed to ensure the walk in- refrigerator and freezer floors were free from food and trash debris. The facility census was 166. Review of the facility's daily kitchen cleaning checklist, undated, showed: -Daily or after each use: all freezers and refrigerators are cleaned, floors swept and mopped daily. Review of the facility's weekly kitchen cleaning checklist, undated, showed: -Clean all freezers and refrigerators interior and exterior, deep clean oven, polish all stainless-steel surfaces, vents cleaned and free of dust, deep fryer cleaned and oil changed weekly. 1. Observation on 1/22/25, of the kitchen, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity. One resident (Resident #214) required staff assistance with mobility and personal care needs. Staff left the resident's buttocks exposed while propelling the resident through common areas of the facility, and left the resident uncovered in bed with his/her genitals exposed and visible from the hallway outside of his/her room. Staff delivered a meal to the resident's room and failed to empty the resident's urinals, full of urine, leaving the urine in the resident's line of sight while he/she ate lunch. In addition, one employee made a video call on their personal cell phone while in a common area with one resident (Resident #22) in the background of the video. The sample was 33. The census was 166. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were appropriately assessed to self-administer medications, to obtain physician orders to self-administer medications, and to ensure staff adequately supervised residents during medication administration (Residents #20 and #214). The sample was 33. The census was 166. Review of the facility's Self-Administration of Medications policy, revised August 2014, showed: -Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer; -Procedures include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident needs and preferences were accommodated for one resident (Resident #19) with communication and mobility impairments, when staff failed to ensure the resident's call light was within reach and when staff failed to transfer the resident back to bed, per the resident's request. The sample was 33. The census was 166. Review of the facility's Resident Rights policy, last reviewed 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are being followed; -Resident rights included exercise rights, planning and implementing care, making decisions/choices, and self-determination. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain records of residents' personal possessions for four residents (Resident #97, Resident #38, Resident #15 and Resident #265) The sample was 33. The census was 166. Review of the facility's admission agreement, revised June, 2023, showed: -Resident rights: -To keep and use your personal belongings and property as long as they don't interfere with the rights, health, or safety of others; -Personal items: -All personal property must be clearly and permanently labeled with the resident's name; -All food, liquids, medications, and personal effects brought to the resident must be brought to the nurses' station and checked with the nurse in charge before delivery to the resident; -The policy did not address how they would document and maintain personal property inventory sheets. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change in status assessment was completed within 14 days after the determination was made a significant change occurred for one of one residents sampled for hospice (Resident #45). The facility identified three residents who received hospice services. The census was 166. Review of the facility's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) policy, revised 4/26/23, showed: -Policy: The MDS is a standardized comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to Centers for Medicare & Medicaid Services (CMS) in compliance with the guidelines in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify one resident's (Resident #45) hospice status with life expectancy of less than six months, and one resident's (Resident #19) fall within the assessment review period. The sample was 33. The census was 166. Review of the facility's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) policy, revised 4/26/23, showed: -Policy: The MDS is a standardized comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to Centers for Medicare & Medicaid Services (CMS) in compliance with the guidelines in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by failing to transcribe two residents' (Residents #105 and #49) physician orders correctly to the Medication Administration Record (MAR). In addition, the facility administered medications to one resident (Resident #72) who did not have orders for crushed medications. The sample was 33 The census was 166. Review of the facility's Physician Orders policy, reviewed, 9/28/22, showed: -Purpose to provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Physician orders must be documented clearly in the medical record; The required components of a complete orders are: -Date and item of order; -Name of practitioner; -Name and strength of medication and treatment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders, the oxygen administration storage policy, and proper infection control techniques for two of 33 sampled residents (Resident #15 and #315). The census was 166. Review of the facility's Oxygen Administration and Storage policy, dated, 1/1/14, showed: -Purpose: To ensure staff follow safety guidelines and regulation for storage and use of oxygen; -Tubing: Oxygen tubing should be changed weekly; Nasal cannula (NC, tubing that delivers oxygen through the nose) tubing may need to be changed more frequently; -Pulse Oximetry: Residents who have oxygen order should have oxygen saturation levels measured by oximetry (a device that is placed on the finger and measures oxygen levels); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are not working properly) access sites, residents with gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications) and wounds requiring treatments, for three residents [...]

