Windsor Estates of St. Charles

Inspectors wroteBased on record review and interview, the facility failed to implement procedures to accurately acquire and administer prescribed medications for one resident (Resident #1) upon admission, in a review of seven sampled residents. On admission, the facility involved a third-party provider, a group of physicians and nurse practitioners who review and issue orders after hours, to review the resident's medications listed on the resident's hospital discharge orders. The third-party provider placed medications to treat the resident's pain, anxiety, migraine headaches, and attention deficit hyperactivity disorder (ADHD, a disorder causing persistent patterns of inattention, hyperactivity, and impulsivity) on hold until the resident's physician reviewed and approved the orders. [...]

Inspectors wroteBased on interview and record review, facility employees and service providers failed to provide services to a resident (Resident #79) that were necessary to avoid physical harm. Facility staff failed to follow facility policy and procedures, and physician orders for monitoring upon admission and when the resident, who had cardiac-related diagnosis, experienced a change in condition. Staff failed to follow physician's order to check the resident's blood pressure prior to administering blood pressure medication and failed to initiate orders for a muscle relaxer. The facility failed to use nursing judgement and knowledge to advocate for further medical evaluation when the resident expressed possible cardiac-related symptoms, including a feeling of something sitting on their chest on [DATE] and [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reorder an antianxiety medication timely for one resident (Resident #62), in a review of 28 sampled residents, to ensure the medication was available for administration. Resident #62 missed six doses of antianxiety medication. The resident had a panic attack (a sudden surge of overwhelming fear and physical discomfort), experienced withdrawal symptoms, and expressed feelings of hopelessness and not wanting to live. The facility census was 72. Upon request, the facility did not provide a policy regarding re-ordering controlled medications. Review of Resident #62's care plan, revised on 11/04/23, showed the following:-Diagnoses included anxiety disorder;-The resident had mood problems due to major depressive disorder, anxiety, and insomnia; -Give anti-anxiety medications as ordered. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide residents with a safe, clean, and homelike environment, including providing housekeeping and maintenance services necessary to maintain an orderly, odor free, and comfortable interior. The facility census was 72. 1. During an interview on 05/19/26 at approximately 1:30 P.M., the Regional Nurse Consultant said the facility did not have a specific policy related to homelike environment. 2. Observation on 05/11/26 at 3:50 P.M. showed the shared closet door in occupied resident room [ROOM NUMBER] was off the track and dragged on the floor. During an interview on 05/11/25 at 3:50 P.M., the resident who resided in room [ROOM NUMBER] said the closet door dragged on the floor and got off the track. Staff would fix it and then it would break again. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for three residents (Residents #81, #36, and #42), in a review of 28 sampled residents. Staff failed to administer medications as ordered on admission for Resident #81 and failed to obtain blood tests as ordered for Residents #36 and #42. The facility census was 72. Review of the facility's policy, Medication Administration, dated May 2019, showed the following: -Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis;-If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide eight residents (Residents #2, #9, #18, #29, #42, #45, #52, and #64), who required staff assistance for activities of daily living (ADLs), in a review of 28 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 72. Review of the facility's policy, Activities of Daily Living,( ADLs), dated 09/24/25, showed the facility provided each resident with care, treatment, and services according to the resident's individualized care plan. The facility did not provide a policy related to oral care. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 03/16/26, showed the resident was dependent on staff for oral hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, when the facility staff failed to follow facility policy during a manual transfer for one resident (Resident #51), in a review of 28 sampled residents, when staff failed to use a gait belt (device used to transfer residents from one position to another) and lock the resident's wheelchair brakes when assisting the resident to transfer from his/her wheelchair to the common area couch. The facility failed to propel one resident (Resident #18) safely when staff transported the resident in his/her wheelchairs without foot pedals. The resident's right foot was bent backwards and dragged against the floor underneath the wheelchair. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for six of six sampled residents (Residents #1, #2, #3, #4, #5 and #6). The facility withdrew back room and board without the resident and/or financial guardian's written authorization or after the resident expired. The facility census was 72.1. Review of the facility maintained Resident Trust Ledger for the period [DATE] through [DATE], showed Resident #3 expired on [DATE]. Review of Resident #3's Ledger showed $8,119.01 held in the Resident Trust Account on [DATE]. Funds in the amount of $3,904.41 were reported to the Department of Social Services Third Party Liability (TPL) Unit on [DATE] and did not include the full balance of the resident's funds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of six sampled residents, received treatment and care in accordance with professional standards of practice when staff failed to assess Resident #1 following the report of a fall, failed to obtain treatment for two days following the fall, and failed to implement and follow physician orders for treatment following identification of the fall with injury. The resident sustained a fractured left wrist. The facility census was 73. Review of the facility Fall policy dated May 2025 showed the following:-Each resident of the community who experiences a fall will be treated and assessed to adequately treat any current injuries, either physical or psychosocial and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight and prevent falls for one resident (Resident #2) in a review of six residents when staff failed to ensure the resident's bed was always in the lowest