ADAIR VILLAGE
For profit - Individual
120 Beds
CIRCLE B ENTERPRISES
Data: November 2025
Trust Grade
45/100
#131 of 479 in MO
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Adair Village in Clinton, Missouri has a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #131 out of 479 facilities in Missouri, placing it in the top half, and #1 of 3 in Henry County, meaning it is the best option locally but has notable weaknesses to consider. The facility is currently improving, showing a reduction in serious issues from 13 in 2024 to 5 in 2025. Staffing is a concern, with a rating of 2 out of 5 stars and a turnover rate of 56%, which is slightly better than the state average. While they have no fines recorded, which is a positive sign, there have been serious incidents, including a fall and fracture due to inadequate staff assistance during transfers, and failures in managing a resident's pain effectively. Additionally, there were lapses in infection control practices, such as transporting clean laundry uncovered, which could pose risks to residents. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- D
- In Missouri
- #131/479
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Missouri facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Top 27%
Needs review
13 → 5 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 5 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Above Missouri average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 56%
Near Missouri avg (46%)
Frequent staff changes - ask about care continuity
Chain: CIRCLE B ENTERPRISES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Missouri average of 48%
The Ugly 29 deficiencies on record
2 actual harm
Feb 2025
5 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interviews and record review, the facility failed to keep residents free from accident hazards when staff failed to provide care with two staff as trained and care planned for one resident (R...
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Based on interviews and record review, the facility failed to keep residents free from accident hazards when staff failed to provide care with two staff as trained and care planned for one resident (Resident #1) resulting in a fall and fracture. The facility census was 43.
Review of the facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed the following:
-In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents;
-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;
-Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include resident preferences for assistance, resident mobility (degree of dependency), resident's size, weight-bearing ability, cognitive status, whether the resident is usually cooperative with staff and the resident's goals for rehabilitation, including restoring or maintaining functional abilities;
-Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices;
-Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents;
-Safe lifting and movement of resident is part of an overall facility employee health and safety program which involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies, addresses reports of workplace injuries, provides training on safety, ergonomics and proper use of equipment and continually evaluates the effectiveness of workplace safety and injury-prevention strategies.
1. Review of the Resident #1's face sheet (a brief resident profile) showed the following:
-admission date of 10/24/24;
-Diagnoses included cerebral infarction (stroke), obstructive sleep apnea, congestive heart failure (CHF - a long-term condition where the heart can't pump blood well enough to give the body a normal supply), high blood pressure, metabolic encephalopathy (group of conditions that cause brain dysfunction), and acute respiratory failure with hypoxia (low levels of oxygen in the body tissues).
Review of the resident's care plan, last revised on 12/02/24, showed the following:
-Resident was at risk for falls;
-Staff to assist resident with ambulation and transfers, utilizing therapy recommendations;
-Determine resident's ability to transfer;
-Evaluate fall risk on admission and as needed;
-Resident had an activities of daily living (ADL) self-care performance deficit and was totally dependent on staff for repositioning and turning in bed every two hours and as necessary;
-Resident requires a mechanical lift with assistance of two staff for transfers;
-Resident had altered cardiovascular status and received oxygen via nasal cannula as directed by physician;
-Resident was on anticoagulant (medication that slows blood clotting) medication that therapy related to diagnosis of atrial fibrillation (irregular heart beat);
-Administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 01/31/25, showed the following:
-Cognitively intact;
-Resident was totally dependent on staff for bed mobility, toileting, personal hygiene, transfers, showering and dressing for upper and lower body.
Review of the facility's investigation summary, dated 02/17/25, showed the following:
-An alert resident (Resident #1) turned on his/her call light for assistance to be cleaned up. Nurse Assistant (NA) C told the resident he/she had to go get some assistance as he/she was not supposed to provide care alone. The NA felt the resident implied he/she wanted to make him/her wait for care;
-NA C retrieved the cleaning supplies and instructed the resident to turn towards him/her to provide care, and the resident turned the opposite direction, towards the wall and fell on the floor;
-NA C was re-educated on providing care to the resident with the assistance of another nurse aide. NA C was given a corrective action for performing a nursing function he/she had been educated upon hire not to perform alone.
Review of the resident's progress notes showed the following:
-On 02/10/25, at 7:41 A.M., the nurse was called into the resident's room by the aide because the resident rolled out of bed while being changed at 12:20 A.M. The aide told the nurse the resident demanded to be changed and refused to wait for assistance for the aide. The resident lifted his/her hips and rolled toward the door after the aide had told the resident to roll toward him/her and the window. Nurse assessed resident from head to toe and found no injuries. Resident complaint of 8 out of 10 on pain scale in left arm and was unable to lift the arm. Staff contacted the physician and received orders to send the resident to the emergency room (ER) for an x-ray. Emergency medical services (EMS) was called at 12:45 A.M. The resident left the facility for the ER via ambulance at 1:02 A.M.;
-On 02/10/25, at 8:17 A.M., nurse spoke with ER nurse at 2:39 A.M., confirming the resident had a fracture to the left humerus (upper arm bone) head. Resident returned to the facility at 3:07 A.M., wearing immobilizer to left arm and orders to follow up with orthopedic surgery at next available appointment.
During an interview on 02/13/25, at 1:32 P.M., the resident said a staff member was changing his/her brief and got him/her too close to the edge of the bed, and he/she fell and broke his/her shoulder. There should have been two staff members assisting him/her.
During an interview on 02/14/25, at 2:17 P.M., NA C said the following:
-He/she was hired on 11/29/24 and had not started CNA classes;
-The resident required two staff for transfers, and this information could be found on the back of the room door;
-He/she was trained if a resident was a two staff assist for transfers then two staff are required for changing a brief;
-He/she answered the resident's call light, and the resident wanted changed right then. He/she said assistance was required. The resident insisted for him/her to change the resident right then;
-He/she began to change the resident with no assistance and the resident rolled the opposite way as directed and fell with his/her arm hitting the oxygen concentrator.
During an interview on 02/18/25, at 1:46 P.M., NA D said the following:
-Physical therapy developed a sheet that is on the back of the resident's doors showing if the residents are independent, one staff assist, or two staff assist;
-If a resident required two staff for transfer, two staff should also be required to change the resident;
-The resident required two staff for changing and for other cares;
-He/she was given this information during report since the resident admitted ;
-He/she has changed the resident alone a few times due to the resident's impatience.
During an interview on 02/20/25, at 2:52 P.M., NA E said the following:
-Residents have papers on the back of their doors indicating if they require one person or two person assist, and this information is also listed in the care plan book at the nurses' station;
-If a resident required two staff for transfer, then two staff should also be required to change the resident;
-The resident required two staff to assist with a mechanical lift and two staff to assist with changing;
-He/she had changed the resident alone once or twice because the resident did not have the patience to wait for him/her to get assistance;
-Staff should not change the resident without assistance because it was not safe.
During an interview on 02/14/25, at 1:28 P.M., Certified Nurse Assistant (CNA) A said the following:
-The resident required a mechanical transfer with two staff assisting;
-The resident required two staff to change his/her brief and staff should not change him/her with only one staff;
-Staff have walkies to call for assistance.
During an interview on 02/14/25, at 1:54 P.M., CNA B said the following:
-The resident was a two person assist for changing because he/she was unable to physically roll him/her without assistance;
-The staff member assisting the resident with changing during the fall should have waited for help.
During an interview on 02/21/25, at 10:52 A.M., Certified Medication Technician (CMT) F said the following:
-The resident was a two staff assist with all cares, and he/she would not change the resident without assistance;
-NA's should not change the resident without assistance, it is a safety concern.
During an interview on 02/14/25, at 3:23 P.M., Licensed Practical Nurse (D) said the following:
-The resident required two staff for transfers and changing briefs, which was a nursing judgement prior to the fall based on his/her size and lack of mobility;
-Aides are educated about resident requirements for transfers and changing. There are signs on the back of the resident's rooms, and if mechanical lift is checked staff should know two staff are required for changing and transferring;
-NA's should not be changing the resident alone.
During an interview on 02/21/25, at 11:53 A.M., Physical Therapist (PT) G said the following:
-He/she assessed the resident upon admission, and the resident was totally dependent on staff, required mechanical transfers, and was wheelchair bound;
-Therapy completed transfer sheets on all residents to assist staff with providing the appropriate care;
-Two staff members should change the resident's brief for safety reasons.
During an interview on 02/20/25, at 3:52 P.M., the resident's physician said the following:
-The resident would not be a one staff assist due to his/her size and not always following directions;
-It would not be safe to transfer the resident, or roll the resident in bed with one staff assist.
During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing said the resident required a mechanical lift with assistance of two staff.
During an interview on 02/21/25, at 4:10 P.M., the Regional Nurse Consultant said if a resident required two staff assist for cares, two staff should complete brief changing.
During an interview on 02/21/25, at 4:47 P.M., the Administrator said the following:
-Staff know how to transfer residents from the care plan and the transfer sheets on the door completed by therapy;
-Mechanical lift and sit to stand requires two staff for assistance;
-Staff are encouraged to provide care in pairs with the resident because he/she yells and was demanding;
-The NA should have waited for assistance before changing the resident's brief due to his/her behaviors and for safety.
MO00249332
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all residents received care and treatment in accordance...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to document administering medications per physician orders for three residents (Resident #1, Resident #2, and Resident #3). The facility census was 43.
Review of the policy titled, Clinical Administering Medications, revised April 2019 showed the following:
-Medications are administered in accordance with prescriber orders, including any required time frame;
-Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before or after meal orders) for liberal medication passes;
-For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication;
-If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medications will initial and circle the MAR space provided for that drug and dose;
-The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
1. Review of the Resident #1's face sheet (a brief resident profile) showed the following:
-admission date of 10/24/24;
-Diagnoses included type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cerebral infarction (stroke), obstructive sleep apnea (intermittent airflow blockage during sleep), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), rectal cancer, high blood pressure, metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen, leading to a dangerously low level of oxygen blood), and gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints).
