Strafford Rehabilitation & Health Care Center

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure all meals met the nutritional needs of residents when staff failed to follow approved menus, including appropriate serving sizes, for all residents including two residents (Resident #3 and #4) who stated portion sizes were not sufficient. The facility census was 62. Review of the facility's policy titled, Standardized Recipes, undated showed the following:-Standardized recipes will be used for all menu items;-The registered dietician will approve recipe changes or new recipes utilized for a menu item. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect each resident's right to self-determination through support of resident choice when the facility failed to honor the reasonable shower preferences for four residents (Resident #3, #4, #5, and #6). The facility census was 62. Review showed the facility did not provide a policy on showers.1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following information:-admission date of 02/10/25;-Diagnoses included hemiplegia (paralysis of one side of the body), heart disease, type II diabetes (body develops insulin resistance and fails to use insulin properly), Chronic obstructive pulmonary disease (constriction of the airways and difficulty breathing), and major depressive disorder (persistent feelings of sadness). [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect all residents' right to be treated with dignity and respect when one staff member (Registered Nurse (RN) F) insisted one resident (Resident #2) to be placed in a wheelchair and moved against his/her wishes. Seven residents were sampled in the facility with a census of 62. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents right to receive services in the facility with reasonable accommodation of resident needs when staff failed to follow up on and order a customized wheelchair for one resident (Resident #5), which would increase his/her ability to get out of bed and stay out of bed longer. The facility census was 62. Review of a facility policy titled Durable Medical Equipment Manual, dated 04/08/25, showed the following information:-The health plan is financially responsible for custom and power wheelchairs that have been prior authorized by the health plan prior to the enrollment effective date in the fee for service (FFS) program, but placement occurs after the effective date of FFS program enrollment;-Durable medical equipment (DME) is not covered for those participants in a nursing home. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one resident (Resident #8) or the resident's representative with notice regarding a room change, including the reason for the room change, before the facility moved the resident to another room. The facility's census was 62.1. Review of Resident #8's face sheet (brief information sheet about the resident) showed the following information:-admission date of 05/16/25;-Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque builds up in the heart's arteries and restricts blood flow), high blood pressure, dementia (a progressive decline in memory and thinking), anxiety (excessive uncontrollable fear), and age-related cognitive decline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect each resident's right to a safe, clean, comfortable, and homelike environment when staff failed to properly and frequently clean the floor in a resident room for two residents (Resident #5 and Resident #9) resulting the floor being sticky The facility census was 62.1. Review of Resident #5's face sheet (brief information sheet about the resident) showed the following information:-admission date of 01/16/25;-Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness or inability to move one side of the body) following a stroke affecting the left side, and unsteadiness on feet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide wound care per standards of practice when staff failed to obtain physician ordered wound treatment supplies and failed to complete dressing changes as ordered by the physician for one resident (Resident #7's) amputation site and left ankle pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of four sampled residents. The facility census was 62. Review showed the facility did not provide a policy regarding physician's orders. Review showed the facility did not provide a wound care treatment and management policy. [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed maintain an effective pest control system when were present in one resident's (Resident #6) room. The facility census was 62. Review showed the facility did not provide a pest control policy. 1. Review of a pest control invoice, dated 12/12/25, showed the following:-General pest control maintenance;-Scion insecticide treatment applied to the interior perimeter of the building for the aid and control of occasional invaders;-Mouse caught in snap trap by the refrigerator in the employee breakroom;-Spoke with staff who had no other pest concerns at this time of service;-Call with any concerns between now and next visit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all resident representatives were notified of changes in condition in a timely manner when staff failed to inform one resident's (Resident #2) representative of falls resulting in bruising and skin tears. The facility census was 66. [...]