position while the resident was in bed. The facility also failed to ensure the resident's low air loss mattress (a specialized, medical, mattress with inflatable air cells that continuously circulate ai and provides pressure redistribution) was at the appropriate weight setting to prevent falls from bed. The facility census was 73. Review of the facility Fall Policy, dated May 2025, showed the following:-The purpose of the fall program was to develop, implement, observe and evaluate an interdisciplinary approach and manage strategies and interventions that foster resident independence and quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #9) of ten sampled residents, with a history of pressure ulcers received the necessary care and services, when staff failed to identify the presence of, history or risk of pressure ulcers including a pressure ulcer on admission on the resident's sacrum. The resident was identified eight days following admission [DATE]) with a Stage III pressure ulcer on his/her sacrum with an old dressing prior to the resident's transfer to a hospital. The facility had no documentation to show prior identification of the ulcer, assessment, treatment or a care plan to address the pressure ulcer. The facility census was 72. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four residents (Resident #1, #3, #4, and #6), of eight sampled residents, who required assistance with Activities of Daily Living (ADL's) received the necessary care and services to maintain good grooming when staff failed to provide nail care. The facility census was 63. Review of the undated facility policy for Activities of Daily Living showed this facility provides each resident with care, treatment, and services according to the resident's individualized care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility census was 68. Review of the undated facility policy for Monitoring Food Temperatures for Meal Service showed:-Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures;-Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper servicing temperatures. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the main parking lot. The facility census was 68. Observation on 8/7/25 at 12:45 P.M. and again at 7:30 P.M. showed the facility front driveway and parking lot with a large area of damaged asphalt. The area was approximately ten feet in diameter and approximately 8-10 inches in depth at the center. This area was at the end of the visitor parking area and would affect any vehicle using the area for travel. During an interview on 8/15/25 at 2:00 P.M. the Administrator said he was aware the area needed repair, there were several projects in the works; he would expect the area to be repaired.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) of 10 sampled residents when the resident fell out of bed while receiving care, sustained injuries and required treatment at a local hospital. The resident required staff assistance for bed mobility and care. The resident's bed had a mattress overlay that reportedly shifted on the bed. Staff rolled the resident to his/her side, turned away from the resident to get supplies, and the resident fell out of the bed to the floor. The resident sustained a laceration to the right side of the forehead, a skin tear to the right outer eyebrow area, a skin tear to the right forearm, and bruising to the right elbow. The resident was sent to a local hospital and required staples to close the laceration to the forehead. The facility census was 62. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills set to carry out the function of the food and nutrition services. This practice effected all residents in a facility. The facility census was 62. The facility did not have a policy regarding training or competency requirements for the Dietary Manager. 1. Review of the Food Establishment Inspection Report from the local county health department dated 2/12/25 showed: -Foodborne Illness Risk Factors and Public Health Interventions: Supervision: Certified Food Protection Manager out of compliance; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label food for expiration date, failed to discard food that has passed the expiration date as identified on the food label, failed to maintain one refrigerator to be free of rust and ice build up and failed to ensure a thermometer was present in the refrigerator. The facility failed to label and date when a food item was opened and refrigerated. The facility census was 62. Review of the undated facility policy for Food storage (Dry, Refrigerated, and Frozen) showed the following: -Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided four residents (Resident #2, #6, #10 and #11), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor, in a review of 11 sampled residents. The facility census was 61. Review of the facility's undated policy, Activities of Daily Living, showed the following: -The facility provides each resident with care, treatment and services according to the resident's individualized care plan; -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including bathing and grooming. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the water supply to the dishwasher in good working condition. The water pipe to the dishwasher leaked, causing water to pool under the dishwasher and run onto the floor in the dishwashing area. The facility census was 62. 1. Review of an inspection report dated 2/12/25 from the local county public health department showed: -Leaking plumbing or plumbing in disrepair; -Out of compliance with plumbing. Observation on 5/1/25 between 9:50 A.M. to 2:30 P.M. and again on 5/2/25 between 6:30 A.M. to 12:30 P.M. showed the following: -Water dripped out of pipes located under the dishwashing machine in the kitchen; -Pooled water under the dishwasher and the shelving attached to the dishwasher that flowed out from under the dishwasher and onto the floor. During an interview on 5/2/25 at 11:15 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice when staff failed to ensure ordered medications were available for administration for two residents (Resident #1 and Resident #2), in a review of four sampled residents. The facility census was 61. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of infection of a joint prosthesis and low back pain. Review of the resident's physician orders dated 2/18/25 showed an order for Tramadol (medication used to relieve moderate to moderately severe pain, including pain after surgery) 50 milligrams (mg) every six hours as needed (PRN) for pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a call system that was adequately equipped to to ensure staff received alerts through a communication system which relayed the call directly to a staff member or to a centralized staff work area with an audible sound. This affected the entire facility. The facility census was 66. 