Review of the resident's care plan, last revised on 02/10/25, showed the following:
-Resident was on anticoagulant (helps prevent blood clots and stroke) therapy related to diagnosis of atrial fibrillation. Staff to administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift;
-Resident had diagnosis of anemia. Staff to give medications as ordered and monitor side effects, effectiveness;
-Resident was at risk for complications related to use of antidepressant medication. Staff to administer antidepressant medications as ordered by physician and monitor for side effects and effectiveness every shift.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool administered by staff) dated 01/31/25, showed the following:
-Cognitively intact;
-Resident is totally dependent on staff for bed mobility, toileting, personal hygiene, transfers, showering and dressing for upper and lower body.
Review of the resident's January 2025 and February 2025 Physician Order Sheet (POS) showed an order, dated 10/25/24, for apixaban (an anticoagulant) oral tablet 5 milligrams (mg), give one tablet by mouth two times a day for prophylaxis related to cerebral infarction.
Review of the resident's January 2025 and February 2025 Medication Administration Record (MAR) showed the following:
-An order dated 10/25/24, for apixaban oral tablet 5 mg, give one tablet by mouth two times a day for prophylaxis related to cerebral infarction;
-Staff failed to document administering the 5:00 P.M. dose on 01/15/25, 01/18/25, 01/19/25 and 01/22/25;
-Staff did not document administering the 8:00 A.M. and 5:00 P.M. doses on 02/01/25 and the 5:00 P.M. dose on 02/02/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/25/24, for pantoprazole sodium tablet (used to treat acid reflux) delayed release 40 mg, give one tablet by mouth two times a day for acid reflux.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/25/24, for pantoprazole sodium tablet delayed release 40 mg, give one tablet by mouth two times a day for acid reflux;
-Staff did not document administering the 5:00 P.M. dose on 01/15/25, 01/18/25, 01/19/25 and 01/22/25;
-Staff did not document administering the 8:00 A.M. and 5:00 P.M. doses on 02/01/25 and the 5:00 P.M. dose on 02/02/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/25/24, for ziprasidone (antipsychotic) HCI oral capsule 40 mg, give 40 mg by mouth two times a day for psychosis with meals.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/25/24, for ziprasidone HCI oral capsule 40 mg, give 40 mg by mouth two times a day for psychosis with meals;
-Staff did not document administering the 5:00 P.M. dose on 01/15/25, 01/18/25, 01/19/25 and 01/22/25;
-Staff did not document administering the 8:00 A.M. and 5:00 P.M. doses on 02/01/25 and the 5:00 P.M. dose on 02/02/25.
Review of the resident's February 2025 POS showed an order, dated 10/25/24, for allopurinol (an antigout medication) oral tablet 100 mg, give one tablet by mouth one time a day for gout.
Review of the resident's February 2025 MAR showed the following:
-An order dated 10/25/24, for allopurinol oral tablet 100 mg, give one tablet by mouth one time a day for gout;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 11/17/24, for cetirizine (an antihistamine) hydrochloride (HCI) tablet 10 mg, give one tablet by mouth one time a day for allergy symptoms.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 11/17/24, for cetirizine hydrochloride (HCI) tablet 10 mg, give one tablet by mouth one time a day for allergy symptoms;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 10/25/24, for ferrous sulfate tablet (iron) 325 mg, give one tablet by mouth one time a day for anemia.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 10/25/24, for ferrous sulfate tablet 325 mg, give one tablet by mouth one time a day for anemia;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 10/25/24, for glycolax powder (used to treat constipation), give 17 grams by mouth one time a day for constipation in eight ounces of fluid.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 10/25/24, for glycolax powder, give 17 grams by mouth one time a day for constipation in eight ounces of fluid;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 11/05/24, for lidocaine (pain control medication) external patch 5%, apply to right hip topically one time a day for pain on 12 hours then off 12 hours.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 11/05/24, for lidocaine external patch 5%, apply to right hip topically one time a day for pain on 12 hours then off 12 hours;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 10/25/24, for metoprolol succinate (an antihypertensive medication) extended release 24-hour oral tablet 50 mg, give one tablet by mouth one time a day for hypertension.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 10/25/24, for metoprolol succinate extended release 24-hour oral tablet 50 mg, give one tablet by mouth one time a day for hypertension;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 10/25/24, for sertraline HCI (an antidepressant) oral tablet 100 mg, give one tablet one time a day for depression.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 10/25/24, for sertraline HCI oral tablet 100 mg, give one tablet one time a day for depression;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's February 2025 POS showed an order, dated 10/25/24, for tamsulosin HCI (used to treat BPH (condition where the prostate gland enlarges, causing urinary problems)) oral capsule 0.4 mg, give one capsule by mouth one time a day for prophylaxis.
Review of the resident's February 2025 MAR showed the following:
-An order, dated 10/25/24, for tamsulosin HCI oral capsule 0.4 mg, give one capsule by mouth one time a day for prophylaxis;
-Staff did not document administering the 8:00 A.M. dose on 02/01/25.
Review of the resident's January 2025 and February 2025 nurses' notes showed staff did not document related to the medications that were not administered as ordered.
2. Review of Resident #2's face sheet showed the following:
-admission date 10/29/24;
-Diagnoses included spondylosis with myelopathy (condition where the spinal cord is compressed due to degenerative changes in the spine), cervical disc disorder with myelopathy (condition that occurs when the spinal cord in the neck is compressed) depression, generalized anxiety disorder, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and repeated falls.
Review of the resident's quarterly MDS, dated [DATE], showed resident was cognitively intact and
required substantial assistance with toileting and lower body dressing.
Review of the resident's care plan, last revised on 02/10/25, showed the following:
-Resident was at risk for uncontrolled pain. Staff to administer analgesic medication as ordered by physician and monitor/document side effects and effectiveness every shift;
-Resident used antidepressant medication. Staff to administer antidepressant medications as ordered by physician, monitor/document side effects and effectiveness every shift.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/29/24, for celecoxib (an antiinflamatory) oral capsule 200 mg, give one capsule by mouth two times a day for pain.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/29/24, for celecoxib oral capsule 200 mg, give one capsule by mouth two times a day for pain;
-Staff did not document administrating the 9:00 A.M. dose on 01/22/25;
-Staff did not document administrating the 9:00 A.M. dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/29/24, for duloxetine HCI (an antidepressant) capsule delayed release sprinkle 30 mg, give one capsule by mouth one time a day for depression.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/29/24, for duloxetine HCI capsule delayed release sprinkle 30 mg, give one capsule by mouth one time a day for depression;
-Staff did not document administrating the morning dose on 01/22/25;
-Staff did not document administrating the morning dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/29/24, for gabapentin (an anticonvulsant) oral tablet 600 mg, give one tablet by mouth three times a day for neuropathy.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/29/24, for gabapentin oral tablet 600 mg, give one tablet by mouth three times a day for neuropathy;
-Staff did not document administering the morning and noon dose on 01/22/25;
-Staff did not document administering the morning and noon dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 11/27/24, for lidoderm patch 5%, apply to bottom of feet topically one time a day for pain related to cervical disorder with myelopathy.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 11/27/24, for Lidoderm patch 5%, apply to bottom of feet topically one time a day for pain related to cervical disorder with myelopathy;
-Staff did not document administering the morning dose on 01/22/25;
-Staff did not document administering the morning dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order,dated 10/29/24, for pantoprazole sodium tablet delayed release 40 mg, give one tablet by mouth one time a day for acid reflux.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/29/24, for pantoprazole sodium tablet delayed release 40 mg, give one tablet by mouth one time a day for acid reflux;
-Staff did not document administering the morning dose on 01/22/25;
-Staff did not document administering the morning dose on 02/01/25.
Review of the resident's January 2025 and February 2025 nurses' notes showed staff did not document related to the medications that were not administered as ordered.
3. Review of Resident #3's face sheet showed the following:
-admission date 04/23/24;
-Diagnoses included acute and chronic respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen, leading to a dangerously low level of oxygen blood), acute and chronic respiratory failure with hypercapnia (a condition where the body has too much carbon dioxide in the bloodstream), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should), high blood pressure, obstructive sleep apnea (intermittent airflow blockage during sleep), pneumonia, post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), fibromyalgia (a long-term condition that involves widespread body pain and tiredness), pulmonary embolism with acute cor pulmonale (situation where a blood clot lodges in the lung artery, causing a sudden strain on the right ventricle of the heart, leading to acute right-sided heart failure) low back pain, generalized anxiety disorder, and gastroesophageal reflux disease symptoms (GERD-acid reflux).
Review of the resident's significant change MDS, dated [DATE], showed the resident was cognitively intact and independent with ADL's except required supervision for showering.
