Warrensburg Manor Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week and failed to ensure a Director of Nursing (DON) or interim DON was onsite full -time 8 hours a day for a minimum of 40 hours a per week. The facility census was 43 residents. Review of the facility Policy for Nursing Services-RN revised 1/1/24 showed: -It is the intent of the facility to comply with RN staffing requirements. -The facility will utilize the services of a RN for at least 8 consecutive hours per day, seven days a week. -The facility will designate a RN to serve as the DON on a fulltime basis. -The DON may serve as a charge nurse only when the facility has a average daily occupancy of 60 or fewer residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) was accurate for two sampled residents (Resident #1 and #2) out of 14 sampled residents. The facility census was 43 residents. Review of the facility's policy titled MDS Completion and Submission Timeframes dated July 2017 showed the MDS Coordinator or designee was responsible for ensuring that resident assessments were submitted in accordance with current federal and state guidelines. 1. Review of Resident #2's face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered, individualized care plan describing care and services furnished by the facility to treat a resident for edema (swelling due to the retention of fluid) was developed for one sampled resident (Resident #8)and failed to complete a comprehensive care plan that included nutritional status for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 43 residents. 1. Review of Resident #8's care plan, dated 2/1/24, showed: -A focus of decreased cardiac output related to congestive heart failure (a disease in which the heart functions at a reduced capacity). -An intervention to evaluate the resident for edema with no specific schedule on when to do so. -No information regarding the resident's active edema including interventions or goals. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation to determine the root cause and fall follow-up report of a resident's fall, failed to update the resident's care plan with appropriate interventions and monitor the effectiveness of interventions to prevent additional falls for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 43 residents. Review of the facility's Fall Assessing and their Cause revised 10/2010 showed: -The purpose of this procedure was to provide guidelines for assessing after a fall and to assist staff in identifying causes of the fall. -Incident report must be completed for resident falls; The incident report form should be completed by nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored and changed using proper infection control practices when not in use and in a timely manner for three sampled residents (Resident #1, #40,and #37) out of 14 sampled residents. The census was 43 residents. Review of the facility's policy titled Oxygen Administration dated 1/1/24 showed: -The resident's care plan should identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: --The type of oxygen delivery system. --When to administer, such as continuous or intermittent and/or when to discontinue. --Equipment setting for the prescribed flow rates. --Monitoring of oxygen saturation levels (the amount of oxygen in the blood with a normal range of 96% to 100%) and/or vital signs as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe secure storage of cleaning chemicals including liquid laundry soap and a liquid bleach bottle for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 43 residents. Review of the facility's undated Chemical Storage policy showed: -Chemicals should never be left within reach of a resident and must always be properly stored. -Residents may not have personal chemicals stored in their rooms. Review of the facility's undated Important information for residents and families showed items that cannot be brought into the nursing home due to State and Federal regulations included but was not limited to: Bleach and Laundry detergents provided by facility. 1. Review of Resident #33's face-sheet showed he/she had diagnoses of: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a safe medication storage system in place regarding the facility's Cubex system (a smart cabinet that secures different types of medications that can be dispensed when accessed) by not monitoring and reconciling the medications in the Cubex. This deficient practice had the potential to affect all residents who received medications from the Cubex system. The facility census was 53 residents. A policy for the Cubex was requested and was not received at the time of exit. Record review of the facility's pharmacy undated policy titled MEDBANK CUBEX Station Policy and Procedures showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the ceiling fan in the dry good storage room and the wall mounted fan in the main kitchen were maintained free of a heavy buildup of dust; to ensure the light fixtures were free from a heavy buildup of dust; to ensure the faucet at the three compartment sink operated properly so it would not continue to leak a stream of water after the valves were turned off; to maintain the floors under the reach in refrigerators and the six burner stove, free of food crumbs and debris; and to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) of one refrigerator in good repair. This practice potentially affected all residents who ate food from the kitchen. The facility census was 53 residents. 1. Observations on 2/8/23 from 6:40 A.M. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control practices were performed in order to prevent cross contamination and spread of infection by not following their policy when an outbreak had been identified by not educating all staff, notifying visitors, posting signs, identifying exposed residents, and monitoring hand hygiene; failed to implement transmission based precautions and isolation for residents with known signs and symptoms of a norovirus (a group of viruses that cause a sudden onset of severe vomiting and diarrhea). Facility staff failed to ensure the correct Personal Protective Equipment (PPE) was to be utilized while providing personal cares for three sampled resident and handwashing during care (Resident #43, #156, and #31); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain Resident #31's wheelchair in a clean manner and without clumps of hair on the wheels; to prevent the storage of trash that was contaminated with human waste, in two shower rooms located on the [NAME] North and [NAME] South Halls; to maintain the [NAME] South Hall shower room in good repair; and to maintain ceiling fans in offices (the Social Service Designee (SSD), the business office and the Administrator's office) where residents would potentially go into. This practice potentially affected at least 40 residents who resided in or used those areas. The facility census was 53 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care plans that were comprehensive, individualized and represented the resident's current health status for six sampled residents (Resident's # 43, #53, #8, #7, #14 and #16) out of 13 sampled residents. The facility census was 53 residents. Record review of the facility's undated policy titled Wound Protocol Checklist-(First Discovery of Wound) showed step seven of the protocol was to add the wound to the care plan and put interventions in place. Record review of the facility's policy titled Goals and Objectives, Care Plans , dated April 2009, showed: -Goals and objectives were to be entered on each residents' care plan so that all staff had access to the information. 