Inspectors wroteSee the deficiency cited at F567 under Event ID LQCK12. Based on interview and record review, the facility failed to receive authorization in writing to use personal funds of a resident that was discharged from the facility January 2024 with a credit in the amount of $772.00, until October 2024 when the resident was charged $875.00 after an updated bill was received from the resident's co-insurance. The facility failed to notify the resident and/or responsible party of additional charges and deducted $875.00, leaving the resident a balance owed in the amount of $103.00. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. [...]

Inspectors wroteSee the deficiency cited at F569 under Event ID LQCK12. Based on interview and record review, the facility failed to refund resident funds within 30 days of discharge for one resident reviewed (Resident #15). The resident was discharged from the facility January 2024 with a credit in the amount of $772.00. The facility failed to issue a refund after attempts to notify the corporate office to send a refund. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. All payments not paid when due shall be late payments and may be subjected to late payment charges of one percent per month. [...]

Inspectors wroteSee the deficiency cited at F693 under Event ID LQCK12. Based on observation, interview and record review, facility staff failed to provide appropriate care and services to a resident with a gastrostomy tube (g-tube, a tube surgically placed into the stomach for administration of nutrition and medications) by failing to ensure the g-tube machine infused the correct amount of feeding formula and failed to turn off the g-tube machine at 8:00 A.M. as ordered on two of two days of observation. Resident #16. The sample was 14. The census was 166. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24, showed: -Severe cognitive impairment; [...]

Inspectors wroteBased on interview and record review, the facility failed to receive authorization in writing to use personal funds of a resident that was discharged from the facility January 2024 with a credit in the amount of $772.00, until October 2024 when the resident was charged $875.00 after an updated bill was received from the resident's co-insurance. The facility failed to notify the resident and/or responsible party of additional charges and deducted $875.00, leaving the resident a balance owed in the amount of $103.00. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. [...]

Inspectors wroteBased on interview and record review, the facility failed to refund resident funds within 30 days of discharge for one resident reviewed (Resident #15). The resident was discharged from the facility January 2024 with a credit in the amount of $772.00. The facility failed to issue a refund after attempts to notify the corporate office to send a refund. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. All payments not paid when due shall be late payments and may be subjected to late payment charges of one percent per month. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one resident (Resident #3) when the resident's medication and treatment orders were not reentered into the electronic medical record (EMR) until two days after the resident was readmitted to the facility from a hospital stay. The resident returned on 9/24/24 and the orders were entered on 9/26/24. The sample size was 10. The census was 166. Review of the facility's Physician Orders policy, reviewed 9/28/22, showed: -Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines. -Procedure: -Physician Orders shall be provided by Licensed Practitioners authorized to prescribe orders; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide appropriate care and services to a resident with a gastrostomy tube (g-tube, a tube surgically placed into the stomach for administration of nutrition and medications) by failing to ensure the g-tube machine infused the correct amount of feeding formula and failed to turn off the g-tube machine at 8:00 A.M. as ordered on two of two days of observation. Resident #16. The sample was 14. The census was 166. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24, showed: -Severe cognitive impairment; [...]

Inspectors wroteSee Event ID 6YPW12. Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. The resident left the building without staff knowledge and remained out of the building for approximately four hours before staff realized the resident was missing. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer a medication prescribed for cancer treatment for one resident (Resident #5). The sample was six. The census was 177. Review of the facility's Medication Administration General Guideline, dated August 2014, showed the following: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions; -Procedures: -Administration 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff who transport residents in the facility van were certified in Cardiopulmonary Resuscitation (CPR) for healthcare providers, when residents potentially requiring CPR were being transported. This affected one resident (Resident #10) who was a full code (CPR to be provided in the event the heart stops beating) observed to be transported in the facility van with staff who was not CPR certified. The census was 169. The Administrator was notified on [DATE] at 1:04 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's cardiopulmonary resuscitation policy, last reviewed 9/2023, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's safety during transportation in the facility's van. The facility failed to properly secure one resident's safety belt prior to transporting (Resident #1). Resident #1 required full assistance due to a diagnosis of quadriplegia (paralysis that affects all four extremities) and had been assessed with unsteady balance. On 6/13/23, Driver/Social Worker A and Driver H were returning the resident to the facility from a medical appointment. When another car swerved in front of the facility van, Driver/Social Worker A pressed the brake quickly. The resident fell out of the wheelchair, and sustained a head injury when he/she hit his/her head on a fire extinguisher. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent significant medication errors when staff failed to ensure residents admitted to the facility received ordered medication timely (Residents #5, #8 and #9). The facility failed to administer medications that were available in the onsite medication administration machine and emergency kit. The census was 169. Review of the admission/readmission order policy, reviewed 9/27/23, showed: -Policy: upon admission/readmission, orders for care of the resident are received from attending physician, transcribed onto physician's orders and kept in the medical record; -Procedure: Admission/readmission orders are obtained on the day of admission in one of the following ways: -Physician provides written orders; -Nurse receives orders via telephone, in which case via telephone is indicated by nurse signature; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' right to retain and use personal possessions, including clothing, when personal clothing that was sent to laundry was not consistently returned and/or not returned timely for three residents investigated for missing clothing (Resident's #98, #70 and #56). Four of four linen rooms observed contained stacks of unlabeled resident clothing. In addition, seven of seven residents interviewed, who represented the resident counsel, reported concerns with personal clothing going missing. The census was 157. The sample was 31. Review of the facility's Inventory of Personal Items policy, dated 2/28/23, showed: -The facility will inventory the residents' personal items upon admission and discharge; [...]

