Willowcreek Wellness & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure staff immediately reported an allegation of abuse in accordance with the facility's policy, resulting in a delayed response and investigation, and the facility's failure to report the allegation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe for one resident (Resident #1). The sample was 4. The census was 110. The Administrator was notified on 05/27/26 of the past non-compliance, which occurred on 05/15/26. The facility in-serviced staff regarding Abuse and Neglect reporting protocols and staff demonstrated understanding. The deficiency was corrected on 05/20/26. Review of the facility's Abuse Prevention and Prohibition policy, revised 01/26, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document physician ordered treatments on the Treatment Administration Record (TAR) for three residents (Residents #77, #112 and #92). The sample was five. The census was 112. Review of the facility's Documentation - Nursing Policy, dated 6/20, showed:-Purpose: To provide documentation of resident status and care given by nursing staff;-Policy:--Nursing documentation will be concise, clear, accurate and evidence based. Narrative charting, as outlined in specific policies and procedure, will be used for initial treatments or procedure. Documentation for subsequent and/or routine care and procedures may be completed by exception. [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to Resident #99's change in condition when the resident, who had a tracheostomy (surgical opening in the trachea to create an airway), experienced a change in breathing, becoming abnormally fast. Facility staff failed to complete a thorough, documented assessment and failed to contact the resident's physician in a timely manner. The resident expired at the facility. This deficient practice affected one out of three residents sampled. The census was 119. The Administrator was notified on [DATE] of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy regarding notifying the resident's responsible party when one resident (Resident #81) had a fall and was subsequently sent to the hospital. Staff did not notify the resident's representative until the day after the fall, when the family member, who was listed as an emergency contact, arrived at the resident's room for a visit with the resident and found the room empty. The sample was 15 and the census was 119. Review of the facility's Response to Falls Policy, undated, showed:-Purpose: To ensure the facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention;-Policy:--I. Residents experiencing a fall will be promptly assessed and treated for injuries;--II. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for one resident (Resident #8). The resident called staff to the room and requested to be cleaned of incontinence and was told to wait for the next shift. The sample was 7. The census was 107. Review of the facility's Perineal Care policy, dated 6/2020, showed:-Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown;-Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when staff failed to change a Peripherally Inserted Central Catheter line (PICC, central line placed in the upper arm into a large vein near the heart for long term intravenous (IV) medications) dressing as ordered and ensure the dressing was secured to prevent the risk of infection to the insertion site, for one resident (Resident #10). The sample was 7. The census was 107. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injury to the skin as a result of pressure or friction) receives treatments as ordered when staff failed to apply wound care as ordered by the physician for one resident (Resident #8). The sample was 7. The census was 107. Review of the facility's Wound Management policy, dated 6/2020, showed:-Purpose: To provide a system for the treatment and management of residents with wounds, including pressure and non-pressure injury;-Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #55) was free from significant medication errors when he/she did not receive his/her required Biktarvy (an antiviral medication) on a scheduled basis, per the physician's order, to control the resident's human immunodeficiency virus (HIV, a virus attacking the immune system). The sample was 15 and census was 119. Review of the facility's Physician Order Policy, dated 6/2020, showed:-Purpose: This will ensure that all physicians' orders are completed and accurate;-Policy: The Medical Records Department will verify the physicians' orders are complete, accurate and clarified as necessary;-Whenever possible, the licensed nurse: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services based on acceptable standards of practice by not clarifying a physician order for one resident who was not being monitored throughout the day for his/her diabetes (Resident #2) and for failing to complete a follow up accucheck (blood sugar test) per physician order for one resident who had elevated blood sugar (Resident #5). The sample was 5. The census was 104. Review of the facility's Physician Orders Policy, revised dated June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was ordered timely and administered as ordered for one resident (Resident #1) who suffered from chronic pain. This caused the resident to experience severe pain and call emergency medical services to transport him/her to the hospital to receive his/her medication. The sample size was nine. The census was 118. Review of the facility's Pain Management policy, revised 6/20, showed:-Purpose: To ensure accurate assessment and management of the resident's pain;-Policy: A licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain;-Procedure: --Pain assessment: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Behavior Management and Resident Drug and Alcohol Abuse policies by failing to provide local services and resources for two sampled residents (Resident #1 and Resident #2) who were admitted with a history of substance abuse and continued to use and abuse illegal substances in the community. The residents left the faciity on leave of absences (LOAs), sometimes for days. Resident #1 overdosed several times in the facility with illegal substances. Staff used Narcan several times to revive the resident. Resident #2 overdosed once in the facility and once in the community and was hospitalized twice with a diagnosis of drug overdose and severe intoxication. Both residents were allowed to continue to go out on LOA and return to the facility intoxicated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from neglect when staff failed to provide necessary services to avoid physical harm. On 5/26/25, Certified Nursing Assistant (CNA) D provided care to Resident #1, who had limited mobility after a stroke affecting his/her dominant side and an above the knee amputation. The resident had been assessed as needing total dependence on staff for personal hygiene and required substantial/maximal assistance to roll left to right. Resident #1 was left unattended in a raised bed when CNA D walked away to change his/her gloves. The resident fell out of the elevated bed onto the floor and was transported to the emergency room. The resident sustained a fracture to his/her right femur, a contusion to his/her shoulder, and the resident expressed feelings of being scared due to the traumatic event. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy when a resident experienced a change in condition. Resident #1 fell out of an elevated bed onto the floor and was transported to the emergency room on 5/26/25. The resident sustained a fracture to his/her right femur (thighbone), and a contusion to his/her shoulder, The resident was readmitted to the facility on [DATE], with discharge instructions identifying symptoms to monitor for that may require the resident to return to the hospital. Facility staff documented a change in condition consistent with the hospital discharge instructions, including vomiting and lethargy, beginning on 5/29/25. On 5/30/25, the resident's oxygen saturation and respiratory rate were low and the physician was notified with orders obtained for oxygen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control for three of three residents observed during wound care. Staff failed to change their gloves or sanitize their hands prior to entering the room, prior to exiting the room, and in-between removing soiled dressings, cleaning the wound, and applying new wound dressings. The staff also failed to use Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatment, for three residents (Residents #5, #8, and #9). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their grievance policy to maintain an effective grievance process for residents to voice grievances and promptly resolve them for one resident who voiced a grievance over staff treatment (Resident #1). The facility failed to take immediate action to prevent further potential violations of any resident rights while the grievance was being investigated. The facility failed to provide a summary of the pertinent findings including whether the grievance was confirmed and failed to follow up with the resident to inform him/her of the findings of the investigation and any corrective actions recommended in a timely manner. The facility also failed to ask the resident if he/she was satisfied with the outcome of the results of the investigation. The failures had the potential to affect all residents. The sample size was 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a thorough investigation of alleged abuse for one resident per facility policy (Resident #1). Review of the facility soft investigation, provided during the onsite investigation, showed no written statement from the resident, actions taken, summary, and/or conclusion of the investigation or findings. The sample size was 4. The census was 115. Review of the Abuse Prevention policy, revised 8/2020, showed: -Investigation: -The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure residents were free from abuse by Resident #3, who yelled, cursed and threatened them. Resident #3 was described as bullying residents and used racial slurs towards his/her roommate. Residents refused to go to activities or eat in the dining room to avoid being around the resident. The census was 120. The Administrator was notified on 3/3/25 at 11:15 A.M., of an immediate jeopardy (IJ) which began on 1/29/25. The IJ was removed on 1/30/25 as confirmed by surveyor on-site verification. Review of the facility Abuse Prevention and Prohibition Program policy, revised on 10/24/2022, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a behavioral management program for one resident (Resident #3) who frequently yelled, cursed and threatened both residents and staff members. Staff failed to develop and/or implement a care strategy that focused on behavior prevention through on-going Social Service counseling sessions when other options failed. After a behavior occurred, staff failed to closely monitor the resident to ensure the safety of other residents, failed to consistently report behaviors to the physician, and/or psychiatrist/psychiatric Nurse Practitioner (NP) as per policy. The facility failed to ensure Social Services and/or the interdisciplinary team (IDT) consistently followed up on the resident's behaviors in a timely manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure concerns voiced during Resident Council meetings were consistently addressed in writing and returned to the Resident Council for review in a prompt and timely manner. Resident #2, the Resident Council President, confirmed the facility did not always respond to the Resident Council's concerns. This deficient practice had the potential to affect all residents who resided at the facility. The census was 120. Review of the facility's Resident Council policy, revised on 6/2020, showed: -Purpose: To promote the exercise of a resident's right to organize and participate in resident groups at the Facility; -Policy: The facility encourages residents' involvement and input in the operation of the Facility through the Resident Council; -Responsibilities of the Resident Council: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Quality Assessment & Assurance (QAA) Program policy by failing to provide ongoing monitoring and evaluation of one resident (Resident #3) with frequent disruptive verbal behaviors that affected both staff and residents. The facility provided their last four (September, October, November and December 2024) Quality Assessment and Assurance Committee's meeting minutes. Although the resident's behaviors were ongoing during those four months, the facility was only able to provide documented evidence the resident's behaviors had been addressed for two of those four months, September and December 2024. The census was 120. Review of the facility Quality Assessment & Assurance Program policy, revised on 6/2020, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Prevention and Prohibition Program policy by failing to promptly and thoroughly investigate one resident's allegation of abuse. Resident #15 alleged an unknown female employee with braids threatened to have his/her brothers come to the facility and whip the resident. The sample size was 16. The census was 120. Review of the facility Abuse Prevention and Prohibition Program policy, revised on 10/24/2022, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Prevention and Prohibition policy, by failing to notify the State Survey Agency within two hours after one resident (Resident #15) alleged to the Administrator, Assistant Director of Nursing (ADON) N and the Social Service Director (SSD) on Thursday 2/27/25, that an unknown female employee with braids said she was going to have her brothers come up to the facility and whip the resident's ass. The sample size was 16. The census was 120. Review of the facility's Reporting Abuse policy, undated, showed: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor one resident's (Resident #3) weight weekly as recommended by the Registered Dietitian on 9/26/24 for four weeks and failed to monitor and reassess the resident when he/she had a low blood pressure two days in a row and the blood pressure medicine was held. The nurse failed to notify the physician of holding the medication related to hypotension the first day (Resident #3). The sample was 7. The census was 107. Review of the facility's Change of Condition Notification policy, last revised 6/2020, showed: -Purpose: To ensure residents, family, legal representative, and physicians are informed of change in the resident's condition in a timely manner. -Policy: Definition: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weekly weights as ordered by the Registered Dietician (RD) and failed to communicate with the RD that the weights were not obtained for three out of three residents sampled for weight loss (Residents #3, #4 and #5). The sample was 7. The census was 107. Review of the facility's Nutrition Hydration Management policy, revised 06/2020, included: -Purpose: To ensure that each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem; -The concept of nutrition management is an interdisciplinary process. The key components of this system are: [...]

Inspectors wroteSee the deficiency cited at F684 under Event ID H40G12. This deficiency is uncorrected. For previous examples see the examples at 8/14/24. Based on observation, interview and record review, staff failed to ensure acceptable infection control practices during dressing change, did not administer the correct wound care orders (Resident #86), and failed to intervene when the resident had a pillowcase with a rubber band around his/her leg, due to excessive drainage from a wound. The facility also failed to ensure a resident with known bilateral foot and hand wounds received wound care supplies. The resident was noted to use personal protective equipment (PPE) including gowns, gloves, and foot booties (Resident #99) to conduct self wound care. The sample was 26. The sample was 111. Review of the change of condition policy, revised 6/2020, showed: -Purpose: [...]

