Summit, the

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 6 sampled residents (Resident #4, #5, #6, #7, #14 and #15) out of 15 sampled residents when live bedbugs were observed in their rooms. The facility census was 55 residents. Review of the facility's Bedbug Policy dated 2024 showed:-Staff should report immediately any signs of bedbug infestation to the department head, direct supervisor and/or the administrator.-When bedbugs were discovered in a resident room, if possible, the resident should be showered or bathed, clothes changed and transferred to another room; resident belongings, equipment and furnishings including beds should not leave the room until thorough inspection found them bed bug free; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual 12 hours of in-service training and competencies skill check off for Certified Nursing Assistants (CNAs). This had the potential to affect all of the residents residing in the facility. The facility census was 56 residents. Review of the facility's Certified Nursing Assistant (CNA) Continuing Education Policy dated 5/25/23 showed:-All CNA's must complete a minimum of 12 hours of continuing education annually, in accordance with State and Federal regulations. -The Director of Nursing (DON) will create an annual training schedule and ensure relevant topics are covered. -CNAs must submit proof of completed training (e.g., certificates of completion) to the facility human resource department. -Supervisor will review training records quarterly to ensure compliance and document compliance. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the fan vent cover in the dining room that had heavy dust buildup; maintain the floor behind and under equipment where debris had built up; maintain the drains throughout the kitchen especially by the Victory refrigerator that had grime build up; maintain the cleanliness of the floor in the dry goods storage room; maintain the cleanliness of the ceiling above the wall mounted fan had food splashes present; maintain the fans inside the refrigerator that had debris on them that were blowing directly on drinks and the bottom shelf; maintain the cleanliness of the stove from dust and grime built up on the front, sides, the shelf, and behind on the hoses; maintain the cleanliness of the racks, floors, and walls in refrigerator #3 that had a white substance growing on it; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Quality Assurance and Performance Improvement (QAPI-a structured approach to improving quality in healthcare settings) and QAPI activities (development of performance improvement action plans, monitoring, analysis and feedback) were documented to show how the facility was measuring the success of quality improvement actions and performance. This failure potentially affected 56 residents. The facility census was 56.1. Review of the facility Certification and Survey Provider Enhanced Reports (CASPER-reports generated from information submitted by the facility to assess their performance and identify areas for improvement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an on-going process for monitoring facility-wide Infection Prevention Control Program (IPCP) was established; failed to ensure surveillance logs were maintained with written documentation for 17 months out of 18 months (January 2024 to May 2025) of surveillance to include but not limited to: documentation of monitor, track, and identify trends of infections in the facility and outcome of findings; and failed to ensure infection control prevention practice of proper hand hygiene preformed during personal care for one sampled resident (Resident #2) out 24 residents. The facility census was 56 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a certified Infection Control Preventionist at least part time to coordinate the surveillance of the facility's Infection Control and Prevention Program. The facility census was 56 residents. Review of the facility General Infection Control Program Policy dated 2023 showed:-Infection Control Preventionist (ICP), a person designated to serve as coordinator of the facility's infection prevention and control program. -Surveillance including process and outcome surveillance, monitoring, data analysis, documentation and communicable disease reporting (as required by state and federal law and regulation. 1. Review of the requested copy of the facility ICP's certification on 8/4/25 at 10:30 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to repair a drainpipe that was coming off the Victory Refrigerator and dripping water on to the floor next to a bolt which was causing it to rust instead of draining directly into the nearby drain. The facility census was 56 residents.1. Observation on 7/31/25 from 9:04 A.M. to 1:33 P.M. showed:-The drainpipe leading from the Victory Refrigerator was not draining into the adjacent drain.-It was draining on the floor next to a bolt which was causing it to rust and then the rust and water would run on to the floor into the drain. During an interview on 7/31/25 at 1:33 P.M. Dietary Manager said:-The drainpipe had not reached the drain for about a month. -He/She did not know what happened to it.-He/She thought it was on the schedule to be fixed but wasn't sure.

