Steelville Senior Living

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 50 with a capacity of 72.1. Review of the facility provided policies showed they did not contain a policy related to the qualifications for the Director of Food and Nutrition Services. Review of the Dietary Manager's (DM) personnel records showed a new hire start date of 01/26/26 and the file did not contain documentation of food service management education, certification or experience. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure the internal temperature of foods placed in hot holding for service to residents remained at least 140 degrees Fahrenheit (F). Facility staff also failed to ensure the internal temperature of hot foods remained at least 120 degrees F upon service to residents who at in their rooms. These failures have the potential to affect all residents. The facility census was 501. Review of the facility's policy titled Food Code Temperatures, dated 02/26, showed staff directed to hold hot foods at 140 degrees F or above. Observation on 04/21/26 at 12:26 P.M., showed hot food items for service at the lunch meal held in the kitchen steam table and an adjacent warming cabinet. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. This failure has the potential to affect all residents. The facility census was 50.1. Review of the facility provided policies showed they did not contain a policy related to food labeling, dating or storage. Observation on 04/20/26 at 10:54 A.M., showed the kitchen dry storage area contained: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed acceptable standards of practice when staff failed to complete neurological checks for two residents (Resident #36 and #38), staff failed to complete post-fall documentation for one resident (Resident #20), and failed to document administration of medications and/or treatments for four residents (Resident #2, #9, #31, and #50) out of 19 sampled residents. The census was 50. 1. Review of the facility policy titled, Falls and Fall Risk, Managing, dated March 2018, showed staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide Activities of Daily Living (ADLs) assistance for seven residents (Resident #2, #11, #50, #1, #31, #15 and #20) out of 19 sampled residents who required assistance with ADLs. The facility Census was 50. 1. Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, dated March 2018, showed Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing and grooming. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to all residents who received regular diets. The facility census was 50.1. Review of the facility's menus dated 04/21/26 (Day 10), showed the menus directed staff to serve the residents on regular diets with 10 ravioli with garlic cream sauce at lunch. Review of the Day 10 recipe for regular textured ravioli with garlic cream sauce showed the recipe directed staff to serve 10 ravioli with garlic cream sauce. Observation on 04/21/26 at 12:30 P.M., showed [NAME] Q served the residents on regular diets with six ravioli (less than directed by the menus). During an interview on 04/21/26 at 12:35 P.M., [NAME] Q said the Dietary Manager (DM) said six ravioli was one serving. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate hand hygiene and glove changes to prevent the spread of bacteria during incontinence care for three residents (Resident's #9, #2, #27 and #30) of four sampled residents. The facility census was 50.1. Review of the facility's policy titled, Handwashing/Hand Hygiene, undated, showed staff are directed as follows: -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: -Before and after direct contact with residents; -Before donning sterile gloves;-Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #1, #4, and #52) out of 19 residents sampled. The facility census was 50. 1. Review of the facility policy titled Bed-Holds and Returns, dated October 2022, showed residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. All residents/representatives are provided with written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided with written notice about these policies at least twice: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to document they provided the physician ordered wound treatment for one resident (Resident #2) and failed to ensure one resident (Resident #27) out of seven sampled residents received the necessary treatment and services in accordance with professional standards to promote the prevention of pressure ulcer/injury development when staff failed to provide pressure relief to the resident's heel which resulted in a new pressure ulcer/injury. The facility census was 50.1. Review of the National Pressure Injury Advisory Panels (NPIAP) showed a Stage 1 Pressure Injury is Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Residents' #20, #27 and #31) out of four sampled residents were transferred in a manner to prevent accidents with a mechanical lift. The facility Census was 50.1. Review of the facility's mechanical lift manual, dated 10/01/18, showed: -Although the manufacturer recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, ourequipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 50.1. Review of the facility's policy titled, Antibiotic Stewardship, revised 12/2016, showed the purpose of the antibiotic stewardship program is to monitor the use of antibiotics. The policy did not direct staff on how to track and trend antibiotics in the facility. During an interview on 04/23/26 at 1:43 P.M., the Infection Preventionist (IP) said he/she was hired in November 2025 for the IP position and received his/her certification at the end of December 2025. The IP said the facility has been short staffed since December and he/she has not kept up with the program as he/she has been working on the floor. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to perform hand hygiene in a manner to prevent cross-contamination in the kitchen during the noon meal service. The facility's census was 41. 1. Review of the facility's policy tilted Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 11/2022, showed food and nutrition services employees should follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness, and directed staff to wash hands: -Whenever entering or re-entering the kitchen; -Before coming in contact with any food surfaces; -After handling soiled utensils or equipment; -After engaging in other activities that contaminate the hands; -After gloves are removed, hands are washed before gloves are replaced. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight (8) consecutive hours per day, seven days a week. The facility census was 41. 1. Review of the facility's policies showed staff did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, and payroll detail, dated June 2024, showed the facility did not have an RN in the building the following dates: -Sunday 06/02/24; -Saturday 06/08/24; -Sunday 06/09/24. 