Review of resident's care plan, last revised 02/14/25, showed the following:
-Resident had a history of CHF. Staff to give medications as ordered;
-Resident had a history of high blood pressure. Staff to give blood pressure medication as ordered and monitor for side effects;
-Resident had history of GERD. Staff to give medications as ordered and monitor/document side effects and effectiveness;
-Resident had a history of receiving diuretic therapy. Staff to administer diuretic medications as ordered by physician and monitor for side effects and effectiveness every shift;
-Resident used anti-depressant medication. Staff to administer anti-depressant medications as ordered by physician and monitor/document side effects and effectiveness every shift;
-Resident used anti-anxiety medications. Staff to administers anti-anxiety medications as ordered by physician and monitor for side effects and effectiveness every shift;
-Resident was on anticoagulant therapy. Staff to administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 11/12/24, for Zithromax (antibiotic) oral tablet 250 mg, give one tablet by mouth one time a day related to pneumonia unspecified organism.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 11/12/24, for Zithromax oral tablet 250 mg, give one tablet by mouth one time a day related to pneumonia unspecified organism;
-Staff did not document administering the 8:00 A.M. dose on 01/19/25;
-Staff did not document administrating the 8:00 A.M. dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for alprazolam oral tablet 0.5, give one tablet by mouth two times a day for anxiety.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/08/24, for alprazolam oral tablet 0.5, give one tablet by mouth two times a day for anxiety;
-Staff did not document administering the 5:00 P.M. doses on 01/14/25, 01/15/25, 01/18/25, 01/19/25, and 01/22/25;
-Staff did not document administering the 5:00 P.M. doses on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for bumetanide (diuretic) oral tablet 0.5 mg, give one tablet by mouth two times a day related to CHF.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/08/24, for bumetanide oral tablet 0.5 mg, give one tablet by mouth tow times a day related to congestive heart failure;
-Staff did not document administering the 5:00 P.M. doses on 01/14/25, 01/15/25, 01/19/25, and 01/22/25;
-Staff did not document administering the 5:00 P.M. dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for buspirone HCI (an antianxiety medication) oral tablet 15 mg, give one tablet by moth two times a day related to PTSD.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/08/24, for buspirone HCI oral tablet 15 mg, give one tablet by moth two times a day related to post-traumatic stress disorder;
-Staff did not document administrating the 5:00 P.M. doses on 01/14/25, 01/15/25, 01/19/25, 01/22/25;
-Staff did not document administrating the 5:00 P.M. dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/07/24, for Eliquis (anticoagulant) oral tablet 5 mg, give one tablet by mouth two times day related to pulmonary embolism with acute cor pulmonale.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/07/24, for Eliquis oral tablet 5 mg, give one tablet by mouth two times day related to pulmonary embolism with acute cor pulmonale;
-Staff did not document administering the morning dose on 01/19/25;
-Staff did not document administering the morning dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for aspirin oral capsule 81 mg, give one capsule by mouth one time a day related to peripheral vascular disease.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/08/24, for aspirin oral capsule 81 mg, give one capsule by mouth one time a day related to peripheral vascular disease;
-Staff did not document administering the morning dose on 01/19/25;
-Staff did not document administering the morning dose on 02/01/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for duloxetine HCI (an antidepressant) oral capsule delayed release particles 60 mg, give one capsule by mouth one time a day related to PTSD.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/08/24, for duloxetine HCI oral capsule delayed release particles 60 mg, give one capsule by mouth one time a day related to post-traumatic stress disorder;
-Staff did not document administering the morning dose on 01/19/25;
-Staff did not document administering the morning dose on 02/01/25.
Review of the resident's January 2025 POS showed an order, dated for 10/26/24, for ferrous sulfate tablet 325 mg, give one tablet by mouth one time a day for low iron.
Review of the resident's January 2025 MAR showed the following:
-An order, dated 10/26/24, for ferrous sulfate tablet 325 mg, give one tablet by mouth one time a day for low iron;
-Staff did not document administering the morning dose on 01/19/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 12/13/24, for metoprolol succinate extended release 24-hour tablet 50 mg, give one tablet by mouth one time a day for high blood pressure.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 12/13/24, for metoprolol succinate extended release 24-hour tablet 50 mg, give one tablet by mouth one time a day for high blood pressure;
-Staff did not document administering the morning dose on 01/19/25;
-Staff did not document administering the morning doses on 02/01/25 and 02/02/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for pantoprazole sodium tablet delayed released 20 mg, give one tablet by mouth one time a day related to GERD.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order, dated 10/08/24, for pantoprazole sodium tablet delayed released 20 mg, give one tablet by mouth one time a day related to GERD;
-Staff did not document administering the morning dose on 01/19/25;
-Staff did not document administering the morning doses on 02/01/25 and 02/02/25.
Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for spironolactone (a diuretic) oral table 25 mg, give one tablet by mouth one time a day related to high blood pressure.
Review of the resident's January 2025 and February 2025 MAR showed the following:
-An order dated 10/08/24, for spironolactone oral table 25 mg, give one tablet by mouth one time a day related to high blood pressure;
-Staff did not document administering the morning dose on 01/19/25;
-Staff did not document administering the morning dose on 02/01/25.
Review of the resident's January 2025 POS showed an order, dated 10/15/24, for pregabalin (an anticonvulsant) oral capsule 150 mg, give one capsule by moth two times a day related to fibromyalgia.
Review of the resident's January 2025 MAR showed the following:
-An order, dated 10/15/24, for pregabalin oral capsule 150 mg, give one capsule by moth two times a day related to fibromyalgia;
-Staff did not document administering the 9:00 A.M. doses on 01/18/25 and 01/19/25.
Review of the resident's January 2025 POS showed an order, dated 10/08/24, for tramadol HCI oral tablet 50 mg, give one tablet by mouth two times a day for pain.
Review of the resident's January 2025 MAR showed the following:
-An order, dated 10/08/24, for tramadol HCI oral tablet 50 mg, give one tablet by mouth two times a day for pain;
-Staff did not document the pain level and administering the 5:00 P.M., dose on 01/14/25, 01/15/25, 01/18/25, 01/19/25, and 01/22/25.
Review of the resident's January 2025 and February 2025 nurses' notes showed staff did not document related to the medications that were not administered as ordered.
4. During an interview on 02/21/25, at 10:52 A.M., Certified Medication Technician (CMT) F said the following:
-Staff document medication administration in the MAR;
-CMT's administer scheduled medications only;
-Staff will either check yes in the MAR if a medication is administered or no and then the applicable code for why the medication was not administered such as resident refused or was out of the facility;
-If there is a blank space on the MAR for documenting medication administration, it either means the medication was not administered or there was no documentation of any type.
During an interview on 02/14/25, at 3:23 P.M., Licensed Practical Nurse (LPN) D said the following:
-Staff document medication administration in the MAR;
-The MAR should not contain blank spaces for scheduled medication;
-Staff should check no if not administered and then enter whatever code is applicable such as out of the facility.
During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing (DON) said the following:
-Staff document medication administration in the MAR;
-CMTs and nurses administer medications, CMTs only administer scheduled meds and nurses administer both scheduled and as needed (PRN);
-Staff should choose either yes or no in the MAR when documenting medication administration;
-If the medication was not administered choosing no will then require a code for the reason such as refused or out of the facility;
-A blank space on the MAR would indicate staff either did not administer the medication or did not document administration of the medication;
-Management goes over MAR information during morning meetings, but a blank space would not trigger a concern.
During an interview on 02/21/25, at 4:47 A.M., the Administrator said the following:
-Staff administer medications according to the MAR and document the administration in the MAR;
-Staff either check yes or no in the MAR and if no must give a reason with the applicable code.
MO00249332
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure all residents received recommended interventions to help maintain acceptable parameters of nutritional status when staff failed to ...
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Based on interviews and record review, the facility failed to ensure all residents received recommended interventions to help maintain acceptable parameters of nutritional status when staff failed to document administering a dietary supplement per physician's order for one resident (Resident #4). The facility census was 43.
Review of the facility's policy titled, Weight Assessment and Intervention, revised March 2022, showed the following:
-Residents are weighed upon admission and at intervals established by the interdisciplinary team;
-Weights are recorded in each unit's weight record chart and in the individual's medical record;
-The threshold for significant unplanned and undesired weight loss will be based on the following criteria; one month 5% weight loss is significant and greater than 5% is severe, 7.5% weight loss is significant and greater than 7.5% is severe, six-month 10% weight loss is significant and great than 10% is severe;
-Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met;
-The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss;
-Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietician, the consultant pharmacist, and the resident or resident's legal surrogate;
-Individualized care plans shall address, to the extent possible the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment;
-Interventions for undesirable weight loss are based on resident choice and preferences, nutrition and hydration needs of resident, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing, swallowing, or digestion, the use of supplementation and/or feeding tubes, and end of life decision and advance directives.
1. Review of Resident #4's face sheet (a brief resident profile) showed the following:
-admission date of 01/22/24;
-Diagnoses include dementia, type III traumatic spondylolisthesis of second cervical vertebra, subsequent encounter for fracture with routine healing (severe fracture of the second cervical vertebra), high blood pressure, dysphagia (difficulty swallowing foods or liquids), and repeated falls.
Review of the resident's weight record showed the resident weighed 109.8 pounds on 09/12/24, and 97.2 pounds on 10/16/24, indicating a 12.6-pound weight loss in a month.
Review of the resident's nursing notes showed, dated 10/28/24, showed the Registered Dietician (RD) note the following:
-RD reviewed for weight loss. On 10/28/24, resident weighed 100.4 pounds and body mass index (BMI - calculated measure of weight relative to height) was underweight status. Resident lost 10 pounds (9%) in 30 days; 10.5 pounds (9.4%) in 90 days; and 12.8 pounds (11.3%) in 180 days.
-Current diet order of regular diet with supplements three times daily with meals and 30 milliliter (ml) 2 Cal (nutritional shake) three times daily with medication pass. Resident does feed self in the dining room with decreased intake at meals.
-Recommended staff to add ice cream to shakes three times daily, increase 2 Cal to 60 ml (if resident accepts) and other preferences. Encourage intake of meals, shakes, and snacks. Regular diet follow as appropriate/requested.
Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by staff) dated 01/24/25, showed the following:
-Moderate cognitive impairment;
-Weight of 96 pounds;
-Weight loss of 5% in the last month or 10% in the last six month and not on a physician prescribed weight loss program.
Review of the resident's care plan, last reviewed on 02/14/25, showed the following:
-Resident had unplanned/unexpected weight loss;
-Staff to alert dietician if consumption was poor for more than 48 hours;
-Staff to provide 2 Cal supplement three times daily;
-Staff to provide resident supplements as ordered and alert nurse/dietician if resident not consuming on a regular basis;
-Staff to provide house supplements daily;
-If weight decline persists, staff to contact physician and dietician regularly;
-Staff to monitor and evaluate any weight loss, determine percentage lost and follow facility protocol weight loss;
-Staff to offer substitutes as requested or indicated. Resident prefers breakfast.
Review of the resident's current physician order sheet showed the following:
-An order, dated 07/30/24, for regular diet with regular texture, regular/thin consistency;
-An order, dated 07/30/24, for house supplement with meals;
-A current order for 2 Cal supplement 30 ml each medication pass for breakfast, lunch, and dinner with meals to increase calories.
Review of the resident's January 2025 Medication Administration Record (MAR) showed the following:
-An active order for 2 Cal supplement, 30 ml each medication pass for breakfast, lunch, and dinner with meals to increase calories;
-Staff failed to document administering the 12:00 P.M. supplement on 01/15/25, 01/18/25, 01/19/25, and 01/22/25;
-Staff failed to document administering the 5:00 P.M. supplement on 01/14/25, 01/15/25, 01/19/25, and 01/22/25.