Inspectors wroteBased on observation and interview, the facility failed to ensure the fan in the laundry area was free from a heavy buildup of dust. This practice potentially affected an unknown number of residents because the fan was directed towards the clean clothing on a hanger. The facility census was 56 residents.1. Observation on 7/28/25 at 1:41 P.M., showed one fan with heavy buildup of dust on the blades and the grate (the plastic/metal covering over the exposed parts of machinery) which was directed towards the clean clothes on a hanger behind Laundry Aide (LA) A.During an interview on 7/28/25 at 1:42 P.M., LA A said he/she did not know the last time the fan was cleaned. During an interview on 7/28/25 at 1:49 P.M., the Housekeeping/Laundry Supervisor said he/she brought the fan out of a closet somewhere and did not know the last time the fan was cleaned.

Inspectors wroteBased on observation and interview, the facility failed to ensure there was negative air flow (a ventilation system that continually attempts to move air out of the room) in required areas such as the soiled utility/biohazard rooms, shower rooms and the restrooms of resident rooms. This practice affected all residents, because none of the resident room restrooms had negative air flow. The facility census was 56 residents.1. Observation on 7/29/25 with Maintenance Person A showed the following:-At 10:04 A.M., there was the absence of negative air flow in the biohazard room located behind the first floor nurse's station.-At 10:10 A.M., there was the absence of negative air flow in the restroom of resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a closed record was complete by showing a recapitulation of stay for one sampled closed record resident (Resident #62) out of 24 sampled residents. The facility census was 56 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure perineal (peri) care was provided as needed for one sampled resident (Resident #3) out of 24 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Policy for Daily Activities of Daily Living (ADL) dated 2024 showed bed mobility care is performed daily every 2 hours for limited mobility residents and every 4-6 hours depending on tissue tolerance and whenever needed. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an individualized activity plan was goal directed and incorporated the interest and ability of one sampled resident (Resident #20) out of 24 sampled residents. The facility census was 56 residents. Review of the facility Activity policy dated 2022, showed:-The purpose to ensure residents receive meaningful activities. To ensure assessments for activities preferences are completed on admission. To ensure progress documentation of activity assessment. -Provide a plan of activities appropriate to the needs of the residents. -Assess resident needs and develop resident activities goals for the written care plan. -Encourage resident participation in activities and document outcomes. -Review goals and progress notes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed regarding a medical device being placed by proper personnel and administered as ordered for one sampled resident (Resident #1) that was not supposed to be self-administered out of 24 sampled residents. The facility census was 56 residents. Review of the facility's Medication Administration policy and procedure dated 2024, showed there was no policy or procedure for administering treatments or medical equipment or devices. Review of the facility's Self Administration policy and procedure dated 2018, showed there was no policy or procedure for self-administering medical equipment or devices.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident smoking materials were stored safely for one sampled resident (Resident #40); failed to ensure a safe smoking environment after a resident fell asleep while holding a lit cigarette; failed to re-assess the resident for safe smoking; and failed to develop care plan interventions to prevent the incident from recurring for one sampled resident (Resident #42), out of 24 sampled residents. The facility census was 56 residents. Review of the facility's Smoking Policy dated 2022 showed:-The resident's Safe Smoking ability was to be completed yearly or on quarterly assessments.-Assess resident's safe smoking behavior. Determine needs for safety such as a smoking apron, 1:1 supervision and address in the care plan. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician's orders for self-administration and care for a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) were obtained and documented on the Physician's Order Sheet (POS) for one sampled resident (Resident #13) out of 24 sampled residents. The facility census was 56 residents. Review of the facility's undated Ostomy-Colostomy policy and procedure showed the purpose was to prevent infection and ensure proper drainage, enhancing hygiene and dignity. It showed:-The resident will be informed of care for the (colostomy).