Inspectors wroteBased on interview and record review the facility failed to provide care per standards of practice for all residents when staff failed to follow physician orders to obtain an x-ray and failed to follow-up regarding completion of the orders for x-rays for one resident (Resident #1) after a fall. The facility census was 66. Review of the facility policy titled, Test Results, dated 01/2017, showed the following: -Results of laboratory, radiological, and diagnostic tests shall be reported to the facility;-The medical practitioner shall be notified of the results;-The Director of Nursing Services, or nurse receiving the test results, shall be responsible for notifying the medical practitioner of such test results.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two hours timeframe when the facility did not report one resident's (Resident #1) statement of abuse. The facility census was 68. Review of the facility's policy titled Abuse, Prevention and Prohibition Policy, dated November 2025, showed the following:-Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly investigated in a timely manner and that steps were taken to protect all residents during the investigation when staff failed to document an investigation and steps to protect all resident during the investigation after an allegation of abuse involving one resident (Resident #1). The facility census was 68. Review of the facility's policy titled Abuse, Prevention and Prohibition Policy, dated November 2025, showed the following:-Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to prevent loss of strength and range of motion when staff failed to have a process in place to ensure ordered and care planned restorative services we were provided and documented for four residents (Resident #1, #2, #3, and #4). The facility had a census of 63. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to report an allegation of employee to resident abuse of one resident (Resident #1) in a timely manner. The facility census was 62. Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to report an allegation of employee to resident abuse of one resident (Resident #1) in a timely manner. The facility census was 62. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to transcribe new admission orders resulting in one resident (Resident #2) not receiving insulin for six days. The facility census was 62. Review of the facility policy titled Medication Administration-General Guidelines, dated July 2021, showed the following: -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;-Medications are administered in accordance with written orders of the prescriber. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure each resident's right to privacy was maintained when a staff member posted a photo to social media that showed one resident's face (Resident #1) and private medical information of another resident (Resident #2). The census was 62. Review of the facility's policy named, Social Media, undated, showed the following:-The community recognizes the importance of social media websites as a form of communication in today's society and to a great extent respects the staffs privacy while off-duty. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure catheter (a tube that is inserted into the bladder allowing your urine to drain) use and care per standards of practice when staff failed to obtain complete catheter orders for one resident's (Resident #3's ) self-catheterization, including specifications or monitoring. The facility census was 62. Review of the facility's policy, Catheter Care, Urinary, dated 12/24, showed the following:-The purpose of this procedure is to prevent catheter- associated urinary tract infections (CAUTI);-The following information should be recorded in the resident's medical record: the date and time that catheter care was given, any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain; any problems or complaints made by the resident related to the procedure; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide food in a form to meet each resident's needs when staff failed to thicken all liquids as ordered for one resident (Resident #4). The facility census was 62. Review of the facility's policy Therapeutic diets, undated, showed the following:-Therapeutic diets shall be prescribed by the attending physician. The facility will strive for the fewest possible dietary restrictions;-Mechanically altered diets, as well as diets modified for medical nutritional needs will be considered therapeutic diets;-A therapeutic diet must be prescribed by the resident's attending physician. The physicians diet order must match the terminology used by food services. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate and complete medical records for each resident when staff failed to fully document regarding a wound and treatments, including a wound VAC (a medical device that uses negative pressure to remove drainage from wounds and promote healing), for one resident (Resident #3) who admitted with the wound. The facility census was 62. Review of the facility's policy, Skin Identification, Evaluation, and Monitoring Policy, dated 01/25, showed the following:-The purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from verbal and physical abuse by staff when one staff (Certified Nursing Assistant (CNA) C) yelled at and physically forced a resident to receive incontinent care. The facility census was 64. Review of facility policy titled Abuse, Prevention, and Prohibition Policy, dated March 2025, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion; -Residents must not be subjected to abuse by anyone; -The facility prohibits mistreatment, neglect, or abuse of residents. Review of the facility Abuse Investigative Guidelines, dated May 2024, showed the following: -A nursing progress note should be entered after an allegation of abuse; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide care for all residents per standards of practice when staff failed to obtain and enter wound care orders, failed to document wound care provided, and failed to care plan current wounds and current treatments for three residents (Residents #2, #3, and #4) of six sampled residents. The facility census was 63. Review showed the facility did not provide a policy regarding obtaining, entering, and following treatment/monitoring orders. 