Review of the resident's January 2025 weights showed the following:
-On 01/07/25, 99.6 pounds;
-On 01/14/25, 99.4 pounds (a .2 pound loss);
-On 01/21/25, 95.6 pounds (a 3.8 pound loss);
-On 01/28/25, 98.4 pounds.
Review of the resident's February 2025 MAR showed the following:
-An active order for 2 Cal supplement, 30 ml each medication pass for breakfast, lunch, and dinner with meals to increase calories;
-Staff failed to document administering the 8:00 A.M. supplement on 02/03/25;
-Staff failed to document administering the 12:00 P.M. supplement on 02/02/25 and 02/03/25;
-Staff failed to document administering the 5:00 P.M. supplement on 02/01/25, 02/02/25, and 02/03/25.
Review of the resident's January 2025 weights showed the following:
-On 02/05/25, 95.8 pounds;
-On 02/12/25, 97 pounds;
-On 02/19/25, 94.6 pounds (a one pound loss from 01/21/25);
-On 02/20/25, 94.4 pounds (a .2 pound loss).
During an interview on 02/21/25, at 1:22 P.M., the Dietary Manager said the following:
-She completed dietary evaluations on every resident upon admission, quarterly, and upon a weight loss trigger;
-The resident triggered for a weight loss and was administered a supplemental 2 Cal three times daily on medication pass and received a house shake three times a day with every meal;
-The resident drank the shakes and the 2 Cal regularly;
-The resident's weight has been staying stable between 93 to 97 pounds.
During an interview on 02/21/25, at 1:30 P.M., Certified Medication Technician (CMT) F said the following:
-The resident was given 30 ml of 2 Cal three times daily at the medication pass for weight loss;
-He/she watched the resident drink the 2 Cal;
-The resident only refuses if he/she was very ill, and staff should document the administration and refusals in the MAR.
During the interview on 02/21/25, at 1:41 P.M., Licensed Practical Nurse (LPN) D said the following:
-The resident received 2 Cal during medication pass three times per day with meals;
-He/she observed the resident drink the 2 Cal;
-The resident refused the 2 Cal at lunch and dinner at times;
-Staff should document the administration or refusals in the MAR.
During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing (DON) said the following:
-The resident had weight loss and was receiving 2 Cal at every meal, which should be documented in the MAR;
-Blank spaces in the MAR would indicate the 2 Cal was either not documented or not given, which was a concern for a resident with weight loss.
During an interview on 02/21/25, at 4:47 P.M., the Administrator said staff should administer the resident's 2 Cal per physician order and document in the MAR.
MO00249332
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure documentation of oxygen administration/checks every shift p...
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Based on interviews and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure documentation of oxygen administration/checks every shift per physician orders for one resident (Resident #1). The facility census was 43.
Review of the facility policy titled, Oxygen Administration, revised October 2010, showed the following:
-Purpose was to provide guidelines for safe oxygen administration;
-Verify there is a physician's order for the procedure. Review physician's orders or facility protocol for oxygen administration;
-Review the resident's care plan to assess for any special needs of the resident;
-Before administering oxygen, and while the resident is receiving therapy, assess for signs or symptoms of cyanosis (blue tone to the skin and mucous membranes), signs or symptoms of hypoxia (rapid breathing, rapid pulse rate, restlessness, and confusion), signs and symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, or slow, shallow rate of breathing), vital signs, lung sounds, and arterial blood gasses and oxygen saturation.
1. Review of the Resident #1's face sheet (a brief resident profile) showed the following:
-admission date of 10/24/24;
-Diagnoses include cerebral infarction (stroke), obstructive sleep apnea, congestive heart failure (CHF - a long-term condition where the heart can't pump blood well enough to give the body a normal supply), and acute respiratory failure with hypoxia (low levels of oxygen in the body tissues).
Review of the resident's current physician order sheet showed an order, dated 11/04/24, for oxygen at two-three liters per nasal cannula every shift for shortness of air.
Review of the resident's care plan, last revised on 12/02/24, showed the following:
-Resident was at risk for ineffective breathing pattern;
-Resident had altered cardiovascular status;
-Staff to administer oxygen as prescribed or per standing order.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool administered by staff). dated 01/31/25, showed the resident was cognitively intact and received oxygen therapy.
Review of the resident's January 2025 Treatment Administration Record (TAR) showed the following:
-An order, dated 11/04/24, for oxygen at two-three liters per nasal cannula every shift for shortness of air;
-Staff failed to document administration of oxygen on the A.M. shift on 01/01/25, 01/05/25, 01/08/25, 01/11/25, 01/14/25, 01/22/25, and 01/26/25;
-Staff failed to document administration of oxygen on the P.M. shift on 01/02/25.
Review of the resident's nurses' notes, dated 01/01/25 to 01/31/25, showed staff did not document whey the oxygen administration check was not completed.
Review of the resident's February 2025 TAR for showed the following:
-An order, dated 11/04/24, for oxygen at two-three liters per nasal cannula every shift for shortness of air;
-Staff failed to document administration of oxygen on the A.M. shift on 02/01/25 and 02/12/25.
Review of the resident's nurses' notes, dated 02/01/25 to 02/12/25, showed staff did not document whey the oxygen administration check was not completed.
During an interview on 02/13/25, at 1:32 P.M., the resident said staff have forgotten to put the oxygen nasal cannula back in his/her nose following a mechanical transfer.
During an interview on 02/14/25, at 1:54 P.M., Certified Nurse Aide (CNA) B said nurses document any oxygen administration or checks in the electronic record.
During an interview on 02/21/25, at 10:52 A.M., Certified Medication Tech (CMT) F said nurses complete the oxygen tasks and documentation for the TAR.
During an interview on 02/14/25, at 3:23 P.M., Licensed Practical Nurse (LPN) D said the following:
-If a resident had a physician order for oxygen administration for shortness of breath every shift, the nurse should complete this task and document on the TAR;
-There should not be blank spaces on the TAR where documentation;
-If no check is completed, the nurse should use the applicable code reasoning for not completing such as the code for the resident not in the facility.
During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing (DON) said the following:
-Nurses complete the tasks and documentation on the TAR;
-There should be no blank spaces on the TAR for oxygen checks as this would mean the task was not completed.
During an interview on 02/21/25, at 4:47 P.M., the Administrator said the following:
-If a resident had a physician order for oxygen administration/checks every shift, staff should document checks in the TAR, and if not checked, staff should document the reason.
MO00249332
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to have a system in place to ensure nurses aides (NA) completed their training, competencies, and testing in a timely manner whe...
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Based on observation, interview, and record review, the facility failed to have a system in place to ensure nurses aides (NA) completed their training, competencies, and testing in a timely manner when two NA's failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification within four months of hire and continued to work providing care to residents. The facility census was 43.
Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following:
-Nurse aides must undergo a state-approved training program;
-A nurse aide is any individual providing nursing or nursing-related services to residents in a facility;
-In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), the facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities;
-The facility will not employee any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless that individual is competent to provide designated nursing care and nursing related service and has completed a training program and competency evaluation program or a competency evaluation program approved by the state or has been deemed competent as provided in 483.150 (a) and (b) of the requirements of participation;
-Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services.
1. Review of a facility list of current nurse aides showed NA D had a hire date of 08/05/24 (over four months prior).
During an interview on 02/18/25, at 1:46 P.M., NA D said the following:
-He/she was hired in August of 2024;
-He/she began CNA classes toward the end of October of 2024 and completed the classes at the end of January 2025;
-He/she was scheduled to take the CNA test on 03/03/25.
Review of the state agency CNA registry website, on 02/26/25, showed NA D was not listed as a CNA.
2. Review of a facility list of current nurse aides showed NA E had a hire date of 08/13/24 (over four months prior).
During an interview on 02/20/25, at 2:53 P.M., NA E said the following:
-He/she was hired in August of last year;
-He/she began taking CNA classes in October of 2024, and completed the classes 01/25/25;
-He/she was scheduled to take the CNA test on 03/03/25;
-He/she has worked the floor since hire and was paired with a CNA for about five days.
Observations on 02/13/25, and 02/21/25, showed NA E provided direct care to residents.
Review of the state agency CNA registry website, on 02/26/25, showed NA D was not listed as a CNA.
3. During an interview on 02/21/25, at 4:10 P.M., the CNA Instructor said NAs should be certified within 120 days of employment. Four NA's finished classes at the end of January 2025 and will test at beginning of March 2025.
During an interview on 02/21/25, at 4:47 P.M., the Administrator said NAs should begin CNA classes within four months of their hire date.
MO00249332
Aug 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide effective pain management consistent with professional standards of practice when staff failed to administer requested...
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Based on observation, interview, and record review the facility failed to provide effective pain management consistent with professional standards of practice when staff failed to administer requested pain medication timely, failed to assess the resident's pain level, failed document the administration of pain medication, and failed to follow-up with the resident regarding the effectiveness of the pain mediation for one resident (Resident #1) who displayed physical verbal signs of pain. The facility census was 34.
Review of the facility's policy titled Medication and Treatment Orders. dated July 2016, showed the following information:
-Drug and biological orders must be recorded on the physian's order sheet in the resident's chart;
-Orders for medication must include, name and strength, dose, duration, number of doses, route of administration, clinical condition or symptoms for which the medication is prescribed, and any interim follow up related to the medication.
Review showed the facility did not provide a policy regarding pain management.
1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:
-admission date of 07/11/24;
-Diagnoses include kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism (long term condition that occurs when a clump of material, most often a blood clot gets stuck in an artery in the lungs, blocking the flow of blood).
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool that is filled out by facility staff), dated 07/18/24, showed the following information:
-Cognitively intact;
-Required substantial to maximum assistance from staff for dressing, bathing, and mobility, and completely dependent on staff assistance for toileting;
-Received as needed pain medication and received non-medication pain intervention.
Review of the resident's care plan, revised on 07/22/24, showed the following information:
-Evaluate pain daily by using 1 to 10 pain scale;
-Administer pain medications as ordered;
-Assist with positional changes slowly;
-Monitor for worsening of symptoms and report them to the physician.