-A resident who is able to perform self-care will be provided information and education on (colostomy) care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly assess the resident's chewing and swallowing ability, failed to re-assess the resident's dietary need and preferences to address the resident's weight and eating status and failed to care plan recent weight loss and nutritional interventions for one sampled resident (Resident #13) with gradual weight loss out of 24 sampled residents. The facility census was 56 residents. Review of the facility's Unplanned Weight Management policy and procedure dated 2006, showed the purpose was to ensure each resident received appropriate nutritional care and ensure significant weight loss or gain be addressed and clinically managed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician's orders were followed for monitoring and documenting one sampled resident's (Resident #1) dialysis access site (a surgically created pathway that allows blood to be removed from and returned to the body during hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) out of 24 sampled residents. The facility census was 56 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication refrigerator temperatures were checked daily and documented on the facility temperature log sheet to maintain safe storage of temperature controlled refrigerated medication; and failed to ensure to medication refrigerators were cleaned as scheduled and free of spills. This deficient practice had the potential to affect all residents with medication stored in the medication refrigerators. The facility census was 56 residents. Review of the facility's Storage of Medications policy dated 2024 showed:-Medications are to be stored in a safe, secure, and orderly manner.-Drugs are to be stored at proper temperatures. -Temperature logs are to be completed daily by the 11:00 P.M. -7:00 A.M. night shift. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure wound care treatments and skin assessments were completed and documented for one sampled resident (Resident #3) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Non-Pressure Ulcer Assessment and Treatment dated from 2006 showed: -The purpose of the policy was to maintain skin integrity and prevent any type of wound development. -All non-pressure ulcers would be assessed and documented weekly using the provided form. -All residents would be assessed every thirty days for skin integrity. -All non-pressure wounds would be treated according to physician order. -Skin screenings were done according to bath schedule. -Assessment weekly/monthly or more frequent would occur as instructed by the Registered Nurse (RN) or Director of Nursing (DON). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that wound care treatments were completed and documented including weekly wound tracking and measuring was completed for one sampled resident (Resident #2) who had pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin); and failed to ensure weekly skin assessments were completed and documented for one sampled resident (Resident #1) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Pressure Ulcer Treatment Policy and Procedure dated from 2006 showed: -Staff were to assess pressure ulcers by using the wound assessment form weekly and for any change in condition. -The staff were to use appropriate topical therapy per physician order or recommendation from wound care specialists. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall investigations were complete and thorough to include root-cause analysis (RCA- a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) for three sampled residents (Resident #1, Resident #4, and Resident #5) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Policy and Procedures for Fall Investigation dated from 2006 showed: -Licensed nurses perform an assessment within a time frame appropriate to the clinical circumstance, right after a fall has occurred and coordinate other indicated evaluation and management of injuries or underlying causative conditions. -Licensed nurses completed the fall investigation upon each fall on the provided form. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight for one sampled resident (Resident #1) when Certified Nursing Assistant (CNA) A exploited the resident by cultivating a relationship with him/her who was hearing impaired, took the resident from the facility to hi/her bank out of state, attained access to the resident's accounts without an American Sign Language (ASL) or Certified Deaf Interpreter (CDI) present, then used the access to the resident's account to withdraw $24,952.83 out of three sampled residents. The facility census was 64 residents. Review of the facility's undated Abuse and Neglect Policy showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing was posted at the beginning of each shift that included the resident census, the current date, the total numbers and actual hours worked for all licensed and unlicensed staff that provided direct care to residents, and to display it in a way that was readily accessible to residents and visitors to view. This had the ability to effect all residents. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled Policy for Staffing showed: -A staffing board was to be displayed in a public area and include the number of licensed and unlicensed direct care staff. -The staffing board was to be visible to visitors and others. -A form, with areas for all the required information, was attached. 1. Observation on 9/10/23 at 11:05 A.M. showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was adequate dietary staff to ensure the breakfast meal on 9/10/23, was served on time and to ensure dietary staff used the proper cooking equipment (baking pans for chicken) to ensure the lunch meal was served timely on 9/11/23. This practice potentially affected all residents. The facility census was 54 residents. 1. Review of an Undated sign in the dining room showed the following: -Meal Times: --Breakfast - 8:00 A.M. --Lunch - 12:00 P.M. --Dinner - 5:00 P.M. 2. Review of Resident #42's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 7/7/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. During an interview on 9/10/23 at 11:13 A.M., the resident said: [...]