1. Review of the facility's daily census sheet provided by the facility on 2/21/25 showed the following: -100 hall with 19 residents; -200 hall with 29 residents; -300 hall with 18 residents. 2. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/19/24 showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decision; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one resident (Resident #2), a resident dependent on staff for bed mobility, when staff rolled the resident to his/her side in the bed to provide care, the resident reached out to the side opposite of staff, and fell from the bed to the floor. The resident was to have a fall mat in place on the floor per his/her care plan. No fall mat was in place at the time of the fall. Staff reported the resident often reached out during care, but the resident had not been reassessed for safety with bed mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of five sampled residents, who was dependent upon staff for transfers and at risk for falls. Staff left the resident in bed positioned on mechanical lift mat with the bed in the high position and then left the room, leaving the resident unattended. The resident slid off the bed and fell to the floor sustaining a fracture of the left leg. The facility census was 60. The administrator was notified on 7/30/24 at 10:00 A.M., of the Past Non-Compliance which occurred on 7/16/24. On 7/16/24, the administrator became aware of the injury to Resident #1 which resulted from a fall from the bed. The facility began an investigation and determined that the resident was left unattended and had a fall from the bed which resulted in a fractured left leg. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an admission policy and implement an admission protocol to ensure residents and/or residents' representatives signed the admission agreement for one resident (Resident #10). The facility also failed to ensure at least a 30 day notice was provided to four residents (Resident #2, #5, #6, and #11) and/or the resident representatives in writing for an increase in charges for services provided to residents at the facility. The facility census was 59. During an interview on 7/22/24 at 2:45 P.M. the administrator said the facility did not have an admission policy. Review of the facility's Financial Responsibility Agreement, private method of payment section, dated October 2015, showed the following: -The agreement is for payment for the care and services that are provided to the resident by the facility; [...]

Inspectors wroteBased on interviews and record review, the facility failed to employee a Food Service Director (FSD) with credentials that were not expired. This failure had the potential to affect 55 of 55 residents as there were no enteral feeding residents at the facility.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure a resident that had nasal medication and two inhaler medications on the resident's bedside had a self-administration of medication assessment, a physician's order, and care plan completed for one of one resident (Resident (R) 3) reviewed for self-administration of medications. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure an allegation of injury of unknown origin was reported to the State of Missouri Department of Health and Senior Services State Agency (SA) timely for one or one (Resident (R) 21) reviewed for abuse in the sample of 19.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure an investigation was immediately initiated when an allegation of injury of unknown origin was found for one of one resident (Resident (R) 21) reviewed for abuse in the sample of 19.

Inspectors wroteBased on record review, and interview, the facility failed to update the resident's care plan with new interventions for one of three residents (R )21) care plans reviewed in the sample of 19. Specifically, R21, who had wandering behaviors, left the skilled nursing unit without staff knowledge or supervision and was found in the portion of the building identified as the independent living Bistro on 09/03/23 and then again found missing for over two hours on 10/05/23 in the portion of the building identified as the chapel which was located past two closed double doors at the end of the hall.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to prevent a resident with wandering behaviors from leaving the skilled nursing unit without staff's knowledge or supervision for one of three residents (R )21) reviewed for accidents in the sample of 19. Specifically, R21 left the skilled nursing unit and was found in the portion of the building identified as the independent living Bistro on 09/03/23 and then again found missing for over two hours on 10/05/23 in the portion of the building identified as the chapel which was located past two closed double doors at the end of the hall.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure that the Certified Nurse Aide (CNA)changed gloves and performed hand hygiene when going from a contaminated area to a clean area for one of one resident (Resident (R) 18) observed for catheter care from a total of 18 residents sampled, to prevent possible cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided one resident (Resident #1 and #2 ), who were unable to perform own activities of daily living (ADLs), in a review of 5 sampled residents, the necessary care and services to maintain good personal hygiene. The facility census was 57. The facility did not provide a policy for Peri Care for the gender specific resident. Review of the undated Skills Checklist for Peri Care ( a tool used to train staff on how to properly provide peri care showed the following: -Apply gloves; -Help the resident into a dorsal recumbent (lying on the back with the knees slightly bent) position; -Wash and dry upper thighs; -Separate the perineal folds and wash in a down stroke alternating from side to side moving outward on the thighs; -Use a different wash cloth for each stroke; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed gloves appropriately while performing peri care for two residents (Resident #1 and #2), of five sampled residents. The facility census was 57. Review of the undated facility policy for Hand Hygiene showed the following: -Appropriate hand hygiene is essential in preventing transmission of infectious agents; -Hand hygiene continues to be the primary means of preventing the transmission of infection. Hand hygiene (washing hands and or Alcohol-Based Hand Rub (ABHR) are consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled (e.g. [...]