Review of the resident's Physician Order Sheet (POS), dated 08/24/24, showed the following orders for pain:
-A current order for lidocaine external gel 4% (used to treat pain), apply to area of pain topically (on skin) one time a day;
-A current order for tramadol 50 milligram (mg) tablet (used to treat chronic pain or moderate/severe pain), give one tablet by mouth every six hours as needed.
During an interview on 08/27/24, at 10:08 A.M., the resident said often times, when he/she asked for pain medication, he/she had to wait two to three hours before someone would administer the medication. He/she was always told it will be a few minutes, or we're busy.
Observation and interview on 08/27/24, at 12:24 P.M., showed the resident sat in his/her recliner. The resident was visually uncomfortable with grimacing and asked the surveyor if he/she had brought him/her a pain pill. The resident said he/she had requested a pain pill this morning and pressed his/her call light.
Observation on 08/27/24, at 12:27 P.M., showed Certified Nursing Assistant (CNA) C entered the resident's room. The resident asked the aide if he/she minded asking the nurse if the resident could have some pain medication. CNA C said yes and exited the room.
During an interview on 08/27/24, at 12:34 P.M., CNA C said if a resident was in pain he/she would let both the certified medication technician (CMT) and charge nurse know. The Director of Nursing (DON) was the charge nurse on this day. The CMT passed some pain medications while the charge nurse passed others, so it was best to notify them both. A resident should not have to wait two to three hours for pain medication.
Observation on 08/27/24, at 1:24 P.M., showed the DON observed the resident's arm and the resident told the DON that he/she was in pain and had requested a pain pill. The DON did not ask the resident where his/her pain was or what his/her pain level, and exited the room. (Fifty minutes after the resident asked staff for pain medication.)
Observation and interview on 08/27/24, at 3:22 P.M., showed the resident in the same position, in his/her recliner, visually uncomfortable with grimacing. The DON, Assistant Director of Nursing (ADON), and CNA F were present in the room. The resident said he/she was still waiting for pain medication. At this time, surveyor asked the DON if the resident had been administered any pain medication. The DON said no and the DON would go get it now. The DON did not ask the resident where his/her pain was, or pain level. The ADON and CNA F transferred the resident from the recliner to the bed with a sit to stand mechanical lift (a device that helps people who have difficulty standing up from a seated position). During the transfer, the resident was observed grimacing, moaning, and voicing pain. The resident told the staff that the lift swing was causing additional pain to his/her left arm which was visibly red, swollen, and bruised. The resident continued to voice his/her pain while laying on the bed. At 3:44 P.M., the DON re-entered the resident's room with pain medication. The ADON and CNA F transferred the resident back to his/her recliner. The DON administered the pain medication, said to be tramadol, to the resident at 3:48 P.M. (Over three hours after the resident requested pain medication from staff.)
Review of the Stat Lock (a safe containing several different types of on-hand medications that can be pulled from when a resident is out of medication) form titled Sterling Pharmacy, dated 08/27/24, showed one tablet of Ultram (tramadol) for the resident obtained from the stat lock at 3:27 P.M.
Review of the resident's Medication Administration Record (MAR), on 08/27/24 at 3:54 P.M., showed the DON had not documented the administration of the tramadol or the resident's pain level.
Review of the resident's MAR on 08/28/24, at 9:15 A.M., showed staff did not document tramadol 50 mg as administered on 08/27/24 at 3:48 P.M.
Review of the resident's medical record showed staff did not document follow-up regarding the effectiveness of the pain medication.
Review on the resident's pain scale assessments, dated 08/27/24, showed staff completed one pain assessment for the resident on 08/27/24, at 10:51 P.M. The resident rated his/her pain at a 5 out of 10.
During an interview on 08/28/24, at 9:50 A.M., CMT H said that nurses give all as needed pain medications. The nurse should evaluate the resident's pain. If resident complained of pain the CMT would notify the nurse. If returned and the nurse had not evaluated and provided pain medication, staff would return to the nurse or go to the DON if the nurse was busy.
During an interview on 08/28/24, at 10:42 A.M., Registered Nurse (RN) G said that nursing staff should provide pain medications in a timely manner when resident requests and with the appropriate orders. The resident should not have to wait three hours for pain medication.
During an interview on 08/27/24, at 12:20 P.M., the ADON said that the nurses give as needed pain medications because they will complete an assessment of the resident's pain. The CMT only gives routine ordered pain medications.
During an interview on 08/28/24, at 10:14 A.M., DON said that he/she had given the resident tramadol 50 mg on the afternoon of 08/27/24. The medication was signed out from the E-Kit because the resident needed the pain medication right away. She was unable to locate the order to document the administration of the pain medication. She did not make a progress note related to the pain medication. She knew the resident needed the pain medication right then. The administration of pain medication was passed on verbally to the next shift. The DON was not aware that the resident needed pain medication prior to 3:30 P.M. The DON said no staff notified the DON previously.
During an interview on 08/28/24, at 10:49, the resident's doctor said if a resident was complaining of pain, the resident should be given whatever was ordered for that pain. He/she wouldn't expect two to three hours to be an acceptable wait time for pain medication.
During an interview on 08/28/24, at 12:28 P.M., the Administrator, DON, Regional Nurse Consultant, and Regional Director of Consultants said a resident should not have to wait two to three hours to receive pain medication. The nurse should perform a pain assessment, administer the medication if it is within the allotted time frame, and document the administration.
MO00238842, MO00239423, & MO00239941
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide care per standards of practice when staff failed to identify, assess, document, monitor, obtain orders for treatment o...
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Based on observation, interview, and record review the facility failed to provide care per standards of practice when staff failed to identify, assess, document, monitor, obtain orders for treatment of, and notify the physician of wounds for one resident (Resident #1). The census was 34.
Review of the facility's policy titled Wound and Skin Care Protocols and Procedures, dated June 2021, showed the following:
-The facility would include the orders on the physician's order sheet (POS);
-May use facility skin and wound care protocols. Each resident's personal physician must approve of orders at the time of admission and then sign the order sheets monthly;
-Each individual resident required treatment and specific telephone orders would be written based on protocols.
-If a wound was not making progress, it was important to attempt to reduce the bioburden and manage infection.
-Treatment included cleansing with sterile water, select appropriate type of alginate with silver property, moisten the alginate with sterile water, and cover, change every three days and ensure the alginate (assists with wound healing) stays moistened. Contact physician for the consideration of a negative pressure pump (wound vac).
1. Review of Resident #1's face sheet (brief look at resident information), showed the following information:
-admission date of 07/11/24;
-Diagnoses included kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism (long term condition that occurs when a clump of material, most often a blood clot gets stuck in an artery in the lungs, blocking the flow of blood).
Review of the resident's care plan, revised on 07/15/24, showed the following information:
-Required skin to be observed daily during routine care for irritation and redness.
-Required a full skin evaluation weekly with showers.
Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool that is filled out by facility staff), dated 07/18/24, showed the following information:
-Cognitively intact;
-Required substantial to maximum assistance from staff for dressing, bathing, and mobility, and completely dependent on staff assistance for toileting;
-At risk for pressure ulcers with no current pressure, venous (wounds that are due to vein and blood flow issues), or arterial (wounds that are due to poor circulation) ulcers;
-Required pressure reducing devices for chair and bed, and required a turning and repositioning program.
Review of the resident's weekly Skin Only Evaluation sheets showed the following information:
-Staff did not document skin evaluations from 07/11/24 through 08/01/24;
-On 08/02/24, staff noted the resident had no skin issues, aside from a current healing hematoma (a collection of blood that pools in an organ, tissue, or body space) to the left knee, measuring 5 centimeters (cm) by 5 cm, with 0 cm depth.
Review of the resident's care plan, updated 08/07/24, showed open area to left knee with daily dressing changes as directed. Staff to notify physician if no improvements in two weeks.
Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheets showed the following information:
-On 08/09/24, no skin issues documented (two days after care planned updated with open are to knee requiring dressing changes);
-On 08/13/24, shower was rescheduled to 08/14/24 with no skin issues documented;
-On 08/15/24, staff noted open area to left knee, and redness and open areas to the backs of both legs in the calf regions;
-On 08/16/24, resident refused a shower;
-On 08/20/24, staff noted sore to left knee, and sores to the backs of both legs.
Review of the resident's care plan, updated 08/20/24, showed a new order to refer resident to wound care. Staff did not care plan related to the new sores to the back of the resident's legs.
Review of the resident's care plan, updated 08/21/24, showed open areas to buttocks added. Staff to encourage resident to reposition, provide incontinent care, and apply barrier cream each shift.
Review of the resident's weekly Skin Only Evaluation sheets showed the following information:
-On 08/21/24, staff noted resident had no skin issues, aside from an opened scab on the left knee, measuring 2 cm by 2 cm with bloody drainage.(Staff did not document area on buttocks requiring treatment noted on the same day.)
-On 08/23/24, staff noted the resident had no skin issues, aside from a pressure ulcer injury to the posterior (back side) left thigh that measured 6 cm by 2 cm with a 0.2 cm depth with bloody drainage. Staff also noted the resident had multiple pinpoint areas on the buttocks with bloody drainage.
Review of the resident's Physician Order Sheet (POS) showed the following:
-A current order for an appointment with wound care clinic on 08/28/24 for left knee wound;
-A order, dated 08/27/24, to change wound dressing every three days and as needed with island dressing to left knee.
(The orders did not include orders to address the wounds on the resident's buttocks, thigh, or calf.)
During an interview on 08/27/24, at 10:08 A.M., the resident said he/she did have wounds. He/she had one on his/her left knee and he/she is supposed to be going out to have it treated at a wound clinic soon. The staff change the bandage every couple days.
During an interview on 08/27/24, at 1:02 P.M., the Director of Nursing (DON) said if a resident were to have wounds, he/she would expect to see documentation of that in the progress notes and skin assessments. If the staff are aware that a resident has wounds, the facility outsourced and worked with a wound company and/or will send the resident across the street to be treated in a wound care clinic. The floor nurses complete wound treatments daily and there should be orders within the physician's order sheet as well as care plan for them to follow. The DON said the resident does have wounds. The resident had a wound on the left knee, on his/her bottom, and on the backs of both legs in the thigh area. The DON said the resident's physician was aware of all wounds. The DON looked the resident's record and said there were technically no doctor orders at this time for the areas. He/she is just keeping a dry patch on them for now. She expects staff treat the wounds without the physician orders following the facility protocol book for wounds.