1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 06/20/23; -Diagnoses included dementia (loss of memory), depression, fractured right hip, and muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of physical abuse were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required time frame when staff failed to report an allegation of abuse involving one resident (Resident #1) until the following day. The facility census was 63. Review of facility policy titled Abuse, Prevention, and Prohibition Policy, dated December 2024, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion; -Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely and thorough investigation, to include interviews with multiple staff and other residents, and steps taken to protect all residents during the investigation for an allegation of possible physical abuse involving one resident (Resident #1). The facility had a census of 63. Review of facility policy titled Abuse, Prevention, and Prohibition Policy, dated December 2024, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion; -Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store refrigerated medications at the medication's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 61. Review of the facility's policy titled Medication Storage in the Facility, dated April 2017, showed the following: -Medication and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier; -Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit (F) and 46 degrees F; -The facility should maintain a temperature log in the storage area to record temperatures at least once a day. Review of the Novolog (insulin aspart - rapid acting insulin) package insert, undated, showed the following: [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure all meals met the nutritional needs of residents when staff failed to follow approved menus for all residents and failed to provide potatoes, or comparable substitute, at a meal for all residents. The facility census was 61. Review of the facility's policy titled, Menu Substitutions or Changes and Approval, undated showed the following: -All substitutions, whether a one-time substitution or a permanent menu change, are recorded using a facility specific document or a menu substitution form. The registered dietician periodically reviews the documented menu substitutions or menu changes for nutritional equivalency and appropriateness; -When making a one-time substitution or permanent menu change, the replacement food item is of the same nutritional equivalency as the item being substituted. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to consistently label and date food; and failed to properly close frozen foods to prevent freezer burn; failed to cover foods in the refrigerator being stored under fan with lint and black substance. The facility census was 61. 1. Review of the 2013 Food Code, issued by the Food and Drug Administration (FDA), showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) plan that demonstrated identification, reporting, investigation, analysis, and prevention of adverse events, and documentation that demonstrated the development, implementation, and evaluation of corrective actions or performance improvement activities The facility census was 61. 1. Review of facility policy titled QAPI Policy, updated January 2024, showed the following: -The program would monitor quality and performance, find opportunities for improvement, and meet regulatory requirements; -The QAPI program consists of monthly/quarterly meetings, daily quality assurance activities, and performance improvement plans. Review of facility records showed the following: [...]

Inspectors wroteBased on observations, interviews, and record review, the staff failed to implement and maintain an effective infection control program when staff failed to maintain catheters (a tube that is inserted into the bladder to drain urine) in a manner to prevent the possible introduction bacteria in the system when the catheter bag and tubing for two residents (Resident #24 and #23) were placed or dragged on the ground. The facility also failed to perform proper hand hygiene during medication passes for seven resident (Resident #24, #30, #37, #23, #4, #13, and #50). The facility also failed to have and follow a Legionella (severe form of pneumonia) Water Management Program. The facility census was 61. 1. Review of the facility policy titled Catheter Care, Urinary, dated December 2024, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to follow their infection and control policy when staff failed to designate one or more certified staff persons as the infection preventionist (IP) who was responsible for the facility's infection prevention and control program (ICPC - systematic approach to prevent and control the spread of infections, particularly in healthcare settings). The facility census was 61. Review of the facility policy titled Infection and Control Program, undated, showed the following: -The facility maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors and healthcare workers; -Ultimate responsibility for overseeing and implementing the infection prevention and control program is delegated to the Quality Assurance Committee; [...]

Inspectors wroteBased on interview and record review, the facility failed to effectively implement their abuse and neglect prevention policies, when the facility failed to maintain documentation of completed criminal background checks (CBC), employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) checks, and Nurse Aide (NA) Registry (list that indicates if an individual has a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility) check. The facility census was 61. Review of facility provided policy, dated December 2024, titled Abuse, Prevention, and Prohibition Policy, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report allegations of possible resident abuse immediately to management and within in two hours to the state licensing agency (Department of Health and Senior Services - DHSS) for an allegations involving three residents (Resident #32, #50 and #29). The facility had a census of 61. Review of facility policy titled Abuse, Prevention, and Prohibition Policy, , dated December 2024,, showed the following: -Each resident had the right to be free from abuse, corporal punishment, and involuntary seclusion; -Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; -This facility prohibits mistreatment, neglect, or abuse of residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an immediate investigation for all allegations of abuse and failed to take immediate steps to protect all residents after receiving allegations of abuse involving three residents (Resident #32, #50 and #29). The facility had a census of 61. Review of facility policy titled Abuse, Prevention, and Prohibition Policy. dated December 2024, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion; -Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; -The facility prohibits mistreatment, neglect, or abuse of residents; [...]