3. Review of the facility's RN staff schedule, and payroll detail, dated July 2024, showed the facility did not have an RN in the building the following dates: -Thursday 07/04/24; -Friday 07/05/24. 4. Review of the facility's RN staff schedule, and payroll detail, dated August 2024, showed the facility did not have an RN in the building the following dates: -Saturday 08/03/24; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to discard expired medications from amedication storage cabinet. Failed to ensure medications were stored in a safe and effective manner, by not ensuring medications were properly labeled and contained in their original package until time of administration for two medication carts. Facility staff placed nonmedication in a medication refrigerator in the storage room. The facility census was 41. 1. Review of the facility's storage of medication policy, revised April 2019, showed it directed staff as follows: -Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received; -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to store and serve food at temperatures adequate to prevent food borne illness. Facility staff failed sanitize kitchen wares in a manner to prevent contamination. These failures have the potential to affect all residents. The census was 41. 1. Review of the instructions for completing daily temperature logs, undated, showed refrigerators should be 40 degrees F or lower. Review showed staff were instructed to circle the date and explain any corrective actions on the back of the chart or separate piece of paper. Review of the facility's refrigerator temperature log, dated August 2024, showed the log contained columns labeled AM, Noon and PM and indicated a maximum allowable temperature of 41 degress F. Review showed the log did not contain any circled dates and there were no attached corrective action notes. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria, when staff failed to wash/sanitize hands during wound care and catheter care for one (Resident #1) of one sampled resident. Facility staff failed to change gloves and wash/sanitize hands during perineal care for one (Resident #7) out of two sampled residents. Facility staff failed to follow standard precautions during the performance of routine blood glucose tests for two (Resident #20 and #27) of two sampled residents. The facility census was 41. 1. Review of the facility's policy on Handwashing/Hand Hygiene, dated 2001, showed the facility considers hand hygiene is the primary means to prevent the spread of infections. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to document and update care plans in regard to catheters for two (Resident #19 and #22) out of two sampled residents. Facility staff failed to document and update one resident (Resident #11) out of four resident care plans when the resident had a fall. The facility census was 41. 1. Review of the facility's Goals and Objective, Care Plans Policy, revised 04/2009, showed staff are directed to update and revise care plans when there has been a significant change in residents' condition, when the resident has been readmitted to facility, and at least quarterly. 2. Review of the Resident #19's Quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 05/05/24, showed staff assessed the resident as follows: -Moderate Cognitive impairment; -Dependent of toileting; -Had indwelling catheter. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three residents (Resident #19, #22, and #37) out of twelve sampled residents have appropriate access to their trust fund account to include on the weekends. The facility census was 41. 1. Review of facility's policies showed staff did not provide a policy for resident funds. 2. Review of Resident #19's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/05/24, showed staff assessed the resident as moderate cognitive impairment. During an interview on 08/14/24 at 2:30 P.M., the resident said he/she cannot get money on the weekends and likes to have cash on the weekends for a soda. He/She said it feels like they are ripping me off, it's my money, not theirs. He/she said he/she should have access to it when he/she needs it. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria). On 02/20/24, one resident (Resident #1) tested positive for Legionella. Failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 48 with a capacity of 72. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to protect, label, and date stored food to prevent cross contamination and outdated use, store dented cans of food separate from the in-use food supply. Facility staff failed to ensure the ice machine drained through an air gap, to perform sanitation of a thermometer between use, and to allow clean and sanitized kitchenware to air dry prior to use to prevent the growth of food-borne pathogens. Facility staff also failed to maintain kitchen equipment and flooring in a clean sanitary manner to prevent the potential for cross-contamination. The facility census was 47. 1. Review of the 2017 Food and Drug Administration's (FDA) Food Code showed A primary line of defense in ensuring that food meets the requirements of § 3-101.11 is to obtain food from approved sources, the implications of which are discussed below. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to provide a clean, homelike, and comfortable environment when staff failed to maintain resident rooms clean and in good repair. The facility census was 47. 1. Review of the facility's policies showed staff did not provide a policy for resident environment. 2. Observation on 5/2/23 at 2:05 P.M., showed room [ROOM NUMBER] had a transition strip on the floor between the hallway and the resident's room that was raised off the floor and prevented easy access between the areas. Observation on 5/3/23 at 1:00 P.M., showed Resident #18 unable to propel his/her wheelchair over the transition strip on the floor as he/she attempted to enter room [ROOM NUMBER]. The resident leaned forward in the wheelchair and attempted again with the wheelchair then moved forward suddenly into the room as it bounced over the floor transition strip. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene during the provision of care and failed to use appropriate infection control procedures during incontinence care for one resident (Resident #27). Additionally, facility staff failed to decrease the risk of infection for three residents (Resident #7, #32 and #198) with indwelling catheters by keeping the catheter tubing and catheter bag off the floor to reduce the risk for infection. The facility census was 47. 1. Review of the facility's Handwashing/Hand Hygiene policy, dated 2001, showed: -The facility considers hand hygiene the primary means to prevent the spread of infections; [...]