Review showed the facility did not provide a facility protocol book for wounds signed off on by the physician or medical director.
Observation and interview on 08/27/24, at 3:10 P.M., showed the resident had 4 x 4 gauze squares on top of left knee wound that were secured with paper tape with dried red substance, appearing to be blood, on the gauze. The resident's his/her left knee had a yellow and red substance seen on the pad underneath the residents' legs. The resident said none of his/her treatments have been done in a couple days.
Observation on 08/27/24, at 3:30 P.M., showed the resident transferred into his/her bed. Upon assessment of the resident, two wounds were located on the back of the upper legs. One wound on the left appearing as an open area with a red wound bed approximately 5 cm long with some bruising alongside of the wound and yellow drainage coming from wound. One wound on the right appearing as an open area with a red and yellow wound bed approximately golf ball sized, with yellow drainage. The Assistant Director of Nursing (ADON) sprayed both areas with wound cleanser and left open. The resident also had two open areas on the left knee. Both areas had black and yellow tissue inside, draining a red and yellow substance, with the surrounding tissue was red. ADON sprayed this area with wound cleanser and covered with a dry dressing.
During an interview on 08/27/24, at 3:54 P.M., the DON said the wounds to the resident's backs of legs had been there approximately a week and intervention of encouraging the resident to get off of his/her bottom had been put in place. As far as treatments for all the resident's wounds, she followed the nursing protocols book. If a new wound was found for any resident, she expected staff to assess the area, measure it, notify the doctor, and family, follow the wound care protocol, and document.
During an interview on 08/28/24, at 10:42 A.M., Registered Nurse (RN) G said the following:
-The computer system notified nursing staff when a skin assessment or wound care was due to be completed;
-The aides also do skin assessments with baths and bring skin concerns to the nurse, often having the nurse come evaluate the skin while still in the shower;
-Nursing staff should document all skin concerns;
-The RN was not aware of any areas on the back of the resident's leg or bottom;
-He/she was only aware of the wound on the left knee.
During an interview on 08/28/24, at 11:56 A.M., the Social Services Director (SSD) said wounds and wound treatments should be included in the care plan. If there was no improvement in a wound within two weeks, the physician should be notified. There should also be wound care orders in the physician orders sheet. Those orders should be followed. Any staff member can add information to the care plan, and she will then review it. The resident does have wounds, one on the knee and one on the bottom. The bottom wound is being treated with barrier cream and the wound to the knee is being treated with a dry dressing.
During an interview on 08/27/24, at 3:10 P.M., DON said the resident did not like to move out of his/her recliner. The staff encourage him/her to get off his/her bottom. The resident had an upcoming appointment with the wound care clinic. The nursing staff should see the resident's bottom at least once per day. The resident had a couple of random open areas on his/her bottom and thighs. There was no treatment order, staff were only putting barrier cream and encouraging to get into the bed.
During an interview on 08/28/24, at 10:49 A.M., the resident's physician said she saw the resident a few weeks ago. At that time, the resident had a wound to his/her left knee. She referred to it as a popped hematoma and the wound bed was clean. The physician referred the resident to the wound care clinic for treatment. The physician believed she made specific in-house wound care orders, but could not verify them at this time. She did tell a nurse to be treating the area with the in house wound care protocol. The physician said she was not aware of any other wounds to the resident. The physician expected nursing staff to assess new wounds, measure, notify her, begin treatment, and document.
During an interview on 08/28/24, at 9:00 A.M., the Corporate Nurse said that staff should use the wound protocol and should add to the physician's orders for nurses to know the treatment plan.
During an interview on 08/28/24, at 12:11 P.M., with the DON and Regional Nurse Consultant, the DON said if a new wound was brought to her attention or another nurses attention, they should go down and assess the wound, measurements should be obtained, and it should be documented. The staff are to be completing treatments on all wounds, staff should use the wound care protocol for those treatment orders, and those orders should be found in the POS. The Regional Nurse Consultant said there are weekly skin assessments for all residents. Once Wound Care Plus or wound care clinic is established, the facility used their measurements. Otherwise, wounds were monitored with skin assessments and the electronic medical record should trigger this every seven days for all residents.
During an interview on 08/27/24, at 1:35 P.M., the Administrator the resident had some wounds on his/her left knee and buttock area. The resident was going to see the wound clinic soon. The nursing staff should be treating the wounds until seen at the clinic and received new orders. The staff was probably treating the areas per facility protocol. There should be an order for the nurses to know when a treatment was to be done.
During an interview on 08/28/24, at 12:28 P.M., the Administrator, DON, Regional Nurse Consultant, and Director of Regional Consulting said wounds should be documented and monitored. The wound care treatment protocol should be activated, and those orders should be found in the POS.
MO00239310
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure residents were as free from accident hazards as possible when staff failed to transfer one resident (Resident #1) in a ...
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Based on observation, interview, and record review the facility failed to ensure residents were as free from accident hazards as possible when staff failed to transfer one resident (Resident #1) in a safe manner and failed to follow-up on possible injury from the transfer. The facility census was 34.
Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following:
-The purpose of the procedure was to promote cleanliness, promote comfort, and to observe the condition of the resident's skin;
-Staff should observe the skin for any rashes, reddened areas, and swelling and document all assessment data including reddened areas, and sores on the resident's skin.
2. Review of Resident #1's face sheet (brief look at resident information) showed the following information:
-admission date of 07/11/24;
-Diagnoses included kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism (long term condition that occurs when a clump of material, most often a blood clot gets stuck in an artery in the lungs, blocking the flow of blood).
Review of the resident's care plan, revised on 07/15/24, showed the following information:
-Required skin to be observed daily during routine care for irritation and redness;
-Required a full skin evaluation weekly with showers;
-Potential for bruises due to anticoagulant (medicines that help prevent blood clots) therapy;
-Staff to be gentle in working with the resident;
-Staff to inspect skin daily for bruises;
-Assistance of one staff for all ambulation.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool that is filled out by facility staff), dated 07/18/24, showed the following information:
-Cognitively intact;
-Required substantial to maximum assistance from staff for dressing, bathing, and mobility, and completely dependent on staff assistance for toileting;
-No current skin conditions.
Observation and interview on 08/27/24, at 10:08 A.M., showed the following:
-The resident said he/she was in pain due to something that happened on Friday (08/23/24);
-The resident pulled up his/her left shirt sleeve and showed his/her arm. The resident's skin was red and swollen starting at his/her inner elbow, and moving up the arm. In the bicep region, there was a dark blue to purple golf ball sized area. Past the bruise was more redness and swelling up to and including the resident's armpit.
-The resident said this occurred during an improper transfer. He/she was supposed to be transferred with a mechanical lift called a sit-to-stand (helps a resident into a standing position with the use of a sling). The resident said he/she was sitting on the side of his/her bed and requested to be assisted into the recliner. Certified Nursing Assistant (CNA) A grabbed his/her arm when transferring him/her to the recliner and pulled at the arm roughly leaving the bruising and redness.
-The resident said he/she reported this to Licensed Practical Nurse (LPN) B as well as the therapy department.
During an interview on 08/28/24, at 8:30 A.M., CNA A said on 08/23/24, he/she helped another aide transfer the resident with the sit-to-stand. The resident let go of the handles and let his/her body drop in the sling. The CNA reported this to the Assistant Director of Nursing (ADON). The CNA did not know if the nurse evaluated the resident. If at any time saw any skin issues on a resident, he/she would notify the charge nurse and if they did not check the resident, he/she would tell the Administrator.
During an interview on 08/27/24, at 2:31 P.M., Physical Therapist (PT) D said he/she had not been made aware of any bruising that would affect therapy. The resident had mentioned to him/her that his/her left shoulder was hurting. The resident did report to him/her that the pain was from an improper transfer the side of the bed to the recliner. PT D said the resident was a sit-to stand lift and sometimes the resident would let go and go limp on the lift, unable to stand. In those cases staff should advance to a different mechanical lift called a Hoyer (a mechanical lift that lifts a resident up off the ground with a sling).
Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheets, dated 08/09/24 to 08/27/24, showed staff did not document regarding bruising to the resident's arm. The resident refused a shower on 08/23/24.
Review of the resident's weekly Skin Only Evaluation sheets, dated 08/02/24 to 08/27/24, showed staff did not document regarding bruising to the resident's arm.
Review of the resident's progress notes, dated 08/23/24 to 08/27/24, showed staff did not document regarding the bruising or an investigation into the bruising or transfer.
During an interview on 08/27/24, at 5:37 P.M., LPN B said the expectation when a bruise was reported, was for the nurse to assess the area, and notify the Administrator so she can report it to the state if it is suspicious. New bruising should be documented in the skin assessment notes and progress notes in the electronic medical record. The resident was difficult and didn't like to stand or help when using the sit-to stand, but that's what should be used for transfer. No new bruising to the resident had been reported to him/her. The resident did complain of left shoulder pain on 08/23/24. LPN B assessed the resident's arm at that time and said the resident had good range of motion and he/she didn't see a new bruise at the time. He/she did see a bruise that was quarter size, but believed it to be in the healing process and not related.
During an interview on 08/27/24, at 12:34 P.M., CNA C said he/she wasn't aware of any bruising to the resident. If he/she seen or was reported to him regarding new bruising to a resident he/she would report it to the charge nurse, and the charge nurse would take it from there.
During an interview on 08/27/24, at 1:02 P.M., the Director of Nursing (DON) said she has not had any bruising to the resident reported to her. Bruising should be documented on the weekly skin assessments. She would expect new bruising to be reported to her. The resident is transferred with a sit-to stand so she is unsure of how a CNA could have caused the bruising.