Inspectors wroteBased on observation and interview, the facility failed to do or maintain the following: maintain the automated dishwasher free of food debris inside the nozzles of the dishwasher spray wands; to protect open bowls of fruit and cottage cheese by not placing a cover on those items within the reach-in refrigerator; place a date on the tray that the ground meat in the reach-in refrigerator, was removed from the freezer; place a date on the bag of shredded cheese as to when that bag was opened; remove the food debris and grease buildup from the floor behind the 6-burner stove; remove a buildup of grime and food debris from the bottom of the reach-in refrigerator; discard a bag of lettuce in which the lettuce began to turn to brown; remove two spatulas with handles which were not easily cleanable from service; and remove food debris from under the reach-in refrigerators. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit accurate information to the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for three of the last four quarters, which had the potential to affect all residents. The facility census was 54 residents. No policy regarding PBJ submissions was received at time of exit. 1. Review of the facility's PBJ Quarter Three (2022) from 4/1/22-6/30/22 showed no data submitted for the quarter. Review of the facility's PBJ Quarter Four (2022) from 7/1/22-9/30/22 showed no Registered Nurse (RN) hours and no licensed nurse coverage 24 hours a day. Review of the facility's PBJ Quarter Two (2023) from 1/1/23-3/31/23 showed the facility failed to have a licensed nurse in the facility 24 hours a day. [...]

Inspectors wroteBased on interview and record review, the facility failed to comply with the requirements of a waterborne illness prevention program by failing to having an annual backflow prevention test (a test to find out if the one-way gate that allows water from the city's public water supply to flow into a building's piping but stops water if it ever tries to flow backwards into the main water supply, was working properly) and by failing to develop a specific waterborne illness prevention plan for that facility by failing to conduct a facility specific risk assessment to find out where opportunistic waterborne pathogens could grow; failed to formulate a diagram to indicate which hot water heaters would distribute water to distinct sections of the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process to monitor antibiotic usage including prescribing and documentation of the indication, dosage, and duration of the use of antibiotics. This failure had the potential to affect all residents at the facility. The facility census was 54 residents. Review of the facility's policy titled Antibiotic Stewardship Policy dated from 2021 showed: -Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -Antibiotic Stewardship can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to ensure staff were aware of who was certified in cardiopulmonary resuscitation (CPR-an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth, in an effort to preserve intact brain function until further measures are taken). The facility census was 54 residents. 1. Review of the facility's policy, dated 2023, titled Policy for Medical Emergency Response showed the facility was to maintain a record of any staff who were trained and capable of performing CPR. During an interview on [DATE] at 1:25 P.M., the Administrator in Training (AIT) said: -He/she made the staff schedules. -All staff in the building, including non-nursing staff, were CPR certified. -Staff knew everyone in the building was CPR certified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's privacy by failing to ensure the privacy curtain was operable and was able to be used to provide privacy to one sampled resident (Resident #404) out of 14 sampled residents. The facility census was 54 residents. 1. Review of Resident #404's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including respiratory failure, cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), abnormal mobility and gait, muscle weakness, abnormal posture and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/5/23, showed the resident: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one sampled resident for a seatbelt to determine if it was a restraint or a safety device, to obtain a physician's order for the device and to care plan the seatbelt if needed for one sampled resident (Resident #404) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Physical Restraint policy and procedure updated 2023, showed a physical restraint is an item used to restrain or prevent the movement of a person. These devices include belts .Whether or not a particular item is considered a physical restraint depends on the purpose and effect of its use. The same item may not be used as a restraint if it is used to enable a resident in some way. The procedure showed: -Staff should complete a risk assessment upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold forms were completed for three sampled residents (Resident #48, #28, and #403) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy titled Bed Hold Policy and Readmission dated from 2021 showed at the time of transfer of a resident for hospitalization or therapeutic leave, the facility will provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. 1. Review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: -Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) was completed accurately and in a timely manner for three sampled resident (Resident #48, #9, and #403) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated from 2023 showed: -The MDS Coordinator and the Director of Nursing (DON) are responsible to review the completion of MDS items. -Randomly reviewed by DON or administrator to ensure the timely completion (monthly, quarterly, or Pro Re Nata (PRN) per DON's discretion). [...]