Inspectors wroteBased on record review and interview, the facility failed to notify residents and the resident's representative in writing of a transfer to a hospital that included the reason for the transfer, date of transfer, and destination of transfer when staff failed to provide the written notification to five residents (Resident #31, #48, #15, #21, and #23) and their representative. A sample of 21 residents were in the facility with a census of 61. Review showed the facility did not provide a policy regarding transfer notices. 1. Review of Resident #'31's face sheet (resident's information at a quick glance) showed an admission date of 11/19/21. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) showed the following: -On 02/08/25, the resident was discharged with return anticipated; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written bed-hold policy information to every resident or resident representative at transfer when staff failed to provide written bed-hold policy information to five residents (Resident #31, #48, #21, #23, and #15) or their resident representative when the residents were transferred to the hospital. A sampled of 21 residents was reviewed in a facility with a census of 61. Review showed the facility did not provide a policy regarding bed-hold notification. 1. Review of Resident #'31's face sheet (resident's information at a quick glance) showed an admission date of 11/19/21. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) showed the following: -On 02/08/25, the resident was discharged with return anticipated; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards when the resident accessible hot water temperatures in four resident's (Resident #41, #48, #54, and #39) rooms measured greater than 120 degrees Fahrenheit (F). The facility census was 61. Review of the American Burn Association website, updated 2002, showed hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: -In 1 second at 156 degrees F; -In 2 seconds at 149 degrees F; -In 5 seconds at 140 degrees F; -In 15 seconds at 133 degrees F; -In 1 minute at 127 degrees F. -Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a side or bed rail evaluation form, to include a risk/benefit review and alternatives attempted prior to the use of side or bed rails; failed to document ongoing evaluations; failed to complete a side or bed rail safety check with regular inspections of the bed frame and side or bed rail for risk of entrapment; failed to obtain orders for side or bed rail use; and failed to develop care plan interventions and approaches for side or bed rails for five residents (Resident #21, #23, #43, #8, and #44) out of 21 sampled residents. The facility census was 61. Review of the facility's policy titled Bed Rails, approved December 2024, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and complete infection control program when staff failed to implement a complete antibiotic stewardship program (coordinated effort, often within a healthcare setting, to improve the appropriate use of antibiotics) when staff failed to track residents on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections. The facility census was 61. Review of the facility policy titled Antimicrobial Stewardship Playbook for Long-Term Care Facilities, undated, showed the following: -Antimicrobial stewardship (AS) is the process for ensuring optimal antimicrobial use during patient or resident care; -Optimal antimicrobial use can be assessed by using the 5 D' of AD: diagnosis, drug, dose, duration and de-esculation; [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when the floors in the kitchen had black and white substances present as well as debris under the sink. The facility census is 61. Review of the 2013 Missouri Food Code showed the following: -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -The physical facilities shall be cleaned as often as necessary to keep them clean. Review showed the facility did not provide a policy for the cleanliness of the kitchen. 1. Review of the facility's weekly cleaning schedule, undated, showed all staff were responsible for sweeping and mopping the kitchen daily. [...]