During an interview on 08/28/24, at 9:50 A.M., Certified Medication Tech (CMT) H said he/she would let the charge nurse know of any skin issues, bruises, redness, or open areas on a resident especially if unaware if the nurse was aware of the area. The CMT was aware that the resident had a bruise on his/her left arm that was from the sit-to-stand lift. He/she did not notify the nurse as this was not a new bruise. When staff transfer the resident, the resident would lean back and his/her arms rest on the lift sling. The resident complained of pain in his/her arm area to the CMT on Monday 8/26/24 and he/she notified the nurse.
During an interview on 08/28/24, at 10:42 A.M., Registered Nurse (RN) G said the following:
-Nursing staff should document all skin concerns;
-The resident had told the RN of the bruise over the weekend, however he/she did not document any information about the bruise because he/she thought it was a pre-existing concern;
-The RN did not look at the resident's arm or document any information related to the bruise.
During an interview on 08/27/24, at 2:10 P.M., the Assistant Director of Nursing (ADON) said that nursing staff should look at resident skin, measure and document when notified of new areas. If staff were unable to document under the skin assessment portion of the chart, the staff should at least document a progress note. The ADON said on 08/23/24 she and CNA A transferred the resident with the sit-to-stand lift at about 3:00 P.M. The resident was not compliant and would not try to hold self-up and let go of the handles. The resident's arms were resting on the lift pad.
During an interview on 08/28/24, at 11:56 A.M., the Social Services Director said that she updates the care plans. Care plans should include a good overview of the resident including any skin issues. If she was aware of any new bruising, that is something she would include in the care plan.
During an interview on 08/28/24, at 10:49 A.M., the resident's doctor said she had seen the resident a few weeks ago and wasn't aware of any new bruising, but the resident was on anticoagulants (a medication that prevents blood from clotting) and bruises easily. Staff should report new skin issues her.
During an interview on 08/27/24, at 1:36 P.M., the Administrator said he/she wasn't aware of any bruising on the resident and none had been reported to her. She expected staff to report, assess, and monitor bruising. There have never been any other issues with CNA A.
During an interview on 08/28/24, at 12:28 P.M., the Administrator, Director of Regional Consulting, Regional Nurse Consultant, and Director of Nursing said expectations for bruising include the charge nurse assessing the bruise, reporting it to the DON and Administrator. The Administrator said she was not aware of the bruising to the resident. Regardless, it should be documented on daily and investigated. The physician and family should be notified and there should be a 72-hour follow up per the Director of Regional Consulting.
Mar 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained when staff failed to ensure catheter (a flexible tube inserted through a narrow...
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Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained when staff failed to ensure catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bags were kept in a privacy bag for two residents (Resident #16 and #23) reviewed for catheter care out of 18 sampled residents.
1. Review of Resident #16's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following:
-admission date of 07/06/23 with readmission date of 02/21/24;
-Diagnoses included chronic kidney disease, cellulitis of groin, and retention of urine.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) assessment with an Assessment Reference Date (ARD) of 01/09/24, showed the resident was cognitively intact.
During an observation on 03/11/24, at 1:07 P.M., the resident's catheter was in place without a privacy bag over the collection bag. The bag and urine was visible to others.
During an observation on 03/11/24, at 1:40 P.M., the resident's catheter bag hung on the side of bed without a privacy bag in place. The bag was visible from doorway, contained a clear yellow liquid, and was approximately 25% full.
During an observation on 03/13/24, at 11:00 A.M., the resident's catheter bag hung on the side of the bed without a privacy bag and a small amount of yellow liquid visible.
2. Review of Resident #23's Face Sheet, located the EMR under the Profile tab, showed the following:
-admission date of 12/27/23 with a readmission date of 03/01/24;
-Diagnoses included chronic kidney disease, retention of urine, and heart failure.
Review of the resident's admission MDS assessment with an ARD of 01/03/24, showed the resident was severely cognitively impaired.
During an observation and interview on 03/12/24, at 9:00 A.M., the resident was in bed. His/her catheter bag was lying flat on the floor, urine side down. The bag was noted to be 1/2 full and appeared cloudy. The catheter bag was not in a dignity bag. Registered Nurse (RN) 1 confirmed the lack of a privacy bag when he/she attached it to the bed.
3. During an interview on 03/13/24, at 4:30 P.M., the Regional Nurse Consultant (RNC) said catheter bags should be contained in a privacy bag. It is the expectation that they should be bagged appropriately.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize all resident's right to self-determination ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize all resident's right to self-determination when the facility failed to provide showers as scheduled, care planned, and preferred for one resident (Resident #4) of 18 sampled residents.
Review of the facility's policy titled, Activities of Daily Living (ADL)s, Supporting, dated March 2018, showed the following:
-Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out services of daily living;
-Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;
-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).
1. Review of Resident #4's admission Record, located in the electronic medical record (EMR) under the Resident Profile tab, showed the resident was admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus, difficulty in walking, and unsteadiness on feet.
Review of the resident's Care Plan, located in the EMR under the Care Plan tab, dated 01/19/24, showed the following:
-Resident had impaired mobility and shortness of breath;
-Resident required assistance with ADLs;
-Approaches included providing assistance to gather items for bathing and assist with bathing and bathe per schedule.
Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) with an Assessment Reference Date (ARD) of 01/19/24 and located under the MDS tab of the EMR, showed the following:
-Resident was cognitively intact;
-Resident required partial to moderate assist with bathing and partial to moderate assist with transferring to the shower.
During an interview on 03/11/24, at 10:47 A.M., the resident said showers were supposed to be given two times a week on Mondays and Thursdays. The resident said he/she had not been getting showers and he/she thought he/she got one on Thursday almost two weeks ago. The resident said It is Monday. I should get a shower today. The resident said, The night nurse helps me get a clean gown and washes me up a little bit, but it still is not a shower.
During an interview on 03/11/24, at 4:30 P.M., the resident said he/she had not received a shower.
Review of the resident's shower sheets provided by the facility for the last four months showed the following:
-In December 2023, the resident was not given a shower on Monday, 12/25/23.
-In January 2024, resident was not given a shower on Monday, 01/22/24, and on Thursday, 01/25/24.
-In February 2024, the resident was not given a shower on Thursday, 02/08/24, on Thursday, 02/22/24, and on Monday, 02/26/24.
-In March 2024, the resident was not given a shower on Monday, 03/04/24, on Thursday, 03/07/24, and on Monday 03/11/24.
During an interview on 03/13/24, at 6:49 A.M., Licensed Practical Nurse (LPN) 2 was asked if the resident had ever told him/her that the resident did not receive his/her showers as scheduled. LPN2 said Yes. The resident has complained about showers not being given.
During an interview on 03/13/24, at 12:34 P.M., LPN1 was asked about ensuring residents received showers. LPN1 said The resident is given a little mini bath, which is a short version of a bed bath. LPN1 was asked why the resident did not receive a shower on Monday and on other scheduled days. LPN1 stated, There have been some plumbing issues. There are days that we only have one CNA scheduled and we do the best we can. The resident's showers take at least 45 minutes or longer.
During an interview on 03/14/24, at 9:06 A.M., Certified Nurse Aide (CNA) 2 was asked about the resident's showers. CNA2 said, the resident is scheduled to receive showers twice a week. We try to get showers done, but some days are crazy, and it may not happen.
During an interview on 03/14/24, at 10:44 AM, the Regional Nurse Consultant (RNC) said the expectation is showers should be given at least two times a week. If residents want them more often, we will give them more often.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident representative of a change in condition for one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident representative of a change in condition for one of three residents (Resident #21) reviewed for change in condition. The facility failed to inform the resident's representative of a urinary tract infection (UTI) and upper respiratory infection (URI) which required the administration of antibiotics.
Review of the facility's policy titled, Change in Resident's Condition or Status, dated 02/21, showed the following:
-The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.
1. Review of the resident's Face Sheet, provided by medical records, revealed Resident #21 was admitted to the facility on [DATE] with a diagnoses that included dementia.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), located in the MDS tab of the electronic medical record (EMR) with, with an Assessment Reference Date (ARD) of 02/22/24, showed the resident had severely impaired cognition.
Review of the resident's Nursing Progress Notes, located in the Progress Notes tab of the EMR, dated 02/27/24, showed staff obtained a urinalysis (UA).
Review of the resident's Nursing Progress Notes, located in the Progress Notes tab of the EMR, dated 02/28/24, showed staff sent the UA to the lab and a chest x-ray would be obtained that day.
Review of the resident's Nursing Progress Notes, located in the Progress Notes tab of the EMR, dated 02/29/24, showed the resident was seen by his/her physician and the labs and x-ray were reviewed. The physician ordered an antibiotic for an urinary tract infection and an upper respiratory infection.
Review of the resident's Nursing Progress Notes showed staff did not document notification of the resident's representative of the change in condition and the antibiotic orders.
During an interview on 03/11/24, at 2:22 P.M., Family Member (FM) 1 said he/she was not notified of the resident's change on condition in February and he/she did not know the resident was on antibiotics.
During an interview on 03/13/24, at 3:21 P.M., Licensed Practical Nurse (LPN) 1 said family should have been notified when the antibiotics were ordered.
During an interview on 03/14/24, at 10:58 A.M., the Regional Nurse Consultant (RNC) said that her expectation was that the resident representative would be notified of any change in condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review, interviews, and record review, the facility failed to ensure that one resident (Resident #3) of 18 sampled residents had a Level I Preadmission Screening Resident Review (PASAR...
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Based on record review, interviews, and record review, the facility failed to ensure that one resident (Resident #3) of 18 sampled residents had a Level I Preadmission Screening Resident Review (PASARR) prior to admission into the facility. This failure had the potential for residents with a mental disorder to go unidentified and not receive specialized services.
Review of facility's policy titled, admission Criteria, dated 03/19, showed the following:
-All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process;
-The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD.
-If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level 2 (evaluation and determination) screening process;
-The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD;
-The social worker is responsible for making referrals to the appropriate state-designated authority.
1. Review of Resident #3's Face Sheet, showed the following:
-admission date of 05/16/22;
-Diagnoses at admission included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder, major depressive disorder, psychosis (when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations)), intermittent explosive disorder (an impulse-control disorder characterized by sudden episodes of unwarranted anger), and intellectual disabilities (ID).