Inspectors wroteRefer to K2AZ12. Based on observation, interview and record review, the facility failed to obtain and administer pain medication timely after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, failed to ensure the medication was available for administration, and failed to plan care with interventions to address the resident's pain for two residents (Resident #1 and #3) out of three sampled residents. Resident #1 had an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain. The facility failed to obtain a refill for the resident's oxycodone resulting in the resident not having the pain medication for five days. The resident's pain level was high and the resident reported he/she became very angry and upset and aggressive due to the pain being out of control. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services consistent with standards of practice, when the facility failed to ensure weekly skin assessments were completed to include measurements, appearance, and any other wound characteristics for one resident, (Resident #2) of two sampled residents. The resident presented with a new open area on the sacrum (triangular bone at the base of the spine) on 9/16/23. The facility failed to consistently assess the wound to identify any changes in the wound necessitating a change in treatment. On 9/30/23, a wound care consultant assessed the resident's wound was now a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead skin) may be present but does not obscure the depth of tissue loss. [...]

Inspectors wroteBased on observation and interview, the facility failed to safely transfer one resident (Resident #1), in a review of two sampled residents, when staff failed to utilize a sit to stand lift to transfer the resident per the resident's plan of care and was at risk for falls. Staff transferred the resident using a transfer belt, the resident's knees buckled, causing staff to lower the resident to the floor and the resident suffered a fractured femur (large bone in the upper leg). The facility census was 58. Review of the facility policy for Safe Lifting and Movement of Residents, dated 1/17, showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and administer pain medication timely after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, failed to ensure the medication was available for administration, and failed to plan care with interventions to address the resident's pain for two residents (Resident #1 and #3) out of three sampled residents. Resident #1 had an order for oxycodone (narcotic medication used to relieve severe pain), 5 milligrams (mg) two times (BID) a day for pain. The facility failed to obtain a refill for the resident's oxycodone resulting in the resident not having the pain medication for five days. The resident's pain level was high and the resident reported he/she became very angry and upset and aggressive due to the pain being out of control. The census was 62. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one resident (Resident #2) of two sampled residents, when staff failed to notify the physician and obtain orders for blood work and an x-ray that were recommended from an outside wound care provider. The facility census was 59. The facility did not provide a policy for following physician orders or policy for notifying the physician of recommendations from an outside wound care provider. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/15/23 showed: -The resident was unable to understand or make self understood; -Was not oriented to person, place or time; -Totally dependent upon two staff members for Activities of Daily Living (ADL's); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #2), of two sampled residents, received care and services to prevent weight loss. Staff failed to obtain weights per facility protocol. As a result, the facility failed to identify the resident's weight loss and failed to notify the physician and dietitian of the weight loss to address the weight loss. The resident had a weight loss of 5.3 pounds in 23 days for a 6.81% weight loss (considered severe loss). The facility census was 59. Review of the facility policy for Weight Assessment and Interventions dated 1/2017 showed: -Weight Assessment: Nursing staff will measure the resident's weights on admission, and weekly for four weeks thereafter If no weight concerns are noted at this point, weights will be measured monthly; -Weights will be recorded in the individual's medical record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for one resident(Resident #205) of 20 sampled residents and one additional resident (Resident #40). Maintenance staff failed to fix a grab bar in Resident #205 and #40's bathroom that both residents used. The grab bar came out of the wall during Resident #205's use, he/she fell, hitting his/her head. The resident was evaluated at the hospital and sustained a closed head injury as a result. The facility census was 54. The facility provided no policy regarding work order completion expectations. 1. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/28/22, showed the following: -Cognitively intact; -Required total dependence of two staff for transfers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed appropriate infection control procedures when staff failed to change gloves after performing an accucheck procedure (finger stick to obtain blood), for one resident (Resident #32) in a review of 20 sampled residents. Staff handled multiple residents' insulin pens with contaminated gloves and gave insulin with contaminated gloves. The facility also failed to keep one resident's (Resident #9)'s ,urine collection bag off the floor to reduce risk of infection. Further review showed the facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility census was 54. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one resident (Resident #10) had a call light or other means of summoning staff when needed, and failed to ensure two residents (Resident #1, 21), who were dependent on staff for activities of daily living, consistently had access to a call light or other means of summoning staff within reach of the residents, in a sample of 20 residents. The census was 53. During an interview on 7/7/22 at 4:36 P.M., the interim administrator said the facility did not have a policy regarding call lights. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to ensure the environment was clean and maintained in good repair. The facility census was 54. Observation on 7/5/22 at 11:18 A.M. in resident room [ROOM NUMBER], showed the following: -Two wood sliding closet doors would not open or close properly. Both sliding closet doors were marred and scratched; -The flooring in the room was covered with numerous white areas of dried debris; -The drywall was marred and the cove base was peeled back at the base of the wall by the bathroom. Observation on 7/5/22 at 9:56 A.M., 11:22 A.M., and 1:48 P.M. in resident room [ROOM NUMBER], showed the following: -The flooring in the room was covered with a heavy buildup of crusty dried debris; -The drywall was marred and missing paint; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents knew how they could file a grievance other than through resident council, failed to ensure the facility responded to all grievances and made prompt efforts to resolve any grievances. Residents said they felt their concerns were not heard or addressed. The facility did not follow their policy with the administrator signing, reviewing and documenting the completion of the grievance process. The facility census was 54. Review of the facility policy, titled Resident Grievance Policy and Procedures, revised February 2021, showed the following: -It is the intent of this facility/community to encourage residents, their representatives or family members, opportunities to communicate any concerns, suggestions, complaints or opportunities for improvement in care or services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #805), in a review of 20 sampled residents, was free from misappropriation of property, when the former Director of Nursing (DON) misappropriated the resident's narcotics. The former DON had pulled the resident's narcotic medication from the active medication cart, stating the medication had been discontinued when there was no documentation to support the medication had been discontinued. Further review showed the former DON improperly prepared the medication for destruction and upon investigation, there was one less tablet accounted for than was on the narcotic control sheet. The facility census was 54. Review of the undated pharmacy Controlled Substance Storage and Handling policy showed the following: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for two of 20 sampled residents (Resident #5 and #6). The facility census was 54. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice and physician orders for four residents (Residents #21, #28, #32 and #42) in a review of 20 sampled residents, and for one additional resident (Residents #5). Staff did not follow physician orders, did not prepare or administer medications as ordered, did not ensure medications were available for administration, administered medications when they were not ordered, did not administer resident's gastrostomy tube (G-tube; a tube inserted into the stomach that brings nutrition/medications directly into the stomach) medication correctly or ensure tube feeding infused per order, did not prime an insulin pen prior to administration to ensure the correct dose was administered and did not check vital signs as ordered before the administration of medications. The facility census was 54. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four residents (Residents #9, #21, #28, and #206), in a review of 20 sampled residents, who required assistance with activities of daily living (ADLs), received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 54. Review of the facility policy titled, Dental Care, revised 2021, did not address expectations of staff providing oral care to residents. Review of the facility's undated document titled, Oral Hygiene Skills Check, showed for the unconscious resident - repeat oral hygiene as often as necessary to keep the mouth and lips clean and moist. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision November 2001, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Residents #1, #21, and #32), in a review of 20 sampled residents, were provided an ongoing activities program in accordance with the resident's comprehensive assessment, care plan, and the resident's preferences, designed to meet their individual interests and their physical, mental, and psychosocial well-being. The facility census was 54. Review of the Nurse Assistant in a Long Term Care Facility manual, revised November 2001, showed the following: -Responsibilities of the nurse assistant in resident activities: -Suggest activities of interest to the resident in a positive, enthusiastic way; -Check activity calendar daily and plan care accordingly. Encourage resident to select activities of personal interest to attend; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) were securely stored behind two locks when staff that received the medications left the narcotic controlled substances on a desk and unattended. The medications came up missing as a result. Further review showed the current Director of Nursing (DON) stored oxycodone immediate release (IR), a schedule II narcotic controlled substance for pain, in his office with no accountability. The facility census was 54. Review of the facility CONTROLLED SUBSTANCE POLICY, revised 2/2021, showed the following: -Controlled substances are subject to special handling, storage, disposal and record-keeping requirements. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure insulin (medication used to treat diabetes) pens for two residents (Residents #8 and #32), were dated when opened and/or discarded within the designated time frame after opening. Further review showed the facility failed to discard expired stock medications and staff administered the expired medication to one resident (Resident #32). The facility census was 54. Review of the Food and Drug Administration guidelines for Novolog (insulin), Levemir (insulin) and Lantus (insulin) showed the following: -Novolog Insulin should be discarded 28 days after opening; -Lantus Solostar pens should be discarded 28 days after opening. The facility provided no policy regarding insulin administration, storage or destruction. 1. Review of Resident #32's July 2022 Physician Order Sheets (POS) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the menu by not preparing or serving all food items for lunch as directed by the spreadsheet menu on 07/07/22. The facility census was 54. Review on 07/07/22 of the facility policies showed no documentation of a policy for following the menu. Review of the diet spreadsheet for lunch on 07/07/22 showed the following: -Residents on a pureed diet were to receive pureed roll and pureed cream cheese brownie; -All residents, except low concentrated sweet and heart healthy diets, were to receive cream cheese brownie. Review of the Diet Roster-By Diet, dated 07/07/22, showed five residents with a physician's order for a pureed diet. Observation on 07/07/22 at 10:23 A.M. showed staff prepared pureed rolls and cream cheese brownies, including pureed cream cheese brownies, for the lunch meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility census was 54. Review on 07/07/22 of the facility policies showed no documentation of a policy for food temperatures. Observation on 07/07/22 at 11:52 A.M. of the dining room showed staff served residents the noon meal from the steam table which included meatloaf and peas. Observation on 07/07/22 at 12:46 P.M. of the test tray, received after the last resident was served, showed the following food temperatures: -The peas were 103 degrees Farenheit (F) and cool to taste; -The pureed peas were 111 degrees F and cool to taste; -The ground meatloaf was 104 degrees F and cool to taste. During interview on 07/07/22 at 1:02 P.M., Dietary staff A said the food should be served at 165 degrees F so it was not too hot. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each side of the hall. The facility census was 54. Observations on 7/5/22 between 10:57 A.M. and 4:33 P.M. and on 7/6/22 at 2:53 P.M. showed the following: -A 6-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -A 3-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -A 2-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -A 3-foot section of handrail between resident room [ROOM NUMBER] and 304 was loose from the wall and not secured; -A section of handrail between room [ROOM NUMBER] and room [ROOM NUMBER] was loose and moved slightly when grasped; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's choice of code status (full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate (DNR), no life prolonging methods are performed)) was consistent and without conflicting information, throughout two residents' (Resident #32 and #206's) medical records, in a review of 20 sampled residents. The facility census was 54. Review of the facility policy titled, Advance Directives, revised February 2021, showed the following: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for one residents (Resident #34), in a review of 20 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status, and required interdisciplinary review and/or revision of the care plan. The facility census was 54. Review of the facility policy titled, Care Planning - Interdisciplinary Team Policy, reviewed February 2021, showed the following: -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed complete a thorough assessment of one resident (Resident #2), in a review of ten sampled residents, upon admission to ensure identification and appropriate services were in place to address the resident's needs. The resident was admitted to the facility from the hospital following the amputation of toes on his/her left foot on 12/8/22. The facility did not conduct a skin assessment, did not remove dressings on the resident's foot, and did not obtain orders to treat the surgical wounds on the resident's left foot until 12/13/22 (five days following admission). The facility census was 58. Review of facility's undated New admission Process Checklist showed the following: -Complete full skin assessment; -Call physician and verify medication orders. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and the reason for the transfer for four residents (Residents #38, #46, #205, and #806), failed to notify one resident and/or the resident's representative in writing of an emergency discharge from the facility for one resident (Resident #806), and failed to notify the Ombudsman when residents were transferred and/or discharged from the facility. The facility census was 54. The facility provided a copy of the transfer/discharge form letter but no transfer/discharge or notification policy was provided. Record review of the facility's undated policy, Resident Involuntary Discharge, showed the following: -The facility will only initiate involuntary discharge proceedings when: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for three residents (Resident #38, #46, #205), in a review of 20 sampled residents. The facility census was 54. The facility did not provide a policy for bed hold notification. Review of the facility admission packet showed it contained a section regarding Bed Hold policy on page eight that read as follows: -When a private pay resident is given an order by a physician to be admitted to a hospital or to be discharged from the facility for therapeutic leave, the resident, designee or resource person will be notified concerning the transfer and the daily rate required to hold such resident's bed if resident desires to return to the same bed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices. The facility census was 58. 