1. Record review of Resident #43's Face Sheet showed he/she was admitted on [DATE] with diagnoses that included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders for Hospice (end of life care) services were transcribed onto the physician's order sheet (POS), to include the service provider, services provided and frequency for four sampled residents (Resident #156, #14, #16 and #7) out of 13 sampled residents. The facility census was 53 residents. 1. Record review of Resident #156's Face Sheet showed he/she was admitted on [DATE], with diagnoses that included: -Heart disease (A type of disease that affects the heart or blood vessels). -Lung cancer (a disease in which cells in the body grow out of control that is in the lungs). -Brain cancer (a disease in which cells in the body grow out of control that is in the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #1 and #18) were treated with dignity and respect. Agency Licensed Practical Nurse (LPN) A was inconsiderate and raised his/her voice when speaking to a cognitively impaired sampled resident (Resident #1); and became argumentative and raised his/her voice to one sampled resident (Resident #18) on 1/21/23, out of 13 sampled residents. The facility census was 53 residents. 1. Record review of Resident #1's Face sheet showed he/she had diagnoses of: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure vaccinations were offered for one sampled resident (Resident #156) out of 13 sampled residents, and one supplemental resident (Resident #33) out of eight supplemental residents. The facility census was 53 residents. Record review of the facility's policy, dated August 2016, titled Influenza Vaccine showed: -All residents were to be offered the influenza vaccine annually. -Residents that received the vaccine were to have the date given, expiration date, lot number, person that administered, and the site of the vaccine documented in their medical record. -A resident that refused the vaccine was to have the refusal documented in their medical record. -The Infection Control Preventionist (ICP) were to monitor vaccinations. Record review of the facility's policy, dated August 2016, titled Pneumococcal Vaccine showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the windows in the rooms of two sampled residents (Resident #31 and #19) operated properly so they could open and close at the resident's convenience; and to ensure the area under the vending machine was free from a buildup of dust and grime. This practice potentially affected at least two residents. The facility census was 53 residents. 1. Record review of Resident #31's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 1/13/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. [...]

Inspectors wrote3. Record review of Resident #25's Face Sheet showed he/she: -admitted to the facility on [DATE] and had diagnoses which included: --Repeated Falls. --Pain. --Breast Cancer. --Chronic Kidney Disease (your kidneys are damaged and can't filter blood the way they should). --Disorientation. --Dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with Behavioral Disturbance. -Had a court-appointed legal guardian. Record review of the resident's care plan dated 8/11/19 showed he/she: -Was at risk for falls due to being up spontaneously/as he/she desired with a roller walker. He/She had a steady gait with walker use most of the time. He/She did have poor safety awareness. Interventions included: --The resident needed a night light on to help see at night. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 47 residents. Record review of the facility's Controlled Substances policy dated 2001 and revised on 12/12 showed: -Nursing staff must count controlled medications at the end of each shift. -The nurse coming on duty and the nurse going off duty must make the count together. 1. Record review of the facility's Controlled Drug Count sheet dated March 2021 for the front medication cart showed: -24 out of 85 opportunities were not signed by either the oncoming or off going staff. -Ten of the 85 opportunities were not signed by both the oncoming and the off going staff. -15 out of 85 opportunities did not have the number of narcotic packages documented on the sheet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper cleaning and storage of a resident Continuous Positive Airway Pressure therapy (CPAP machine, is a machine that treats sleep apnea by delivering a stream of oxygenated air into residents airways through a mask and a tube) mask when not in use for one sampled resident (Resident #250) out of 12 sampled residents and one supplemental resident. The facility census was 47 residents. Record review of the facility's BiPAP/CPAP Administration policy dated 5/13/20 showed: -To clean the face mask with an alcohol prep pad or warm soapy water can be used as needed. Be sure to air dry completely before use if use soap and water. Facility staff were to document in the resident's medical record when cleaned. -Did not indicate how to store a CPAP mask when not in use. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control protocol was in place to ensure proper hand and glove hygiene during care of one sampled resident (Resident #23) out of 12 sampled residents. The facility census was 47 residents. Record review of the facility's Infection Prevention and Control Manual - Standard Precautions dated 2019 showed: -Standard Precautions Overview: it is the policy of this facility that standard precautions will be implemented. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. -Hand Hygiene: hand hygiene continues to be the primary means of preventing the transmission of infection. -Gloves: [...]