Inspectors wroteSee the deficiency F808 cited at Event ID H40G12. Based on observation, interview and record review, the facility failed to ensure residents were provided therapeutic diets as prescribed by the attending physician and/or according to their care plan, for two of two residents with an order for large portions (Residents #99 and #67). In addition, the facility failed to serve the correct portion size for two of two meals. This had the potential to affect all residents. The sample was 26. The census was 111. Review of the facility's Nutritional Assessment, revised December 2020, showed: -Policy: The Dietitian will complete a nutritional assessment initiated by the Nutrition Services Manager upon admission for residents. Nutritional assessments will also be completed upon readmission, annually, and upon change of condition by the Facility's Registered Dietitian; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by not obtaining orders for breast radiation therapy (a cancer treatment that uses high energy radiation to kill cancer cells), assessing the resident after his/her daily breast radiation treatments, and assessing the resident's skin condition after breast cancer surgery for one resident (Resident #83). Staff failed to provide follow physician orders and complete wound treatments on one resident (Resident #75) with chronic vascular wounds. Staff failed to routinely turn and reposition one resident dependent on staff for assistance with bed mobility, who was at increased risk of altered skin integrity (Resident #175). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of a system that assures complete accounting of resident personal funds, and the facility failed to ensure access to resident personal funds was transferred to the facility's new management company upon a change in ownership. This deficient practice affected all 61 residents whose funds were handled by the facility. The census was 120. During an interview on 8/12/24 at 7:15 A.M., the Business Office Manager (BOM) said she reconciles funds in the resident trust account monthly. She does not have records of her monthly reconciliations for the past 12 months due to a recent change in the facility's ownership. The facility changed ownership on 7/30/24 and now the facility no longer has access to the electronic accounting system used to manage funds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration and assessments, including skin assessments, Braden assessments (pressure ulcer risk assessment), Abnormal Involuntary Movement Scale (AIMS, aides in the early detection of tardive dyskinesia (involuntary movements)), bed safety assessments, smoking assessments, elopement assessments, and fall risk assessments were documented and maintained for 11 residents (#175, #115, #76, #1, #83, #75, #40, #107, #36, #67 and #58). The sample was 24. The census was 120. Review of the facility's clinical documentation standards policy, undated, showed: -Policy: it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff, and visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment for residents at the facility, including walls in resident common areas, food and debris left in resident rooms, resident room doors not closing to the hallway, and resident hall bathrooms not kept clean and orderly. The sample was 24. The census was 120. 1. Review of Resident #85's quarterly Minimum Data Set (MDS, a federally mandated instrument completed by facility staff), dated 5/10/24, showed: -Cognitively intact; -History of burn wound to the upper and lower back. Observation on 8/8/24 at 11:28 A.M. and on 8/12/24 at 11:37 A.M., , showed the resident's room with an approximate 4 inch wide by 9 inch long strip of the drywall behind the bed damaged with drywall debris on the floor. [...]

Inspectors wroteBased on observation, interview and record, the facility failed to ensure staff followed the facility's policies regarding tube feeding, and failed to ensure residents received tube feeding in accordance with physician orders to support adequate nutritional intake. The facility identified nine residents receiving tube feedings, five of which were sampled and problems were found with four (Residents #175, #65, #38 and #107). The sample was 24. The census was 120. Review of the facility's Enteral General Nutritional (tube feeding) policy, undated, showed: -The purpose of this policy is to provide guidance for the use of enteral feeding and hydration for residents unable to tolerate oral meals and those who have a stable (not new) enteral tube in place. Enteral feedings are provided by bolus (single/specified dose given all at once) or continuous delivery; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) had physician orders for dialysis and/or documented assessments and monitoring related to dialysis, and ongoing documented communication with the dialysis center. The facility identified seven residents as receiving dialysis, of which four were sampled and problems were identified with all four (Residents #111, #46, #50 and #26). The sample was 24. The census was 120. Review of the facility's Hemodialysis Care and Monitoring policy, undated, showed: -General Vascular Access Device (VAD, device that allows repeated and long-term access to the blood stream) Care and Precautions: --Monitor for infection; --Thrill: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed for the use of side rails, failed to obtain consents for use of side rails, failed to obtain therapy/nursing assessments and/or failed to obtain a physician's order for the use of side rails (Residents #76, #175, #25, #11, #38, and #116). The facility identified 25 residents with side rails in use, and did not include Residents #76, #175, #25, #38 and #116 on the list. The sample was 24. The census was 120. Review of the facility's safe use of bed rails policy, undated, showed: - Policy: It is the policy of this facility to provide resident centered care that meets the safety, psychosocial, physical and emotional needs and concerns of the residents. The corporation prohibits the use of bed rails as a restraint. [...]