1. Review of facility's policy Food Safety, dated 2006, showed the facility will provide food that is free from contamination thus risking the health and well being of the residents and staff. Review of facility's policy Employee Hygiene, dated 2006, showed employees must keep their hands, arms and fingernails clean. 2. Observation on 8/19/19 at 11:21 A.M. showed a bag of pre-cubed potatoes sat on the food preparation table. There were multiple areas of greenish-gray spots on the cubed potatoes with white fuzz around the greenish-gray areas. Observation on 8/19/19 at 11:44 A.M. showed Dietary Staff X cut open the bag of pre-cubed potatoes and dumped the entire bag into a metal pan and set the pan on the preparation table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to the resident when the facility removed partial side rails from the residents' beds which the residents used as assistive devices while in their beds for two residents (Residents #16 and #43), in a review of 15 sampled residents, and for one additional resident (Residents #58). The facility also failed to evaluate residents' preferences for time to awaken for three residents (Residents #19, #21, and #57) and for four additional residents (Residents #56, #9, #52, and #32). The facility census was 58. 1. Review of the facility policy Proper Use of Beds and Bed Mobility Systems, dated 4/2018, showed the following: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the resident's personal funds), to ensure protection of the resident funds. The facility census was 58. 1. Review of the facility Resident Personal Trust Funds Policy & Procedures dated 1/2018 showed the following: -Policy specifications: To establish guidelines and maintain a system for protecting resident funds which assures a full and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf; Standards: 10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable homelike environment and ensure the resident dining room temperature remained between a temperature range of 71 degrees to 81 degrees Fahrenheit (F). The facility census was 58. Record review of the resident council minutes, dated 7/25/19, showed residents said the air conditioning needed adjusted in the dining room. Record review of the resident council minutes, dated 7/29/19, showed residents said the following: -The dining room was cold; -The air conditioning needed adjustment in the dining room; -Departmental response was that dietary staff was to notify maintenance about the temperatures being cold. Observation on 8/19/19 at 12:09 P.M. of the main dining room showed the following: -Eighteen residents were in the dining room eating their noon meal; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice and physician orders for two residents (Residents #7 and #36), in a review of 15 sampled residents, and for three additional residents (Residents #2, #15 and #29) when staff provided treatments without a physician's order, did not follow physician orders and did not administer a resident's gastrostomy tube (G-tube; a tube inserted into the stomach that brings nutrition/medications directly into the stomach) medication correctly. The facility census was 58. 1. Review of the facility policy Medication and Treatment Order Policy, dated 2/2018, showed the following: -A physician may write orders directly in the resident's record at the time they visit the resident or dictate the order(s) to a licensed personnel while in the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were trained and available to provide Cardiopulmonary Resuscitation (CPR) (the manual application of chest compressions and ventilations to persons in cardiac arrest, done in an effort to maintain viability until advanced help arrives) when transporting residents who requested to be full code, in the facility vehicle. Full code residents were transported by facility transporters who were not comfortable with or certified to perform CPR. The facility census was 58. 1. Review of email communication from the administrator, dated [DATE], showed the facility does not have a policy for transporters. Review of the resident list provided by the administrator showed 22 residents with full code status. During interview on [DATE] at 11:56 A.M., Transporter O said the following: -He/She transports facility residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition three residents (Residents #19, #31, and #57), who were at risk for developing pressure ulcers, in a review of 15 sampled residents. The facility census was 58. 1. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation/blood flow and oxygen supply usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; pressure is the main cause; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands when indicated by professional standards of practice during personal care for two residents (Residents #16 and #19), in a review of 15 sampled residents and three additional residents (Resident #26, #41 and #55). The facility census was 58. 1. Review of the facility policy Handwashing Competency Evaluation revised 7/31/17 showed staff should wash hands before leaving the room, upon entering the room, after removing gloves, and before and after pericare. 2. Review of Resident #19's quarterly MDS dated [DATE] showed the following: -Unclear speech; -Rarely/never understood; -Severely impaired cognitive skills for daily decision making; -Required extensive assist of one for bed mobility; -Totally dependent on one staff for personal hygiene; -Totally dependent on two staff for transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures to ensure a pneumococcal vaccine program was appropriately implemented for residents, failed to assess, provide appropriate education, and vaccinate eligible residents with the pneumococcal vaccines in a timely manner as indicated by the current Centers for Disease Control (CDC) guidelines for six residents (Residents #19, #21, #31, #39, #57, and #210), in a review of 15 sampled residents. The facility census was 58. 