Inspectors wroteBased on interview and record review, the facility failed to reconcile the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis. This practice potentially affected 97 residents who had resident trust accounts. The census was 157. Review of the facility's undated Resident Trust Fund policy, showed to assure the total balance of the Resident Trust Fund bank account and Resident Trust Cash Box reconciles with the totals of the Resident Fund Management Services (RFMS) resident accounts, RFMS will automatically reconcile these accounts every day. The Reconciliation Batch Report should be ran on a monthly basis. Any variances should be addressed and corrected immediately by the business office and/or the corporate office. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 Social Security (SSI) limit ($5,301.85) or when the resident's account was over the SSI limit. This affected seven residents reviewed who received Medicaid benefits (Residents #101, #258, #108, #77, #68, #82 and #116). The census was 157. Review of the facility's undated Resident Trust Fund policy, showed a resident's combined personal accounts cannot exceed the amount determined by current state regulations. The Center shall issue a notice to the resident/legal guardian when the resident is within $200.00 of approaching this limit in the Resident Trust account. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide an adequate supply of linens, ensuring staff were able to provide care and residents were able to provide self care. Additionally the facility failed to maintain resident room floors and walls in good repair. This had the potential to affect all residents. The census was 157. 1. Observation on 5/22/23 at 12:10 P.M., on the 300 hall, showed limited inventory in the clean linen rooms and linen carts. 2. Observation on 5/22/23 at 1:41 P.M., on the 400 hall, showed limited inventory in the clean linen rooms and linen carts. 3. Observation on 5/22/23 at 2:04 P.M., on the 200 hall, showed limited inventory in the clean linen rooms and linen carts. 4. Observation on 5/22/23 at 2:09 P.M., on the 100 hall, showed limited inventory in the clean linen rooms and linen carts. 5. [...]

Inspectors wroteBased on observation, interview and record review, staff failed to provide care when requested by the resident, failed to ensure all urine was cleaned from a wheelchair prior to covering with a pad and placing the resident back into the wheelchair (Resident #86), and failed to provide the necessary care and services for residents who were unable to complete their own activities of daily living (ADL) for care, which included meal assistance and good personal hygiene (Residents #73, #139 and #56). The sample was 31. The census was 157. Review of the facility's ADL Care Bathing policy, dated 7/21/22, showed: -Nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing; -Shower: Assist resident into the shower, encourage them to hold onto safety bars. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed facility policy for safe mechanical lift transfers, for two of two residents observed during mechanical lift transfers (Residents #86 and #99). The facility failed to have fully charged batteries to operate mechanical lifts. The facility also failed to secure an unlocked storage room, which contained a retractable utility knife. The sample was 31. The facility census was 157. Review of the facility's Sit to Stand Lift (mechanical lift) Transfer policy, dated 10/25/22, showed: -The facility may use a sit to stand lift for resident transfers with those who require assistance transferring from one surface to another to ensure safety; -Standing sling: -Position the sling around the back so it is two inches about the resident's waist with arms outside of the sling; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to clean a sit to stand lift (mechanical lift) between resident use for two of two residents observed during mechanical lift transfers (Residents #86 and #99) and failed to clean a shower bed between resident use for one resident (Resident #73). Additionally, the facility failed to keep two out of four clean linen closets clean and organized . The sample was 31. The census was 157. Review of the facility's Standard Precautions policy, dated 10/25/22, showed: -The facility will use standard precautions which are the minimum infection prevention practices that apply to all resident care; -Handling soiled equipment: Equipment with blood, body fluid, secretions, and excretions in a manner that prevents mucus membrane exposure, contamination of clothing and transfer micro-organisms to others and the environment; [...]