Inspectors wroteBased on record review and interviews, the facility failed to refer a Pre-admission Screening and Resident Review (PASARR) resident who had a negative Level I Preadmission Screen, who was later identified with a new mental disorder diagnosis to the appropriate state designated authority for a Level II PASARR evaluation and determination for one resident (Resident #54) out of 21 sampled residents. The facility also failed to update the resident's care plan to reflect the new diagnosis and interventions. This failure had the potential to negatively affect the resident's mental and psychosocial well-being. The facility census was 61. Review showed the facility did not provide a policy regarding PASARR requirements. Review of the facility's policy titled Care Planning, undated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with standard of practice when staff failed to timely report obtained laboratory results to the physician causing a delay of care for one resident (Resident #310) who presented with a change in condition. The facility's census was 61. Review showed the facility did not provide a change of condition policy. 1. Review of Resident #310's face sheet (admission data) showed the following: -admission date of 04/02/25; -Diagnoses included acute diastolic heat failure (a type of heart failure), depression, venous insufficiency (veins in the legs are damaged), and fracture of the humerus (upper arm bone). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/10/25, showed the following: -Cognitive skills intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to obtain a physician's order for the use of and complete a care plan for the use of a CPAP (continuous positive airway pressure - a machine that uses air pressure to keep airways open while a resident sleeps) for one resident (Resident #37) and when the facility failed to document refusal of oxygen use and contact supervisory staff and a medical practitioner when one resident (Resident #23) refused to wear oxygen as ordered. The facility census was 61. 1. Review of the facility's policy titled, CPAP/BiPAP (bilevel positive airway pressure - a breathing machine that delivers air pressure to the lungs through a mask) Support, dated December 2024, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective pain management program was in place for all residents when staff failed to care plan resident pain and interventions related to pain and failed to administer pain medication as ordered for one resident (Resident #50)resulting in increased pain for the resident. The facility census was 61. Review of the facility policy titled Medication Administration Policy for Senior Living, undated, showed the following: -Adherence to the Medication Administration Policy was essential to ensure the well-being and safety of the residents; -All staff members were expected to follow the guideline strictly and report any issues or deviations from the policy; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to post daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility census was 61. Review showed the facility did not provide a policy regarding posting of the daily nurse staffing. 1. Observation on 04/16/25, at 3:08 P.M., showed the facility did not post nurse staffing information in a public location accessible to residents and visitors. Observations on 04/17/25, at 09:36 A.M., showed the facility did not post nurse staffing information in a public location accessible to residents and visitors. Observations on 04/21/25, at 10:16 A.M., showed the facility did not post nurse staffing information in a public location accessible to residents and visitors. [...]

Inspectors wrote1. Please refer to event ID P16012, exit date 02/06/25, for details. MO00248905 Based on record review and interview, the facility failed to ensure an effective pain management program was provided to each resident when staff failed to maintain a supply of ordered pain medications and access to emergency use medications resulting in three residents (Resident #7, #8, and #9) not receiving pain medications as ordered. The facility census was 57. Review of the facility's policy titled Medication, Administration Guidelines, undated, showed it was the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies. 1. Review of Resident #7's face sheet showed the following: [...]

Inspectors wrote1. Please refer to event ID P16012, exit date 02/06/25, for details. MO00248905 This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies, dated 10/18/24. Based on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to have ordered medications available for staff administration and failed to have staff access to the emergency medications resulting in seven residents (Resident #4, #5, #6, #7, #8, #9, and #10) not receiving medications as ordered. The facility census was 57. Review of the facility's policy titled Medication, Administration Guidelines, undated, showed it was the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies. 1. Review of Resident #4's face sheet showed the following: [...]