Inspectors wroteBased on observation and interview, the facility failed to offer and provide snacks at bedtime. The sample was 24. The census was 120. During a group interview on 8/12/24 at 10:36 A.M., four residents, who the facility identified as alert and oriented, were in attendance. The residents said the facility used to offer snacks at night, after dinner, and the snacks were kept at the nurse's station. The facility stopped serving snacks in the evening about two to three weeks ago. Observation on 8/12/24 at 6:00 A.M., showed no snacks at the nurse's station on the Serenity hall. Observation on 8/12/24 at 6:17 A.M., showed no snacks at the nurse's station on the Harmony hall. Observation on 8/13/24 at 7:08 A.M., showed no snacks at the nurse's station on the Harmony hall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when the facility's staff left medication in one resident's room who did not have a physician order for self-administration or medications to be left at the bedside (Resident #46). The sample was 24. The census was 120. Review of the facility's Medication Administration policy, undated, showed: -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care; -Procedure: Never leave medications unattended. Review of the facility's Self-Administration of Medication policy, undated, showed: -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for residents #107, #38, and #88. The sample was 24. The census was 120. Review of the facility's routine resident care policy, undated, showed: -Policy: It is the policy of this facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility; -Procedure: Routine care by a nursing assistant includes but is not limited to the following: Assisting or provides for personal care, bathing, dressing, eating and hydration, and toileting. 1. Review of Resident #107's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/16/24 showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing (Resident #75). The sample size was 24. The census was 120. Review of the facility's Skin Care and Wound Management, undated, showed: -Policy: -The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds; -Skin care and wound management program includes, but is not limited to: -Analysis of facility pressure ulcer data for quality improvement opportunities; -Application of treatment protocols based on clinical best practice standards for promoting wound healing; -Daily monitoring of existing wounds; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with limited mobility received appropriate services, equipment and assistance to maintain mobility (Resident #40). The sample was 24. The census was 120. Review of the facility's Routine Resident Care policy, undated, showed: -Definition: Routine resident care: care that is not necessarily medically or clinical based but necessary for quality of life promoting dignity and independence, as appropriate; -Policy: It is the policy of this facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of this facility; -Procedure: Licensed staff will include the following services based upon their scope of practice, but not limited to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility policy for total mechanical lift and ensure two staff were present during a Hoyer (equipment used to lift non-weight bearing persons) lift, as staff obtained the resident's weight (Resident #509). The sample was 26. The census was 111. Review of the total mechanical lift policy, revised 6/2020, showed: -Purpose: a mechanical lift is used appropriately to facilitate transfers of residents; -Policy: -Nursing staff will be trained to use the mechanical lift; -The resident will have a physician's order for the use of a mechanical lift; -At least two people are present while the resident is being transferred with the mechanical lift. Review of Resident #509's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/17/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly ensure physician orders for care of a colostomy (a surgical opening in the stomach to facilitate waste drainage from the colon) were maintained and completed as ordered. The sample was 24. The census was 120. Review of Resident #18's quarterly Minimum Data Set (MDS, a federally-mandated assessment instrument completed by facility staff), dated 5/26/24 ,showed: -Basic Interview for Mental Status (BIMS, an assessment tool used to identify a resident's cognitive status) score not completed; -Diagnoses included hypertension (high blood pressure), cardiac arrythmia (an abnormal heart rate and rhythm), colostomy status, history of cerebral infarction (stroke), and quadriplegia (loss of motor function in the upper and lower limbs). Review of the resident's current care plan, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's dietary orders were updated and accurate for one of two residents sampled with a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach). The facility failed to ensure the resident, with a history of dysphagia (difficulty swallowing) had updated and accurate physician's orders for mechanical soft diet and thickened liquids (Resident #107). The sample size was 26. The census was 111. Review of the facility's Therapeutic Diets policy, revised December 2020, showed: -Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided therapeutic diets as prescribed by the attending physician and/or according to their care plan, for two of two residents with an order for large portions (Residents #99 and #67). In addition, the facility failed to serve the correct portion size for two of two meals. This had the potential to affect all residents. The sample was 26. The census was 111. Review of the facility's Nutritional Assessment, revised December 2020, showed: -Policy: The Dietitian will complete a nutritional assessment initiated by the Nutrition Services Manager upon admission for residents. Nutritional assessments will also be completed upon readmission, annually, and upon change of condition by the Facility's Registered Dietitian; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate assistive devices to residents who needed them to assist the residents in eating independently (Residents #25 and #110). The sample was 24. The census was 120. 1. Review of Resident #25's medical record, showed diagnoses included Parkinson's disease (brain disorder causing unintended or uncontrolled movements) with dyskinesia (uncontrolled, involuntary muscle movements), abnormal posture, muscle weakness and other lack of coordination. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, revised 1/15/24, for divided plate for meals; -An order, dated 2/27/24, for built-up utensils for meals. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/30/24, showed: -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 120. During an interview on 8/7/24 at 12:26 P.M., the Ombudsman said he/she had not received a monthly transfer report from the facility since April 2024. During an interview on 8/14/24 at 6:57 A.M., the Social Services Director (SSD) said she is responsible for notifying the Ombudsman of resident transfers on a monthly basis. By the 5th of each month, she emails the Ombudsman with a list of all residents discharged from the facility the month before. When asked to provide documentation of Ombudsman notification since April 2024, the SSD said she did not have access to her old email due to the facility's recent change in ownership. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow the resident's diet orders for a resident on a puree diet. The resident had an order for a dysphagia puree diet and required supervision with eating. The activity assistant brought a whole donut into the resident's room, left the donut and did not verify the resident's diet order or ensure the resident had supervision while eating. This resulted in a choking incident for this resident (Resident #76). The census was 105. The administrator was notified on 1/27/22 at 3:15 P.M. of an Immediate Jeopardy (IJ), which began on 1/27/22. The IJ was removed on 1/28/22, as confirmed by surveyor onsite verification. During an interview on 1/28/22 at 10:32 A.M., the Dietary Manager said food provided by staff outside the dietary department, even if not on the written menu, is considered an alternate menu item. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions by not using utensils during food service, failing to wash hands before applying and removing gloves, label and date stored food, and ensuring dishes were completely air-dried prior to use. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 105. Review of the facility policy, culinary professionals training, undated, showed: -LABELING & DATING: Labeling and dating our products is a vital step to our operation and cannot be wavered on for even one item. This helps us to stay compliant with Federal Regulations as well as ensures our products are fresh and rotated properly. In this training we are going to discuss what items need to have labels and dates and how long various items are good for; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account and did not allow the residents/guardian the right to manage his/her financial affairs. The facility did not provide residents access to their funds as soon as possible for 11 residents (Residents #201, #202, #203, #204, #205, #206, #207, #208, #209, #210 and #211). The facility census was 105. 1. Record review of the facility's maintained Aged Accounts Receivable Report by Service Date for the period 01/01/2021 through 01/31/2022, dated 02/01/22, showed the following residents with personal funds held in the facility operating account: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, by not ensuring walls, furniture, water pressure, sinks, soap dispenser, toilet, bed pans, bathroom light and exhaust fan were clean and in good repair. In addition, the facility failed to ensure hot water was available in all residents' sinks and failed to complete an inspection of bed control panels as part of a regular maintenance program to identify areas of possible injuries, such as falls, for two residents (Residents #36 and #5). The sample was 22. The facility census was 105. 1. Observations on 1/24/22 at 7:33 A.M., 1/25/22 at 5:11 A.M., 1/26/22 at 11:01 A.M., and 1/27/22 at 7:43 A.M., of room [ROOM NUMBER], showed large linear gouges in the walls on each side of the sink area that extended vertically, approximately 1 foot in length. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to include the required screening of newly hired staff. Of 10 randomly sampled staff hired in 2021, two failed to have the required criminal background checks, one failed to have the required employee disqualification list check (EDL, a list maintained by the department which lists individuals who are disqualified from working in certified long-term care facilities due to findings of abuse, neglect and/or misappropriation of resident property), and three failed to include nurse aide (NA) registry check to identify federal indicators (FI, indicators linked to certified nursing assistant (CNA) certifications for individuals who have been found guilty of abuse or neglect. These are required to be checked for all staff regardless of the position they are hired for). The census was 105. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow acceptable nursing standards. Staff failed to obtain orders for a continuous positive airway pressure (c-pap, a machine used to provide pressurized air to assist with breathing for individuals with sleep apnea, a condition where they stop breathing while sleeping) for two residents (Residents #50 and #44). Staff failed to obtain urinary catheter orders timely for one resident (Resident #158). The facility identified four residents as having indwelling urinary catheters. Of those four, three were included in the sample and issues were identified with one. Staff failed to obtain tracheostomy (an opening surgically created to the windpipe to provide direct access for breathing) and oxygen orders timely for one resident (Resident #94). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment, when facility staff failed to secure the residents' smoking materials (cigarettes and lighters), which allowed one resident to smoke in his/her bathroom (Resident #23), causing irritation to his/her neighbor (Resident #89). One resident's bathroom smelled of smoke (Resident #8). The facility also failed to reassess four residents for smoking (Resident #23, #37, #8 and #40) per the facility's policy. The facility identified 36 residents who smoke, four residents were chosen for sample and problems were found with all four. The sample was 22. The census was 105. Review of the Facility's Smoking Policy, dated reviewed 5/30/19, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, 7 days a week. In addition, the facility failed to ensure the Director of Nursing (DON) did not serve as a charge nurse. The facility census was 105. Review of the facility's Facility Assessment Tool, updated 9/30/21, showed: -The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decision about direct care staff needs, as well as capabilities to provide services to the residents. Using a competency-based approach, focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted practices and included the appropriate expiration date. The facility failed to store all drugs and biologicals in locked compartments. These practices affected three of three medication rooms and four out of nine medication/treatment carts reviewed. The facility identified three medication rooms and nine medication/treatment carts in use at the facility. The census was 105. Review of the facility's Medication Storage Policy, undated, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at a safe and appetizing temperature. The census was 105. Review of the facility Dining Services Policy and Procedure Manual, dated 5/2014, and Revised on 9/2017, showed: -Meal Distribution Policy Statement: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner; -Procedure: All meals will be assembled in accordance with the individualized diet order, plan of·care, and preferences; -All food items will be transported promptly for appropriate temperature maintenance; -All foods that are transported to dining areas that are not adjacent to the kitchen will be covered; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when the facility failed to follow their policy for staff tuberculin skin test (TST, used to test for tuberculosis (TB) infections) for eight of 10 randomly sampled employees. The census was 105. Review of the facility's Tuberculin Skin Test 2-step policy, dated 9/7/21, showed: -TST: The standard method of determining whether a person is infected with TB used at the facility level; -2-step method: Step 1- performing a TST with results analyzed within 48-72 hours. Step 2 is repeating the TST in 7-21 days with results analyzed within 48-72 hours. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the corridors were equipped with firmly secured handrails on each side. The census was 105. 1. Observation on 1/24/22 at 12:59 P.M., on Serenity hall, showed the handrails on the side of therapy, between the two therapy entrances, loose and wobbly. 2. Observation on 1/31/22 at 2:17 P.M., showed the hall handrail between rooms [ROOM NUMBERS] hung visibly lower than the other handrails on the hall. This handrail had three braces that connected it to the wall. The middle brace broken into two pieces and did not connect the handrail to the wall. The brace on the right side had the two top screws partially unscrewed. The wall cracked where the handrail pulled away from the wall. The brace on the left side had the top two screws partially exposed. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when the facility's staff left medications in the one resident's room (Resident #90), who did not have a physician order for self-administration or for medications to be left at bedside. The sample was 22. The census was 105. Review of the facility's Self-Administration of Medication Policy, dated 1/5/22, showed: -Policy: It is the policy of this facility to provide resident centered care that safeguards the resident's right for self-administration of their own medications that support resident dignity and self-determination; -Procedure: Determine if the resident desires to self-administer their own medication; Physician/provider order is required for resident to self-administer medications; Resident may self-administer some or all of their medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have the right to make choices about aspects of their life in the facility that are significant to the resident, when the facility's staff failed to get one resident up out of bed on the weekend (Resident #90) and failed to offer one resident with an elevated blood sugar, the choice of when to receive their insulin (Resident #61). The sample was 22. The census was 105. Review of the facility's Resident Rights Policy, dated 5/30/19, showed: -Definitions: Dignity, a state of worthy of honor or respect; includes but not limited to speaking respectfully to resident, providing privacy for care and treatment, providing safe and secure housing, sanitary food and hydration, respecting resident choice and attending to needs in a timely fashion; -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician and responsible party when there was a change in the resident's status that resulted in the need to alter the resident's treatment. The resident experienced a severely low blood sugar level and required the administration of glucagon (used to increase blood sugar levels) for one resident (Resident #161). The census was 105. Review of the facility's Physician Notification for Change in Condition Reporting policy, revised [DATE], showed: -Immediate notification: Any sign, symptom or apparent discomfort that is acute or sudden in onset and is a marked change (i.e. more severe) in relations to the usual symptoms and signs or is unrelieved by measures already prescribed; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the grievance policy, which required the facility to maintain evidence demonstrating the result of a resident's grievance for a period of no less than three years from the issuance of the grievance decision, for one resident who voiced a grievance to the facility (Resident #16) regarding the housekeeping supervisor. The census was 105. Review of the facility Grievance Policy, dated 1/12/17 and revised on 5/30/19, showed: -Definition: Grievance, an official statement of a complaint over something believed to be wrong or unfair; -Grievance Official: The person designated by the Administrator to receive all grievances to be investigated. This role defaults to the Director of Social Services unless otherwise designed differently by the Administrator; -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are able to communicate freely with the state surveyor when the facility's Social Worker confronted the resident after the resident voiced concerns of not being invited to a care plan meeting. This failure affected one resident (Resident #72). The sample size was 22. The census was 105. Review of the Resident #72's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/21, showed: -Cognitively intact; -Supervision for Activities of Daily Living (ADL); -Diagnoses included thyroid disorder, arthritis, seizure disorder, and asthma. During an interview on 1/24/22 at 11:59 A.M., the resident said he/she has not been invited to a care plan meeting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure services provided meet professional standards of practice when staff failed to properly assess and follow up after a resident experienced a severely low blood sugar level for one resident (Resident #161). In addition, the facility failed to ensure the physician was notified of blood sugar levels that were out of range per facility policy and physician orders (Resident #8). The sample was 22. The census was 105. Review of the facility's Physician Notification for Change in Condition Reporting policy, revised 8/1/16, showed: -Immediate notification: Any sign, symptom or apparent discomfort that is acute or sudden in onset and is a marked change (i.e. more severe) in relations to the usual symptoms and signs or is unrelieved by measures already prescribed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutritional and hydration services to each resident, consistent with the resident's comprehensive assessment for one resident (Resident #94). Facility staff failed to obtain a physician's order for the type of tube feeding formula, failed to follow dietician recommendations and failed to ensure weights were obtained upon admission or throughout the resident's stay. The facility identified three residents as receiving tube feedings; two were included in the sample and issues with identified with one. The census was 105. Review of Resident #94's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/22/21, showed: -admitted [DATE]; -Cognitive status not assessed; -Total dependence on staff for eating; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dialysis services received meet professional standards of care and failed to follow their policy for dialysis when facility staff failed to complete pre and post dialysis assessments for two residents (Residents #50 and #44). The facility identified seven residents as receiving dialysis services, two were chosen for sample and issues were found with both. The sample was 22. The census was 105. Review of the facility's Hemodialysis (process for removal of waste and excess water from the blood due to kidney failure) care and monitoring policy, date reviewed 6/24/21, showed: -Pre-dialysis: evaluation completed within four hours of transportation to dialysis to include but not limited to: accurate weight, blood pressure, pulse, respirations and temperature; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice and failed to follow their policy, when staff failed to sign the drug count sheet when they administered controlled substances. The sample was 22. The census was 105. Review of the facility's Chain of Custody for Controlled Substances Policy, date reviewed 5/29/19, showed: -Definitions: Medication Administration Record (MAR) the legal record for medication administration documentation; -Narcotics are controlled substances, controlled drugs, and scheduled drugs, drugs that have a high risk for addiction and abuse and are controlled or regulated by Drug Enforcement Act (DEA). -Procedure: Administration of controlled substances: Nurse will sign both the MAR and the drug count sheet when administrating a controlled substance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, six errors occurred resulting in a 23% error rate (Resident #94). The census was 105. Review of the facility's Medication Administered by Enteral (via gastrointestinal tract) Tube policy, revised 10/5/21, showed: -The purpose of this policy is to provide guidance for the delivery of medications using the enteral tube for residents having a stable enteral tube in place; -Mixing medications may result in a drug interaction that may include occlusion of the tube and does not comply with medication administration practices of administering medication separately; -Administer medication one at a time and follow with a minimum of 30 milliliters (ml) of liquid between medications unless otherwise directed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors. Staff failed to administer a medication for one resident with a diagnosis of kidney failure who required the medication to decrease the level of phosphorous in the blood (Resident #161). Staff failed to administer an antipsychotic injection, ordered for once a month injection, for several months (Resident #48). For both residents, the facility staff documented the medications as administered when they were not administered. This failure puts residents at risk for significant medication errors that go undetected and unreported to the physician, resulting in potential for compilations related to missed doses. The sample was 22. The census was 105. Review of the facility's Facility Assessment Tool, updated 9/30/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (Resident #75) received treatment and care in accordance with professional standards of practice by not investigating a dressing that had been in place for an extended period of time, not conducting routine skin assessments and not pursuing orders for care. The resident developed two additional wounds in three months time. The sample size was 24. The census was 124. Review of Resident #75's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/26/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Unable to ambulate; -Dependent on staff for transfers; -Limited assistance required for bed mobility and hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to ensure resident bathrooms included grab bars on walls for stabilization and grab bars on toilets in proper working order for two expanded sampled residents reviewed (Residents #107 and #13) and in seven additional resident rooms. The sample was 25. The census was 124. 