1. Review of the facility policy Influenza and Pneumococcal Immunizations dated November 2016 showed the following: Policy: To assure that each resident receives education regarding the benefits and potential side effects before being offered influenza and pneumococcal immunizations and securing their informed consent for administration of these immunizations; Policy Specifications: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's choice of code status was consistent throughout one resident's (Resident #57) medical records, in a review of 15 sampled residents. The facility census was 58. 1. Review of the facility policy Advance Directives, revised December 2006, showed the following: -Policy statement: Advance directives will be respected in accordance with state law and facility policy; -Should the resident indicate he/she has issued advance directives about his/her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record. 2. Record review of Resident #57's outside the hospital do not resuscitate (OHDNR) form, dated 3/12/19, showed the resident's code status as do not resuscitate (DNR). [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for one resident (Resident #4), who were transferred to the hospital, in a review of 15 sampled residents. The facility census was 58. 1. During interview on 8/22/19 at 6:00 P.M., the assistant director of nursing said the facility did not have a policy regarding notification of the Office of the State Long-Term Care Ombudsman regarding resident transfers and discharges from the facility. 2. Review of Resident #4's medical record showed the following: -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]; -No documentation the facility notified the ombudsman of the resident's transfer to the hospital on 7/15/19. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary and recapitulation of stay for one resident (Resident #300), in a review of three closed records with only one requiring the recapitulation. The facility census was 58. 1. Review of the facility policy Discharge Summary and Plan, revised 8/2006, showed the following: Policy Interpretation and Implementation: 1. When the facility anticipates a resident's discharge to a private residence, or another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide incontinence care with a urinary catheter (a sterile tube inserted into the bladder to drain urine) consistent with acceptable standards of practice, failed to maintain the catheter bag below the level of the bladder, and failed to keep catheter tubing and drainage bag off the floor for two residents (Resident #16 and #210) in a review of 15 residents. The facility identified three residents with urinary catheters. The facility census was 58. 1. Review of the facility policy Urinary Catheter Care revised September 2005 showed the following: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract; General guidelines: 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess pain and provide PRN (as needed) pain medication at all, or in a timely manner, prior to dressing changes, personal cares and repositioning for one resident (Resident #210) in a review of 15 sampled residents. The resident cried out in pain during dressing changes, peri care and with position changes. The facility census was 58. 1. Review of the facility policy Pain Assessment revised 8/2008 showed the following: Purpose: the purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team; General guidelines: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess two residents' (Resident #7 and #12) dialysis arteriovenous (AV) shunt/fistula (access used to artificially connect a vein with an artery, so that a higher blood flow is created to allow blood to be pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) daily and after the resident returned from dialysis treatments in a review of 15 sampled residents. The facility census was 58. 1. Review of the facility's policy for Post Dialysis Monitoring and Observation with Implanted A-V Shunt Policy, dated January 2018 showed the following: -Policy - Charge nurse to conduct access site observations one time per day; -Procedure - The A-V access site will be monitored during rounds; -To monitor site: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's (Resident #31) in a review of 15 sampled residents, medication regimen was free of unnecessary medications. The facility failed to ensure that orders for as needed (PRN) psychotropic medications were limited to 14 days as required for Resident #31, except when his/her attending physician believed it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the as needed order. The facility census was 58. 1. Review of the undated facility policy Psychopharmacologic Drug Use Procedure showed the following: Procedure: 6. Dose reductions must be attempted, unless medically or psychiatrically contraindicated as documented by the interdisciplinary team and/or the physician. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure dumpsters, located next to the facility, were covered to prevent access to rodents and pests. The census was 58. Observation on 8/19/19 at 11:28 A.M. showed the facility dumpster was located outside the kitchen. The dumpster had two lids. One of the lids was open and the dumpster contained trash. Observation on 8/20/19 at 9:58 A.M. showed Dietary Staff W took the trash out from the kitchen and placed it in the open dumpster. Dietary Staff W left the dumpster open and returned to the kitchen. Observation on 8/20/19 at 4:18 P.M. showed one of the two lids to the dumpster was open and trash was visible in the dumpster. Next to the dumpster was a sign which read, CAUTION WATCH FOR WILDLIFE IN CONTAINER. Further observation showed a squirrel on top of the dumpster pulling trash out of the dumpster. [...]