Inspectors wrote1. Please refer to event ID P16012, exit date 02/06/25, for details. Based on record review and interview, the facility failed to ensure residents were free from significant medication errors when staff failed to maintain a supply of glucometer (a machine used to test blood sugar) test strips for resident use and as a result nurses were unable to perform physician ordered blood sugar checks and subsequently did not administer insulin as ordered to the three residents (Resident #3, #4, and #6 ). The facility census was 57. Review of the facility's policy titled Blood Glucose Monitoring, dated December 2016, showed the following: -Check physician's order for blood sugar testing; -Glucometer testing is conducted a maximum of one hour prior to administration of insulin; -Insulin should not be administered until accurate glucometer results obtained, for the best interest of the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when a staff member moved one resident (Resident #1) by pulling him/her across the floor by his/her feet while the resident laid on the floor. The facility census was 64. Record review of the facility's policy titled Resident's Rights, undated, showed residents shall be treated with consideration and respect, with full recognition of their dignity and individuality. 1. Review of Resident #'1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 04/13/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was free from abuse when two staff (Certified Nurses Aide (CNA) E and Certified Medication Technician (CMT) F) physically forced one resident (Resident #1) to shower against his/her wishes- resulting in the resident yelling out for help, fighting against the aides, receiving bruises on both the right and left hand/wrist, and voicing he/she was upset. The facility census was 72. The Assistant Administrator and the Administrator were notified on 10/29/24, at 4:05 P.M., of an Immediate Jeopardy (IJ) which began on 10/26/24. The IJ was removed on 10/31/24 as confirmed by surveyor onsite verification. Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when staff did not report an allegation of possible abuse received from a staff member regarding two staff (Certified Nurse Aide (CNA) E and Certified Medication Technician (CMT) F) forcing one resident (Resident #1) to shower against his/her wishes. The facility census was 72. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all licensed nurses had the specific competencies and skills necessary to care for residents, when one facility staff member (Licensed Practical Nurse (LPN) C) continued to work as a nurse in the facility after his/her nurse license was no longer valid in the State of Missouri. The facility census was 68. Review of the facility policy/protocol titled, Screening, undated, showed: -It is the policy of the facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect all residents from misappropriation of resident property when the facility could not account for all resident medication, while in the medications were in the possession of the facility staff, for four residents (Resident #1, Resident #2, Resident #3, and Resident #4). The facility census was 68. Review of the facility's Abuse Prohibition Protocol Manual, dated 11/28/2016, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an effective pain management program was provided to each resident when staff failed to maintain a supply of ordered pain medications and access to emergency use medications resulting in three residents (Resident #7, #8, and #9) not receiving pain medications as ordered. The facility census was 57. Review of the facility's policy titled Medication, Administration Guidelines, undated, showed it was the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies. 1. Review of Resident #7's face sheet showed the following: -Diagnoses included congestive heart failure (CHF - chronic condition where the heart muscle is weakened and cannot pump blood efficiently throughout the body), kidney disease, and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to to have pharmacy services in place to ensure a consistent counting and reconciliation of controlled substances when staff failed to consistently document the number of medication packages and when staff failed to consistently initial the change of shift controlled medication count on the controlled substance shift change log located in four of four medication carts in the facility. The facility census was 68. 1. Review of the October 2024 Controlled Substance Shift Change Log, for the Alzheimer's unit medication cart, showed the following: -Every shift, 6:30 A.M., 2:30 P.M., and 10:30 P.M., staff to initial oncoming and off going counts and list the total number of medication packages; -On 10/02/24, 10/03/24, and 10/04/24, at 10:30 P.M., the oncoming staff failed to initial the count; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from significant medication errors when staff failed to maintain a supply of glucometer (a machine used to test blood sugar) test strips for resident use and as a result nurses were unable to perform physician ordered blood sugar checks and subsequently did not administer insulin as ordered to the three residents (Resident #3, #4, and #6 ). The facility census was 57. Review of the facility's policy titled Blood Glucose Monitoring, dated December 2016, showed the following: -Check physician's order for blood sugar testing; -Glucometer testing is conducted a maximum of one hour prior to administration of insulin; -Insulin should not be administered until accurate glucometer results obtained, for the best interest of the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received care per standards of practice when staff failed to administer antibiotics for a food infection timely, failed to routinely monitor the wound dressing follow toe amputation, and failed follow-up with the physician/surgeon when the wound dressing became saturated for one resident (Resident #1). The facility census was 68. Review of the facility policy titled, Resident Examination and Assessment, undated, showed the following: -The purpose of this procedure is to examine and assess the resident for any abnormalities in health status; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide wound care and monitoring consistent with standards of practice when when staff did not document complete pressure ulcer wound assessments, when staff did not obtain physician orders to treat pressure ulcers on the resident's left buttocks, and when staff did not obtain timely orders to treat pressure ulcers on the resident's right buttocks for one resident (Resident #1). The facility census was 68. Review of the facility policy titled, Wound Protocol, dated 2018, showed, in part, the following: -Use care when removing dressings and tapes to avoid damage to fragile skin; [...]