Inspectors wroteBased on interview and record review, the facility failed ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, for three residents. The sample was 31. The census was 157. 1. Review of Resident #91's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 3/24/23, showed: -Should brief interview for mental status (BIMS) be conducted: Yes; -BIMS assessment left blank; -Should resident mood interview be completed: Yes; -Mood interview left blank. During an interview on 5/23/23 at 1:52 P.M., MDS Coordinator B said the resident is alert and oriented, and the BIMS assessment should have been completed. 2. Review of Resident #86's physician orders, during the time frame of February 2023, showed no orders for anticoagulant medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document narcotic pain medication was administered on the Medication Administration Record (MAR) for one resident who received pain medication (Resident #73). In addition, the facility failed to ensure one resident received enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract) at times specified by the physician (Resident #138). The sample size was 31. The census was 157. 1. Review of Resident #73's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/23, showed: -Moderate cognitive impairment; -Required extensive assist for bed mobility, dressing, toilet use and personal hygiene; -Always incontinent of bowel and bladder; -No behaviors; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #99) with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing. The sample size was 31. The census was 157. Review of the facility's Wound Management policy, dated 11/15/22, showed: Policy: To promote wound healing of various types of wound, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; Procedure: Wound Management: -Wound treatment will be provided in accordance with physician's order: -Cleansing method; -Type of dressing; -Frequency of dressing change; -The charge nurse will notify physician in the absence of treatment orders; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received appropriate person-centered care to meet his/her highest practical psychosocial well-being when the facility failed to provide medically related social services and accurate social service evaluations for one sampled resident with a known history of depression (Resident #150). In addition, the facility failed to provide social services regularly for one resident (Resident #73). The sample size was 31. The census was 157. 1. During an interview on [DATE] at 8:44 A.M., the Social Services Director (SSD) said the facility did not have a policy on behavioral management. Review of Resident #150's medical record, showed; -admitted on [DATE]; -Diagnoses included major depressive disorder, colon cancer, dementia and insomnia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document adequate indications and non-pharmacological interventions to support the use of haloperidol (an antipsychotic used to treat certain types of mental disorders) for one of five residents investigated for unnecessary medications (Resident #101). The census was 157. Review of the facility's Psychotropic Management Guidelines policy, revised September 2017, showed: -Purpose: A psychotropic drug is any drug which affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic; -Based on the comprehensive assessment of the resident, the facility must ensure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, medical records are maintained that are complete and accurately documented for one resident observed after a fall when staff failed to document the fall timely or completely (Resident #61). The sample was 31. The census was 157. Review of the facility's Fall Management policy, dated 2/28/23, showed: -To provide an environment that remains as free of accident hazards as possible. The facility will complete a Morse Fall Scale Evaluation on residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or reduce injuries; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to repair the resident's headboard of the bed after he/she reported it was not in working order (Resident #6). The sample was 31. The census was 157. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/18/23, showed: -Severely impaired cognition; -Diagnoses included coronary artery disease, aphasia (language disorder), dementia and depression; -Required extensive assistance with one person physical assist with bed mobility, dressing and hygiene; -Required extensive assistance with two or more person physical assist with toileting; -Required limited assistance with two or more person physical assist with transfers; -Bed rails not used. Review of the resident's care plan, updated 5/5/23, showed: -Focus: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident was afforded the right to manage his/her financial affairs, when the facility failed to advise residents of money held in the facility operating account that belonged to the resident. The facility failed to deposit funds, in excess of $100 for residents receiving Medicare and $50 for residents receiving Medicaid, in an interest bearing account that was separate from any of the facility's operating accounts, and credit all interest earned on resident's funds to that account. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Medicaid spend down letters when the balance of the resident's trust fund account exceeded $2,800.00. This deficient practice affected four residents (Residents #77, #84, #107 and #122). Additionally, the facility failed to provide a final accounting of individual resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for two residents (Residents #156 and #157). The facility census was 177. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents who live on the 100, 200 and 400 halls could exercise their right to private communication when they failed to replace the resident telephones in a timely manner. The facility census was 177. 1. During an interview on 5/16/19 7:22 A.M., Resident #42 said he/she could not make a private phone call. There used to be cordless phones at the nurse's stations, but since the facility rewired the phone system about three months ago, they took the cordless phones away and never replaced them. If he/she wanted to make a call, he/ she had to ask the nurse to dial and then could only go as far away as the cord would stretch. There were always staff and other residents around. He/she felt bad about tying up the phone because the nurse needed to use it too. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement person-centered comprehensive care plans to meet preferences and goals and address residents' medical, physical, mental and psychosocial needs, by not including depression, pressure ulcers, oxygen use, activities, restorative therapy, pain, contractures, paralysis and edema on the care plans, for eight of 35 sampled residents (Residents #23, #151, #88, #49, #25, #28, #44 and #77). The census was 177. 1. Review of Resident #23's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/19, showed the following: -No cognitive impairment; -Total dependence on staff for activities of daily living; -Upper and lower extremity impairment; -Incontinent; -No antidepressant medication administered in past 7 days; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans reflected current needs by not updating them to include psychotic medication use and interventions, failed to reflect lower leg edema (swelling) and lower leg wraps, specific and current wound treatments, failed to reflect the change in wound treatments used and reflect the long term use of antibiotic as a prophylaxis. The affected five of 35 sampled residents (Residents #8, #144, #60, #56 and #47). The census was 177. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/19, showed the following: -Cognitively intact; -No mood issues; -Verbal behaviors daily; -Daily antipsychotic medication; -Diagnosis of depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer treatments as ordered (Residents #81, #51 and #5), failed to obtain orders for a peripherally inserted central catheter (PICC, a thin, soft, long catheter (tube) that is inserted into a vein. The tip of the catheter is positioned in a large vein that carries blood into the heart and used to administer medication), code status and inflatable boots (Residents #43, #44 and 56), failed to provide dietary supplements as ordered (Residents #23 and #154), failed to clarify orders (Resident #94) and failed to apply medical stockings as ordered (Residents #77 and #152). The census was 177. 1. Review of Resident #81's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/19, showed the following: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and ensure appropriate perineal (peri-care, cleansing the front of the hips, between the legs and buttocks) care to two of three perineal care observations (Residents #77 and #152). The facility also failed to provide meal service set up to one of 35 sampled residents (Resident #58). The census was 177. 1. Review of Resident #77's annual Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/19, showed the following: -Moderate cognitive impairment; -Extensive assistance required for all personal care and mobility; -Frequently incontinent of bowel and bladder; -Diagnoses included stroke and dementia. Observation on 5/15/19 at 9:03 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room, washed hands and donned gloves. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year, based on their individual performance review, calculated by their employment date rather than the calendar year. The facility failed to ensure three of eleven randomly selected certified nurse aides (CNAs), employed by the facility over one year, received the required annual 12-hour resident care training. The census was 177. Review of the CNA individual service records, showed the following: -CNA M hired 8/24/2009, received eight and one half hours of in-service education; -CNA N hired 5/17/2010, received nine and one half hours of in-service education; -CNA O hired 6/5/2007, received eight hours of in-service education. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility failed to properly document narcotic counts for the controlled substances for four of the four facility medication carts. The facility census was 177. 1. Review of the 100 wing controlled substance shift change count sheet (three shifts: days, evening and nights), dated May 2019, showed the following: -On 5/1/19: Three packages of narcotics at 7:00 A.M. -No nurse signatures for the 7:00 A.M. on-coming shift; -No nurse signature or narcotic package counts for the 3:00 P.M. on-coming or off- going shift; -Three narcotic packages and no nurse signature noted for the 11:00 P.M. off-going shift; -On 5/2/19: Three packages of narcotics at 7:00 A.M.; [...]