Inspectors wroteBased on interview and record review, the facility failed to include one sampled resident (Resident #48) when completing their care plan; and to ensure care plans were updated to reflect the resident's correct status for one sampled resident (Resident #403) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled RAI [Resident Assessment Instrument] Process Protocol showed: -The care plan team was to consist of all nursing disciplines, social services, dietary, activities, and other therapies as applicable. -Resident inclusion is not addressed. A policy specifically related to care plans was requested and not received at the time of exit. 1. Review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to complete Annual or quarterly Smoking Safety Assessment to assess the resident's ability to safely smoke unsupervised and to ensure to monitor and assess safe storage of smoking material for one sampled resident (Resident #18), who had a known history of smoking in non-designated smoking areas, out 14 sampled residents. The facility census of 54 residents. Review of the Smoking Safety Assessment form created 2018 showed: -Complete resident Smoking Safe Assessment quarterly, yearly and whenever condition change that affect the resident safety. -Assessment Criteria include: --Express understanding of the facility smoking rule and policy. --Holding cigarette properly (finger not close to fire or ashes). --Using an ashtray properly when disposing ashes. --Falls asleep during smoking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for the resident's colostomy (or ostomy, is a surgical a hole (stoma) in the abdominal wall allows waste to leave the body. A colostomy or ostomy bag attaches to the stoma to collect the waste) care and monitoring of the stoma site; to obtain a physician's order for the resident to provide his/her own colostomy self-care; and to obtain and maintain ongoing nursing assessment of the resident's ability to provide own colostomy self-care for one sampled resident (Resident #18) out of 14 sampled residents. The facility census of 54 residents. Review of the facility's Policy for Colostomy Care dated 2023 showed: -To ensure proper colostomy care that prevents infection and injury. -Nursing care shall maintain integrity of the stoma and skin surrounding the stoma. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and treat one sampled resident (Resident #34) with continued gradual weight loss with significant dental issues resulting in a 6.4% weight loss in three months and an 8% weight loss in six months, and to develop and implement a care plan for the resident with interventions related to the gradual weight loss and dental issues, out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Nutritional Management Program dated 2023 showed: -The Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would be responsible to establish a monthly and weekly weight schedule. -The staff responsible for weighing will compare the current weight and the previous weight and shall re-weigh if the weight of 5 pounds (lbs) in variance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribe physician's order to the resident's Treatment Administration Record (TAR) for monitoring the resident's Arteriovenous (AV) shunt (is access site, were a abnormal connections between coronary arteries and a compartment of the venous side of the heart) used for dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments and failed to ensure to follow the physician's order and document monitoring AV shunt assessment on TAR each shift and on the AV shunt assessment form daily, and failed to provide this resident dialysis contract for review for one sampled resident (Resident #12) out of 14 sampled residents. The facility's census was 54 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate behavioral management for one sampled resident (Resident #50) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy titled Behavior Management Program dated from 2023 showed: -The term behavior symptom is defined as an indication or characteristic of a negative physical or psychosocial outcome, which may indicate negative interactions or negative attitude that result in unpleasant atmospheres and disturbs others. -A change in behavior includes any abnormal or unusual pattern of behavior symptoms including increase or decrease the severity. -Residents who exhibit behavior symptom concerns will be monitored and/or treated to prevent incident. -Monitoring should include check pattern, occurrence. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately care plan and assist one sampled resident (Resident #48), out of 14 sampled residents, in obtaining routine dental care services. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled Ancillary Services showed: -Staff were to follow the physician's order, arrange the appointment, and arrange transportation. -Staff were to address dental concerns in the resident's care plan. -The Minimum Data Set (MDS-a federally mandated tool used for care planning) was to reflect any dental concerns. -Staff were to periodically assess each resident's teeth. 1. Review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: -Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident's preference of non-lactose milk was available for one sampled resident (Resident #500) for a period of 17 days. The facility census was 54 residents. 