Inspectors wrote1. Please see event ID 7LS712, exit date 06/04/24, for citation details. MO00235482 Based on observation, interview, and record review, the facility failed notify the physician and resident representative of a fall with injury in a timely fashion for one resident (Resident #1). The facility census was 70. Review of the facility policy titled, Fall Champion Program, not dated, showed the following information: -Staff are to notify the Medical Director, Fall Champion, and Administrator of falls; -Staff are to notify the resident's physician and family/responsible party and document the notification in the fall event. 1. Review of Resident #1's face sheet (basic information sheet) showed the following information: -admission date of 03/14/24; [...]

Inspectors wrote1. Please refer to event ID 7LS712 for citation details. MO00235482 MO00236961 Based on observation, interview, and record review, the facility failed to provide care per standards of practice when the facility failed to complete/document neurological checks (a series of tests that assess mental status, reflexes, and movements) timely after a fall with a head injury, failed to ensure all nursing staff were aware of the fall with injury and fall monitoring, and failed to timely address x-rays results showing a fracture after fall for one resident (Resident #1). The facility also failed to provide care per standards of practice when staff failed to complete an ordered urinalysis (UA) timely and when failed to administer medications to treat a urinary tract infection (UTI) as ordered for one resident (Resident #2). The facility census was 70. 1. [...]

Inspectors wrote1. Please refer to event ID 7LS12, exit date 06/04/24, for citation details. MO00235482 Based on observation, interview, and record review, the facility failed to ensure all records were complete and accurate when staff failed to document regarding x-ray results and transport to the hospital for one resident (Resident #1) following a fall with injury. The facility census was 70. Review of the facility policy titled, Fall Champion Program, not dated, showed the following information: -Emergency care is to be provided as needed after a fall; -Staff are to take vital signs and assess condition of the resident; -Staff are to complete post fall follow-up for 72 hours including assessment, documentation of the resident's condition in progress notes, and neurological checks (a series of tests that assess mental status, reflexes, and movements). 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect at all times when one staff (Certified Nurses Assistant (CNA) B) was spoke in a rude, loud, and disrespectful manner to one resident (Resident #1). The facility had a census of 69. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Policy, not dated and provided as the facility's dignity/respect policy, showed the following guidance: -Any employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the nursing home administrator. (The policy did not address treating residents in a dignified manner.) 1. Review of Resident #1's face sheet (basic information sheet) showed the following: -admission date of 10/03/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed notify the physician and resident representative of a fall with injury in a timely fashion for one resident (Resident #1). The facility census was 70. Review of the facility policy titled, Fall Champion Program, not dated, showed the following information: -Staff are to notify the Medical Director, Fall Champion, and Administrator of falls; -Staff are to notify the resident's physician and family/responsible party and document the notification in the fall event. 1. Review of Resident #1's face sheet (basic information sheet) showed the following information: -admission date of 03/14/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when the facility failed to complete/document neurological checks (a series of tests that assess mental status, reflexes, and movements) timely after a fall with a head injury, failed to ensure all nursing staff were aware of the fall with injury and fall monitoring, and failed to timely address x-rays results showing a fracture after fall for one resident (Resident #1). The facility also failed to provide care per standards of practice when staff failed to complete an ordered urinalysis (UA) timely and when failed to administer medications to treat a urinary tract infection (UTI) as ordered for one resident (Resident #2). The facility census was 70. 1. Review of the facility policy titled, Fall Champion Program, not dated, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all records were complete and accurate when staff failed to document regarding x-ray results and transport to the hospital for one resident (Resident #1) following a fall with injury. The facility census was 70. Review of the facility policy titled, Fall Champion Program, not dated, showed the following information: -Emergency care is to be provided as needed after a fall; -Staff are to take vital signs and assess condition of the resident; -Staff are to complete post fall follow-up for 72 hours including assessment, documentation of the resident's condition in progress notes, and neurological checks (a series of tests that assess mental status, reflexes, and movements). 1. Review of Resident #1's face sheet (basic information sheet) showed the following information: -admission date of 03/14/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to meet monthly per the facility's policy and failed to ensure the medical director or desginee attended at least quarterly for two of five quarterly Quality Assessment and Assurance (QAA) committee meetings. This had the potential to affect all 72 residents residing in the facility. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, updated 03/21/23 showed the QAA Committee will meet monthly. 1. Review of the QAA sign-in sheets, provided by the facility, showed five meetings were held from 07/2022 to 05/09/2023 and three of the five meetings a physician did not attend. -On 07/19/22, there was no physician signature. -On 09/13/22, there was no physician signature. The physician's signature line included a note via email. -On 01/19/23, there was no physician signature. [...]