Inspectors wroteBased on record review and interview, the facility failed to attempt a gradual dose reduction (GDR) for a psychotropic medication for one resident (Resident #41) and failed to obtain a new order, or discontinue the use of an as needed (PRN) psychotropic drug beyond the 14 day limit for one resident (Resident #144). The sample size was 35. The facility census was 177. 1. Review of Resident #41's electronic physician order sheet (ePOS), showed an order dated 9/15/18 for quetiapine fumarate (Seroquel, an antipsychotic used for major behavior disorders) 25 milligrams (mg) take one tablet daily at bedtime for major depressive disorder. No reduction of the medication was indicated in the POS since 9/15/18. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/19, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to date insulin flex pens (prefilled insulin pens) once opened, discard outdated insulin pens and ensure the resident's name appeared on the medication for 10 of 30 insulin pens and vials observed on two of two medication carts. The census was 177. 1. Observation on [DATE] at 9:04 A.M., of the medication cart on 100 hall, showed the following: -A total of 18 flex-pens and two vials of insulin opened and in use; -One Humalog (fast acting) insulin flex-pen, opened and dated [DATE]; -One Humalog insulin flex-pen opened and dated [DATE]; -One Humalog flex-pen, opened and dated [DATE]; -Four Novolog (short acting insulin) flex-pens with no date opened or date expired; -One Lantus (long acting insulin) flex-pen in use with no resident name; -One Humalog flex-pen opened with no date opened or expired. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and served in a manner to prevent contamination by not covering desserts or the clean mixer bowl after use, and serving oatmeal from a cart, table to table in the dining room, from an uncovered pan. This deficient practice had the potential to affect all residents who ate at the facility. The census was 177. 1. Observation of the kitchen showed the following: -On 5/13/19 at 9:17 A.M. and 5/14/19 at 11:44 A.M., a sign on the wall behind the stand mixer read clean mixer and slicer after use and cover. The mixer bowl sat underneath the sign next to the mixer uncovered; -On 5/14/19 at 11:24 A.M., a cart sat in front of the steam table and held three trays of peach cobbler dessert cups. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure and collaborate care with resident elected hospice providers and failed to obtain a physician's order for hospice services. The facility showed 19 residents elected hospice services and four of those were included in the sample. Problems with coordinated plans of care were found with four of four residents reviewed for hospice services (Residents #151, #41, #85 and #43). The census was 177. 1. Review of Resident #151's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/19, showed the following: -Moderate cognitive impairment; -Required extensive assistance from staff for activities of daily living such as transfers and dressing and limited assistance for personal hygiene and toileting; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain appropriate infection control by ensuring staff handled medications to prevent the potential spread of infection during medication administration by staff who used bare hands to administer medications to one resident (Resident #81) and failed to sanitize hands during medication administration for two of four observations and failed to handle soiled linen appropriately. The census was 177. 1. During an observation and interview on 5/14/19 at 8:20 AM, Certified Medication Technician (CMT) Q prepared to administer morning medications to Resident #81. He/she dispensed medications into a medication cup. One tablet dropped from the medication card and fell onto the top of the medication cart next to the plastic medication cup. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe transfer techniques for two of three observed resident transfers. This practice placed the residents at risk for falls or injuries during transfers. This affected one expanded sample resident (Resident #112) and one of 35 sampled residents (Resident #152). The census was 177. 1. Review of Resident #112's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/19, showed the following: -admitted on [DATE]; -Moderate cognitive impairment; -Total assistance of two staff with all transfers; -Not steady during transfers without staff assistance; -Received hospice services; -Diagnoses of vascular disease, lung disease and schizophrenia. Review of the admission care plan, dated 4/9/19, showed no transfer status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper placement and privacy of one resident's (Resident #59's) indwelling urinary catheter (a tube inserted into the bladder for purpose of continual urine drainage) and two supra pubic (SP, a small rubber tube inserted through the lower abdomen in to the bladder to drain urine) catheters for two residents (Residents #94 and #154). Staff allowed the urinary drainage bags to rest on the floor, staff did not intervene when there were kinks in the tubing preventing proper drainage and staff did not cover a drainage bag with a privacy cover. The facility identified six residents as having urinary catheters and of those six, problems were found with three. The sample size was 35. The census was 177. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to adequately assess pain, record the degree and location of pain, re-evaluate the effectiveness of pain medication, notify the physician of ineffective pain control and failed to follow a physician's order for pain medication administration, all which allowed for unnecessary discomfort. This practice affected two residents (Resident's #80 and #88). The sample size was 35. The census was 177. 1. Review of Resident #80's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Extensive assistance required by staff for all personal care and mobility; -Frequent severe pain that limits day to day activities; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments, monitoring and ongoing communication with the dialysis center for a resident who received dialysis (process for removal of waste and excess water from the blood due to kidney failure). The facility identified four residents who received dialysis. Of those four, two were selected for sample and issues were found with one resident (Resident #88). The sample size was 35. The census was 177. Review of Resident #88's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/19, showed the following: -An admission date of 3/14/19; -Cognitively intact; -Required extensive staff assistance with transfers, mobility, hygiene, dressing and toileting; [...]