1. Review of Resident #500's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 7/29/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. Review of the resident's face sheet dated 9/1/23, showed diagnoses which included Crohn's Disease (a type of inflammatory bowel disease (IBD) which caused swelling of the tissues (inflammation) in the digestive tract, which could lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food stored in the 2nd floor refrigerator used to store food for residents brought in by visitors, was labeled with the resident's name and dated with the date the food was brought in. This practice potentially affected at least three residents who have food stored in the refrigerator. The facility census was 54 residents. Review of the facility's policy entitled Policy Regarding Use and Storage of Foods Brought to Residents by Family and Other Visitors, dated 2019, showed: -Purpose: To ensure the resident's safety while using foods that are not provided by the facility. -The nursing home follows the directions of regulatory requirements and food safety requirements of F 812 and F 813. -The nursing home allows residents to choose to accept food from any friends, family, visitors or other guests. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the lid for the outdoor dumpster was kept closed when it was not in use. This practice potentially affected an unknown number of residents who used the outdoor patio for smoking which the dumpster was adjacent to. The facility census was 54 residents. 1. Observations on 9/10/23 at 11:06 A.M. and at 1:18 P.M., showed the right side lid of the dumpster was lifted to the open position. 2. Observations on 9/11/23 at 8:08 A.M., 10:12 A.M., 12:15 P.M. and 1:47 P.M., showed the right side lid of the dumpster was lifted to the open position. During an interview on 9/11/23 at 1:48 P.M., the Dietary Manager (DM) said the dumpster lid was used by different departments and they do not close the lid like they should. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for rehabilitation services in a timely manner for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled Policy for Ancillary Services showed staff were to ensure all services were offered in a timely manner. 1. Review of Resident #5's face sheet showed he/she was admitted on [DATE] with rheumatoid arthritis (chronic inflammation of the joints) and generalized muscle weakness. Review of the resident's Care Plan, dated 8/15/23, showed: -Staff documented the resident had limited mobility related to arthritis. -The resident was totally dependent on staff for locomotion using his/her wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menu substitutions were reviewed and revised as needed by the Registered Dietitians (RD) or the menu company when facility dietary staff substituted food items for what was written on the menu on three different occasions. This practice potentially affected all residents. The facility census was 51 residents. 1. Record review of the breakfast menu for Wednesday, Day 4 of Week 1 for 7/20/22 showed assorted Juice, hot or cold cereal, sausage gravy and biscuits, margarine and beverage. Observation on 7/20/22 from 7:11 A.M. through 8:40 A.M. showed Dietary [NAME] (DC) A substituted eggs for the sausage and substituted French Toast sticks for the biscuits. Observation on 7/20/22 at 7:18 A.M., showed DC A placed French Toast sticks on a baking sheet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the lowest shelf in the reach-in fridge was free of grime; to remove debris from under the ice machine; to remove debris from the nozzles of the dishwasher spray wand; to ensure the single light bulb in the walk-in ridge was illuminated; to prevent the buildup of debris on the floor of the dry goods storage room; and to ensure thermometer probe wipes were available for use. This practice potentially affected all residents. The facility census was 51 residents. 1. Observations during the initial kitchen review on 7/18/22 from 9:17 A.M. through 9:31 A.M., showed: - The presence of grime on bottom of the fridge. - The presence of the debris under the ice machine. - The presence of debris inside the nozzles of the dishwasher spray wands. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an on-going monitoring facility-wide Infection Prevention Control Program (IPCP) was established; to ensure surveillance logs were maintained for seven months out of 12 months surveillance to include but not limited to: monitor, track, and identify trends of infections in the facility; and to screen and maintain documentation for tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, and abnormal lung tissue and function) for 2 of 8 sampled employees. This had the potential to affect all residents who had infections or who were at potential risk for infections. The facility's census was 51 residents. Record review of the facility policy for Infection Control Surveillance, revised 2006 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received mail on mail delivery days as identified by the United States Postal Service, including Saturdays, and mail that was not opened for two sampled residents (Resident #12 and #6) and one supplemental resident (Resident #33) out of 15 sampled residents and nine supplemental residents. This had the potential to affect all residents. The facility census was 51 residents. The facility failed to provide any policy regarding mail delivery after receiving a request on 7/21/22. 1. Record review of Resident #12's Face Sheet showed he/she was admitted [DATE] with a diagnosis of Congestive Heart Failure (CHF a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the resident rooms 210, 209, 217, 202, free from a buildup of dust and debris on the floors; to maintain the fans in resident rooms 213, 207, 218, 220, 201, 108, and 101 free from a heavy buildup of dust on the fan blades of those fans; to maintain the commode seats and commode risers (an extender to an existing toilet, under or over the lid, that lifts the seat height to a more comfortable level for residents who may be disabled) free from damage or rusty areas in resident rooms 214, 219 and 221; to maintain the ceiling vents free from a heavy buildup of dust in the restrooms of 215, 103, and 111; to maintain the ceiling tiles and ceiling vents over the main dining room free from dust; and to maintain the floor of 2nd floor resident use vending machine area free from food debris and insects. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all employees were screened through the Nurse Aide Registry as part of the facility screening for Employee Disqualification List (EDL) and Criminal Background Check (CBC) procedure upon hiring new employees for 4 of 8 sampled employee records. The facility census was 51 residents. Record review of the Facility's Policy for Checking New Hired Employees dated 2022, showed the facility would make an inquiry to the Missouri Department of Health and Senior Services to whether the employee is listed on the employee disqualification registry, and would follow state laws and federal guidelines regarding employee background review upon employment as part of the facility's hiring procedures. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed and submitted timely for three supplemental residents (Residents #1, #7, and #38), out of 15 sampled residents and nine supplemental residents. The facility census was 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all MDS assessments; to reassess the significant change statue; to develop a comprehensive care plan that reflects level of care delivery to meet resident needs; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed and submitted timely for two sampled residents (Resident #11 and #10) and four supplemental residents (Resident #4, #2, #3, and #5) out of 15 sampled residents and nine supplemental residents. The facility census was 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all MDS assessments; to reassess the significant change statue; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) from the facility to the Centers for Medicare & Medicaid Services (CMS) system within 14 days after completion for two sampled residents (Resident #11 and #10) and seven supplemental residents (Residents #4, #1, #7, #2, #3, #5, and #38) out of 15 residents sampled residents and nine supplemental residents. The facility had a census of 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all MDS assessments; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the comprehensive assessments for two sampled residents (Residents #30 and #45) out of 15 sampled residents and nine supplemental residents. The facility census was 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) assessments; to reassess the significant change statue; to develop a comprehensive care plan that reflects level of care delivery to meet resident needs; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for one sampled resident (Resident #12); to ensure an individualized comprehensive care plan was developed in regards to pain, oxygen, and diuretics (any drug that increases urination) for one sampled resident (Resident #9 ) and to develop and implement an individualized comprehensive care plan for behavioral monitoring including target behaviors for one sampled resident (Resident #10) who received psychotropic medications (drugs which affect psychic function, behavior, or experience) out of 15 sampled residents and 9 supplemental residents. The census was 51 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete and document a comprehensive fall investigation; to reassess the resident's fall risk and mobility status after the resident fell and to create and update a care plan that showed the resident fall interventions for one sampled resident (Resident #45). The facility failed to ensure ongoing monitoring and assessment system in place, to assess the resident ability to smoke safely without supervision and ability to safely store smoking material in residents room and to complete and implement a comprehensive smoking care plan for five sampled residents (Resident #32, Resident #19, Resident #35, Resident #11 and Resident #6) out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Fall Policy/Procedure dated 2022 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to cover trash containers in the kitchen and the dining room during the breakfast meal on 7/20/22. This practice potentially affected at least 25 residents who used the dining room on 7/20/22. The facility census was 51 residents. 1. Observations on 7/20/22 from 7:11 A.M. through 8:40 A.M., showed the trash container in the kitchen and the trash container in the dining room were uncovered during that time. During an interview on 7/20/22 at 8:43 A.M., Dietary [NAME] (DC) A said they do not have covers for the trash containers. Observation on 7/20/22 at 8:48 A.M. showed trash container in dining room and the trash container in the kitchen were uncovered. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to take measures to prevent the existence of numerous flies in the kitchen, and to prevent the existence of bedbugs (small, oval, brownish insects that live on the blood of animals or humans which are flat bodied and about the size of an apple seed) in Resident room [ROOM NUMBER] and in the rooms of Residents #7 and #6. The facility census was 51 residents. 1. Observations during the breakfast meal preparation on 7/20/22 from 7:11 A.M. through 8:23 A.M., showed the following: - The presence of numerous flies in the kitchen. - The door between the Main Dining Room (MDR) and the outdoor smoking patio, was cracked open. - Uncovered trash container in the dining room and an uncovered trash container in the kitchen. During an interview on 7/20/22 at 8:44 A.M., Dietary [NAME] (DC) A said the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and implement a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights that include the residents were free from retaliation after filing a grievance for one sampled resident (Resident #6) and one supplemental resident (Resident #33) out of 15 sampled residents and nine supplemental resident's. The facility censes was 51 residents. Grievance policy requested 7/21/22 and not received. 