Inspectors wroteBased on interviews and record review, the facility failed to complete an accurate Minimum Data Set (MDS - a federally mandated assessment tool used by facility staff) assessment for three residents (Resident #8, Resident #21, and Resident #38) of 20 residents sampled for MDS accuracy. This had the potential for resident care and services to be delayed, and residents not having the chance to achieve their highest practical level of well-being. Review of the MDS 3.0 RAI (Resident Assessment Instrument) Manual v1.18.11, draft October 2023, showed the following: -The purpose of the manual is to offer clear guidance about how to use the RAI correctly and effectively to help provide appropriate care; -Clinical competence, observational, interviewing, and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure seven residents (Resident #7, #8, #25, #38, #43, #47, and #65) of 20 residents sampled for individualized comprehensive care plans, had care plans and approaches individualized to their specific diagnoses and care needs. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed the following: -An individualized comprehensive care plan includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisplinary care plan team with the input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor behavioral symptoms and/or side effects/adverse consequences for five residents (Resident #67, #25, #7, #222, and #65) of seven residents reviewed for the use of psychotropic medications. Review of the facility's policy titled, Psychoactive Drug Therapy, dated 4/2006, showed an unnecessary drug is any drug when used in excessive dose or for excessive duration, or without adequate monitoring, without adequate indication for use, or in the presence of adverse consequences, which indicate the dose should be reduced or discontinued. Review of the psychotropic drug evaluation sheet of the policy included Potential side effects monitored by: [blank]. 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one resident (Resident #47) of one resident reviewed for pressure ulcers out of a sample of 72 did not develop a pressure ulcer unless their clinical condition showed that it was unavoidable. The resident developed a new, facility-acquired pressure ulcer that was not documented and appropriation notifications completed upon discovery by facility staff. Review of the facility's policy titled, Condition Change, Resident Observing, Recording and Reporting, undated, showed staff to observe, record and report any condition change to the attending physician so that proper treatment can be implemented Review of the facility's policy titled, Wound Care and Treatment, undated, showed prevention strategies included ongoing skin assessment with weekly documentation status. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure two residents (Resident # 8 and #38) of 28 sampled residents, received physical therapy (PT) and occupational therapy (OT) per physician orders. 1. Review of Resident #8's Face Sheet, undated, located in the electronic medical record (EMR), showed the following: -admission date of 02/23/22; -readmission date of 07/16/22; -Diagnoses included polyosteoarthritis (joint pain and stiffness), intercostal (rib) pain, muscle weakness, and low back pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to four residents (Resident #7, #32, #50, and #60) who are unable to carry out activities of daily living (ADLs) of grooming and personal hygiene. The facility census was 73. Record review of the facility's policy titled, Activities of Daily Living (ADL), dated March 2015, showed the following: -Verbal directions must be clear and concise; repeat directions as needed. Never assume that resident understands what his meant by verbal commands; -Frequent repetition is often necessary, especially with a confused resident. 1. Record review of Resident #60's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/27/18; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication rate of less than five percent when staff failed to administer a fast-acting insulin (medication used to lower blood sugar levels) timely as directed by the manufacturer for three residents, (Resident # 28, # 30, and # 124) resulting gin five medications errors our of 27 opportunities resulting in a medication error rate of 18.5 percent. The facility census was 73. Record review of the facility's Medication Administration Policy, dated March 2015, showed the following: -It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; -A current Physician's Drug Reference is available at each nurse's station; -Refer to the Pharmacy Manual for pharmaceutical policies and procedures; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored in a manner to protect the food from possible contamination when staff failed to dispose of expired food items and failed to ensure potentially hazardous food was maintained at the proper temperature. Staff failed to ensure dishes were cleaned in a manner to protect food from possible contamination when staff used wet dishes and utensils for food service. This had the potential to affect all residents. The facility census was 73. 1. Record review of the Missouri Food Code, published 2013, regarding refrigerator food storage, showed the following: [...]