1. Review of Resident #107's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 1/13/20, showed the following: -Cognitively intact; -Required limited staff assistance with transfers, personal hygiene, toileting and dressing; -Always continent of bowel and bladder -Diagnoses included: heart failure, diabetes and arthritis. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and send a Third Party Liability (TPL) form (a form which is sent to MO Healthnet which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after the death, for six of six residents who expired and their funds were used for funeral expenses (Residents #300, #301 #302, #303, #304 and #305). The census was 124. 1. Review of Resident #300's resident trust account, showed the following: -He/she expired on [DATE]; -On [DATE], the facility wrote a check from the resident's trust account for $1,333.73, to the funeral home; -No notification was issued to the TPL (form MO [PHONE NUMBER]) within 30 days, showing the resident's final accounting. 2. Review of Resident #301's resident trust account, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to protect and facilitate a resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to a computer, for one resident (Resident #78) who was refused the right to the use of a computer. The census was 124. The sample was 25. 1. Observations of the facility on all days of the survey from 1/29-1/31/20 and 2/3-2/5/20, showed no available computers or tablets available for resident use. 2. During an interview on 1/29/20 at 10:20 A.M., the administrator verified the facility had wireless Internet (wifi). 3. Review of Resident #78's admission Minimum Data Set (MDS), dated [DATE], showed the following: -admission date of 12/21/19; -Cognitively intact; -Required extensive assistance from staff for toileting and limited assistance for personal hygiene and dressing; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and homelike environment for all residents when they did not provide comfortable sound levels in the dining room during meals. The facility also failed to maintain walls in good repair in the dining room. The census was 124. The sample was 25. 1. Observations of the dining room, showed the following: -On 1/29/20 from 12:35 P.M. to 1:00 P.M., dietary aide (DA) H walked throughout the dining room loudly calling out resident names. Residents played music on their cell phones at their tables and could be heard across the dining room; -On 1/30/20 at 8:14 A.M., two residents played music on their cell phones which could be heard throughout the dining room. One resident who sat in the assist dining room, attached to the main dining room, sporadically yelled loudly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all physician's orders were followed by not providing wound treatments, ensuring orders for tube feeding were congruent with the care plan, administering oxygen at the proper rate, applying support stockings, obtaining an order for and checking blood sugar levels, obtaining laboratory tests and ensuring a care plan was updated with the removal of a gastrostomy tube (G-tube, a tube surgically inserted into the stomach to provide hydration, nutrition and medications), for nine (Residents #61, #78, #33, #221, #91, #107, #38, #74 and #93) of 25 sampled residents. The census was 124. 1. Review of Resident #61's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/19, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received showers as scheduled and on a consistent basis by failing to provide documentation showing four of 18 sampled residents received showers/baths, failed to shave one resident on a consistent basis and failed to provide fingernail care and cleanse one resident's contracted hands. These deficient practices affected five of 25 sampled residents (Residents #93, #27, #74, #371 and #39). The census was 124. 1. Review of Resident #93's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/20, showed the following: -Moderate cognitive impairment; -Extensive assistance required by staff for all mobility and personal care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment, care plan and preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for four of 25 sampled residents (Residents #39, #93, #27 and #4). The census was 124. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/18/19, showed the following: -admitted on [DATE]; -Severe cognitive impairment; -Total dependence on staff for self care including personal hygiene, bathing, dressing and toileting; -Preferred activities: staff left blank; -No speech, absence of spoken words; -Rarely/never understands/is understood; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and the manufacturer's recommendations during transfers with a Hoyer lift (mechanical lift used to transfer a resident from one surface to another), resulting in failure to protect one resident from injury during a transfer (Resident #101) and failed to safely transfer two additional residents (Resident's #61 and #76). The facility also failed to follow their smoking policy by not assessing residents for smoking safety and allowing residents to keep smoking paraphernalia on their person (Residents #108, #109, #38, #221 and #33). Additionally, the facility failed to ensure the safety of residents during independent leave of absence (LOA) by not following their policy to obtain physician orders (Residents #38 and 109). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain complete physician's orders for indwelling urinary catheters (a tube inserted into the bladder for the purpose of continual urine drainage) and failed to maintain proper placement of catheter tubing and drainage bag. The facility identified seven residents as having indwelling and/or supra pubic urinary catheters (a sterile tube inserted into the bladder through the abdominal wall to drain urine). Of those seven, three were chosen for the sample and problems found with two (Residents #110 and #47). The sample was 25. The census was 124. 1. Review of Resident #110's medical record, showed the following: -A face sheet, showed an admission date of 1/10/20; -Diagnoses included dysphagia (difficulty in swallowing) and stroke. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis center for three (Residents# 371, #220 and #61) residents. The facility identified five residents who received dialysis. Of those five, three were chosen for the sample of 25, and problems were found with all three. The census was 124. 1. Review of Resident #371's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Extensive assistance with dressing, toileting and personal hygiene; -Special treatments: Dialysis (the mechanical purification of blood as a substitute for the normal function of the kidney); -Diagnoses included end stage renal disease (ESRD-Kidney failure) and heart disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nurse aides (CNA)s received the required 12 hours of training and had a system to track the hours for five of five employees reviewed who worked at the facility for over a year. The census was 124. Review of the training records provided by the facility, showed the following: -A total of 26 CNAs worked at the facility for over a year; -CNA K -received 10.5 hours of training; -CNA L-received 5 hours of training; -CNA U-received 5.25 hours of training; -CNA V-received 5 hours of training; -CNA W- received 7.25 hours of training. During an interview on 2/4/20 at 7:15 A.M., the administrator said each CNA had education on a training site utilized by the facility and it was each employee's responsibility to complete the training. They also had a lot of inservicing provided and staff were responsible to attend. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented timely in the resident's medical record that the irregularities identified during the monthly medication regimen review (MRR) had been reviewed and what, if any, action had been taken to address it, and failed to have all MRRs documented, for four of 25 sampled residents. (Residents #61, #33, #27 and #371) The census was 124. 1. Review of Resident #61's medical record, showed the following: -admitted to the facility on [DATE]; -Diagnoses included end stage renal disease (ESRD, kidney failure), depression, schizophrenia (long term mental condition affecting thought, emotion and behavior), atrial fibrillation (A-fib-irregular heartbeat) and diabetes; -Pharmacy medication regimen reviews (MRRs), completed on 10/21/19 and 11/19/19, with noted irregularities; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for three of 25 sampled residents (Residents #62, #371 and #52). The census was 124. 1. Review of Resident #62's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/16/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Dependent on staff for transfers and toileting; -Received antianxiety zero of seven days; -Diagnoses included stroke, hemiplegia (paralysis on one side of the body), bipolar (mental illness that causes extreme highs and extreme lows and anxiety). Review of the physician's order sheet (POS) showed an order, dated 11/28/19, to administer Clonazepam (antianxiety) 0.5 milligrams (mg) one tablet every 12 hours PRN for anxiety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, four errors occurred, resulting in a 14.81% error rate (Resident's #26, #54 and #58). The census was 124. 1. Review of Resident #26's medical record, showed the following: -Diagnoses included dementia and diabetes; -An order, dated 1/10/20, to administer Flonase nasal spray (treats allergic and non-allergic nasal symptoms) one spray in each nostril daily. Observation on 1/30/20 at 8:10 A.M., showed Certified Medication Technician (CMT) Q, administered the resident's morning medications. He/she administered two sprays of Flonase into each nostril. He/she did not have the resident blow his/her nose before administration and did not block the opposite nostril. 2. Review of Resident #54's medical record, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure insulin vials and flexpens (pre-filled injectable insulin device) were dated once opened, labeled with resident's name, and failed to discard opened, outdated insulin vials and/or insulin flexpens for three of three medication carts checked. The census was 124. 1. Observation on [DATE] at 6:45 A.M., of the Harmony Hall medication cart, showed the following: -One Humulin 70/30 (combination form of long acting) insulin vial opened without date written when opened; -One Humalog (fast acting) insulin flexpen opened without date written when opened; -One Levemir (long acting) insulin flexpen opened without date written when opened; -One Novolog (fast acting) insulin flexpen opened, not dated when opened and not labeled with resident's name; [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent possible cross contamination of the residents' food during preparation and service when staff did not use safe food handling techniques and failed to ensure the air conditioning vents and filters remained free of dust during five of five days of observation. The census was 124. 1. Observation 1/30/20 at 7:52 A.M., of breakfast service, showed [NAME] P stood at the steam table wearing gloves. As [NAME] P received orders, he/she used his/her gloved hands to place French toast and bacon on plates which were then served to residents. [NAME] P used his/her gloved hands to place food on plates at least four times. He/she then used the same gloved hands to take bread out of a bag and scrape off the griddle with a metal spatula. He/she then placed food on three additional plates. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage dumpsters outside the facility were kept closed to prevent access to rodents and pests, during four of four days of observation. The facility census was 124. Observations of the outdoor dumpsters, showed the following: -On 1/30/20 from 7:30 A.M. to 12:08 P.M., two dumpsters with open lids. The green dumpster had cardboard boxes spilling out. The blue dumpster had numerous bags of trash spilling out and on to the ground. At least nine bags of trash lay on the ground next to the dumpster. At 12:57 P.M., two dietary aides (DA) took a large black trash bag (splitting open) and tossed it onto a pile of trash bags on the ground around the dumpsters, then walked away. The lids to the blue and green garbage dumpsters remained opened; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff follow acceptable infection control practices during wound treatment and blood glucose testing (BGT) for two of 25 sampled residents (Residents #75 and #18). In addition, the facility failed to ensure three of nine employees reviewed, received their two step tuberculosis (TB) skin test upon date of hire and ensure one additional employee had a current chest x-ray or screen to rule out TB symptoms. The census was 124. 1. Review of Resident #75's electronic medical record, showed the following: -admission date of 9/18/19; -Diagnoses included deep vein thrombosis (DVT, blood clot usually in the lower leg). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident remained free from restraints, conduct a restraint assessment and obtain a physician's order for the use of a restraint (Resident #27). The facility identified no residents with restraints. The sample size was 25. The census was 124. 1. Review of Resident #27's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/18/19, showed the following: -Severe cognitive impairment; -Extensive assistance of two staff required for bed mobility and transfers; -Dependent on staff for bathing, eating, toileting and locomotion; -Impairment to both upper extremities (UEs) and both lower extremities (LEs); [...]

Inspectors wroteBasedonobservation interviewandrecordreview the facilityfailedtoensureone resident (Resident #39) withlimitedrangeofmotion(ROM receivedappropriatetreatmentsandservicestoincreaseROMandorpreventfurtherdecreaseinROM after identifying the issues on the resident's care plan. The facilityalso failedtoperformrestorativetherapyforone resident per physician order (Resident#61). The sample was 25. The census was 124. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/18/19, showed the following: -admission date of 11/11/19; -Severe cognitive impairment; -Non verbal; -Total dependence on staff for self care including personal hygiene, bathing, dressing and toileting; -Functional limitation in ROM with impairment on both sides; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dental care and services were provided to one sampled resident who requested dental services and required to be fitted for dentures (Resident #38) out of 25 sampled residents. The census was 124. Review of Resident #38's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/19, showed the following: -admitted on [DATE]; -Cognitive impairment; -Independent with all self care activities; -No natural teeth; -Diagnoses included: heart failure, end stage renal disease, diabetes, at risk for malnutrition and seizure disorder. Review of the resident's care plan, last revised on 11/23/19, and in use during the survey, showed the following: -Problem: Edentulous (no teeth). Resident recently had decaying teeth pulled; -Goal: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for a new resident who elected hospice care that included appropriate care and services, include the provider of hospice services on the resident's physician's orders and establish the process for communication between the hospice aide and the facility. The facility identified six residents as receiving hospice care and three were chosen for the sample. Of those three, problems were found with one (Resident #271). The census was 124. Review of Resident #271's face sheet, showed the following: -admitted to the facility on [DATE]; -Diagnoses included kidney disease, encephalopathy (brain disease, damage, or malfunction), atrial fibrillation (A-fib-irregular heartbeat), high blood pressure, diabetes and sepsis (blood infection). [...]