1. Record review of Resident #6's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Major depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing of a transfer or discharge to a hospital, including the reasons for the transfer and to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification of transfer or discharge for three sampled residents (Resident #32, #45, and #10) out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Transfer and Discharge policy dated 2022 showed: -All residents who are discharged or transferred under any circumstances will be reported to the local ombudsmen. -If the resident discharge/transfers to emergency room or hospital for short period of time and anticipated return within 24 hours, the facility can log the short transfer/discharge to the local ombudsman monthly. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide written notification of the facility's bed hold policy to three sampled residents (Resident #32, #45, and #10) and/or responsible party upon discharge/transfer to the hospital, out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Notice of Bed Hold policy and readmission form (provided to the resident/responsible party) showed the facility's bed hold policy and procedure which stated in part: -Bed Hold for days in excess of the Missouri's Bed-Hold limit is considered to be a non- covered service meaning you or your legal representative can pay for the bed hold out of your pocket. -The facility's bed hold policy permits your return if your absence is beyond the Missouri Medicaid Bed Hold Policy. -You can also return to the facility if a new resident has not taken that bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Significant Change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning), for one sampled resident (Resident #44) who started on dialysis treatments (a process of purifying the blood of a person whose kidneys are not working normally) out of 15 sampled residents. The facility census was 51 residents. 1. Record review of Resident #44's Face Sheet showed he/she was admitted on [DATE] with diagnoses including kidney disease, high blood pressure, prostate cancer, and vitamin D deficiency. Record review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented with no memory loss. -Needed no assistance with hygiene, walking and eating and was continent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were assessed for activity preferences in the comprehensive assessment and the care plan, as well as provide an ongoing program to support the residents in their choice of activities for three sampled residents (Resident #6, #12, and #28) out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Activity Policy dated 2022 showed: -Staff were to allot at least 30 minutes of time per resident per week for activities duties. -The facility was to provide a monthly activity calendar to residents and inform the resident groups of activities daily. -The facility was to prepare a monthly calendar of activities in large print and post in a prominent location. -Care plans were to address activity preferences and services. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a process was in place to confirm that skin assessments and wound monitoring was being completed for one sampled resident (Resident #30) out of 15 sampled residents. The facility census was 51 residents. A policy was requested for skin assessments and wound monitoring but was not received from the facility at the time of exit. 1. Record Review of Resident #30's Hospice (end of life care) admittance sheet dated 5/13/21 showed the resident was admitted with the following diagnoses: -Muscle wasting and atrophy (the thinning of muscle mass). -Chronic Kidney Disease (CKD when the kidneys are gradually less able to function). -Type two Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency of insulin production). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper oxygen tubing storage for two sampled residents (Resident #32 and #9) and to have a physician order for the use of oxygen for one sampled resident (Resident #9) out of 15 sampled residents. The facility census was 51 residents. Record Review of the facility Oxygen Therapy Policy dated 2022 showed: -Tubing, cannula, and bottle should be stored properly in an infection control manner. -Oxygen therapy was only permitted with a physician order. 1. Record Review of the Resident #32's Face Sheet showed he/she was admitted on [DATE] with diagnoses: including shortness of breath and Chronic Obstructive Pulmonary Disease (COPD-a progressive disease that is characterized by shortness of breath and difficulty breathing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #44) had a physician's order for dialysis (a process of purifying the blood of a person whose kidneys are not working normally) and monitoring the dialysis site were documented on the Physician's Order Sheet (POS); failed to ensure communication between the facility and the dialysis center was documented; failed to have care plan interventions for monitoring the resident's dialysis site out of 15 sampled residents. The facility's census was 51 residents. 1. Record review of Resident #44's Face Sheet showed he/she was admitted on [DATE] with diagnoses including chronic kidney disease, high blood pressure, history of prostate cancer, and vitamin D deficiency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label food containers in the 2nd floor resident storage fridge with a resident's name or the date the container was received at the facility. This practice potentially affected an unknown number of residents. The facility census was 51 residents. Record review the facility's undated admission Agreement Rules and Regulations under Exhibit C showed: - It is requested that no food or drink be brought in without consultation with the nurse. - Food if allowed by your physician, is to be stored in a container with a tight fitting lid. 1. Observation of the 2nd floor resident food storage fridge on 7/20/22 at 10:23 A.M., showed two bottles of salad dressing, one bag of chicken, one container of roast beef without names and without dates on the items. During an interview on 7/20/22 at 10:27 A.M. [...]