Review of the resident's ''Physician's Orders,'' dated 05/18/22 and found in the electronic medical record (EMR) under the ''Orders'' tab, showed the following:
-An order for risperidone (an antipsychotic medication) give 2.0 mg (milligrams) by mouth two times a day;
-An order for quetiapine fumarate 50 mg two times a day for mood stabilization;
-An order for Divalproex (a mood stabilizing drug) give three tablets to equal 750 mg by mouth two times a day for mood stabilization.
Review of the resident's Care Plan, dated 01/16/24 and provided by the facility, showed the resident had potential to be verbally aggressive at times. The resident was at risk of social isolation and preferred to spend most of his/her time in his/her room.
Review of the resident's reentry Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment with Assessment Reference Date (ARD) of 01/03/24 from a hospital, showed the following:
-The resident did not have a level II PASARR with diagnoses of schizophrenia and psychotic disorder;
-The resident had severe cognitive impairment;
-The assessment indicated the resident had not exhibited any behaviors during the assessment reference period.
Review of the resident's EMR, under the Documents tab, showed not documentation of a level I and/or level II PASARR.
During an interview on 03/13/24 at 2:15 P.M., the Social Services/Minimum Data Set (SS/MDS) Staff confirmed the resident did not have a level II PASARR. When asked about a level I, The SS/MDS Staff said the resident had been at the facility for over 20 years, and a Level I and Level II PASARR was completed, however she was unable to provide it because the resident's records were in a paper chart, and they all have been discarded.
During an interview on 03/13/24, at 3:39 P.M., the Registered Nurse (RN) 1 said that he/she was unsure of the process when residents were screened for Level I PASARR, but the SS/MDS Staff was responsible for the PASARR screening. He/she said that he/she did not know what happened to the Level I form after the resident had been screened.
During an interview on 03/13/24, at 4:12 P.M., the Director of Nursing (DON) confirmed the resident's level 1 PASARR should have been received by the SS/MDS at the time that resident was admitted , and for whatever reason the facility did not have it. The DON indicated that normally the facility did not accept a resident without a level I. The resident had been in the facility for over twenty years, and she was unsure why the resident did not have it.
During an interview on 03/13/24, at 4:12 P.M., the Regional Nurse Consultant (RNC) confirmed that she was not able to find any PASARR screenings or assessments for the resident in the facility's EMR system or in the resident's previous records. She said that if there was a newly evident or possible serious MD or related condition after admission to the facility the resident would be referred and transported for evaluation.
During an interview on 03/14/24, at 11:29 A.M., the Administrator confirmed no PASARR information had been found for the resident. She said that SS/MDS Staff was responsible for the referrals for residents. She stated that she expected PASARR to be completed when they were supposed to be so that residents received the care they deserved.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive plan of care directing measur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive plan of care directing measurable goals and person-centered approaches for all residents when the facility failed to develop an activities care plan for the two residents (Residents #21 and #22) and failed to develop a pacemaker care plan for one resident (Resident #21). A sample of 18 residents was selected for review.
Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 03/22, showed the following:
-A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;
-The comprehensive care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including builds on the resident's strengths and reflects currently recognized standards of practice for problem areas and conditions.
1. Review of the Resident #21's Face Sheet, showed the resident was admitted to the facility on [DATE] with a diagnosis of dementia.
Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 11/23/23, showed the following:
-Resident was severely impaired in cognition;
-Little to no interest in activities, but was interested in the news.
Review of the resident's Activity Progress Note, dated 12/23/23 and located in the Progress Notes tab of the EMR, showed the resident did not attend activity groups. The resident liked to sit in front of the nurses' station and read conservation magazines.
Review of the resident's Activity Progress Note, dated 02/20/24 and located in the Progress Notes tab of the EMR, showed the resident liked to wander in and out of activities. The resident liked to sit and read magazines about wildlife and conservation. The resident liked to take naps during the day in his/her room.
During an observation on 03/13/24, at 1:00 P.M., the resident was observed sitting in a chair across from the nurses' station reading a wildlife magazine.
Review of the resident's Comprehensive Care Plan, dated 11/29/23 and located in the Care Plan tab of the EMR, did not show a problem, goal, or person-centered approaches that had been developed for activities.
During an interview on 03/14/24, at 9:03 A.M., the Activities Coordinator (AC) said the development of the activities care plan was the responsibility of the MDS Coordinator. The AC said the resident is more of a one-on-one visit now. He/she likes working on cars, going on trips, and conservation magazines. He/she has declined since admission, and he prefers to sleep more now. The AC was not aware there was no activity care plan for the resident.
2. Review of the Resident #22's Face Sheet, showed the following:
-admission date of 11/29/22;'
-Diagnoses included Alzheimer's disease.
Review of the resident's annual MDS, located in the MDS tab of the EMR with an ARD of 12/04/23, showed the following:
-The resident was severely impaired in cognition;
-Enjoyed books, magazines, keeping up with the news, and music, which were very important to him/her, as well as being outside.
Review of the resident's Comprehensive Care Plan, dated 12/07/23 and located in the Care Plan tab of the EMR, showed staff did not care plan a problem, goal, or person-centered approach related to activities.
During an interview on 03/13/24, at 9:02 A.M., the MDS Coordinator said he/she must of missed the developing an activities care plan for the resident.
During an interview on 03/14/24, at 9:00 A.M., the AC said the resident has changed, but not by much. He/she used to participate in nail salons, get his/her hair done, and go to parties. Currently, the resident is more one-on-one visits or small groups. He/she likes to reminisce. The AC was not aware the the resident did not have an activities care plan.
3. During an interview on 03/14/24, at 10:58 A.M., the Administrator said the expectation was for all residents to have an activity care plan.
4. Review of the Resident's #21's Face Sheet, provided by medical records, showed the following:
-admission date of 11/22/22;
-Diagnoses included atrial fibrillation (an irregular heart rhythm.)
Review of the resident's quarterly MDS, located in the MDS tab of the EMR with an ARD of 02/22/24, showed the resident had severely impaired in cognition.
During an observation on 03/11/24, at 1:53 P.M., the resident was lying in bed with his/her eyes closed. On the bedside table was a wi-fi activated 24-hour pacemaker monitoring system.
Review of the resident's Comprehensive Care Plan, dated 11/29/23 and located in the Care Plan tab of the EMR, showed staff did not care plan a problem, goal, or person-centered approaches for the resident's pacemaker and the monitoring system.
During an interview on 03/13/24, at 12:19 P.M., Licensed Practical Nurse (LPN) 1 confirmed the resident had a pacemaker. The LPN could not say why there was not a care plan related to the pacemaker.
During an interview on 03/13/24, at 1:07 P.M., the MDS Coordinator said he/she was not aware a pacemaker care plan had not bee completed previously. The resident should have pacemaker care plan.
During an interview on 03/14/24, at 10:58 A.M., the Regional Nurse Consultant (RNC) said that her expectation was that a comprehensive care plan should have been developed for the resident's pacemaker to include the 24- hour monitoring system.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all dependent residents maintained good groomi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all dependent residents maintained good grooming when staff failed to provide showers as scheduled and needed for one resident (Resident #11) dependent on staff for shower of 18 sampled residents.
Review of the facility's policy titled, Activities of Daily Living (ADL)s, Supporting, dated March 2018, showed the following:
-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out services of daily living (ADLs);
-Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;
-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).
1. Review of Resident #11's admission Record, located in the EMR under the Resident Profile tab, showed the resident was admitted to the facility on [DATE] with diagnoses that included chronic bronchitis, chronic pain, and disorientation.
Review of the resident's Care Plan, located in the EMR under the Care Plan tab, dated 07/12/23, showed the resident had impaired mobility and weakness, and required assistance with ADLs. Approaches included staff to assist with bathing and hygiene.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), with an ARD of 01/18/24 and located under the MDS tab of the EMR, showed the following:
-The resident was severely cognitively impaired;
-The resident required substantial to maximal assist with bathing and substantial to maximal assist with transferring to the shower.
During an observation on 03/11/24, at 10:50 AM, the resident was observed to be in a wheelchair and propelling self into his/her room. His/her hair appeared greasy and flat. The resident did not appear well kempt.
Review of the resident's shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays.
Review of the resident's shower sheets provided by the facility for the last four months showed the following:
-In December 2023, the resident was not given a shower on Tuesday, 12/05/23; Friday, 12/08/23; Tuesday, 12/12/23; and Friday, 12/15/23;
-In January 2024, the resident was not given a shower on Tuesday, 01/02/24; Friday. 01/05/24; Tuesday, 01/09/24; Friday 01/12/24; Tuesday, 01/16/24; and Friday ,01/19/24;
-In February 2024, the resident was not given a shower on Friday, 02/09/24; Friday, 02/16/24; and Tuesday, 02/20/24;
-In March 2024, the resident was not given a shower on Tuesday, 03/05/24, and Friday, 03/08/24.
During an interview on 03/13/24, at 11:07 A.M., Registered Nurse (RN) 1 was asked if staff monitored to ensure resident showers were given. RN1 said, I walk around and ask residents. I observe and listen. If a resident refuses staff should go back and ask again later. RN1 added that he/she looked at the skin and that usually occurred on shower days. RN1 was asked about the missing days for the resident. RN1 stated, The sheets may not be turned in.
During an interview on 03/14/24, at 9:06 A.M., CNA2 was asked about the resident's showers. CNA2 said, The resident is scheduled to receive showers twice a week. We try to get showers done, but some days are crazy, and it may not happen. It also depends on his/her mood.
During an interview on 03/14/24, at 10:44 A.M., the Regional Nurse Consultant (RNC) said the expectation is showers should be given at least two times a week. If residents want them more often, we will give them more often.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure all resident's with catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the ...
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Based on observation, record review, and interview, the facility failed to ensure all resident's with catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) received treatment to prevent possible infections when the catheter bags of two residents (Resident #16 and #23) were observed on the floor of 18 sampled residents.
Review of the facility policy, Catheter Care, Urinary, dated 08/22, showed the following:
-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;
-Use aseptic technique when handling or manipulating the drainage system;
-Be sure the catheter tubing and drainage bag are kept off the floor
1. Review of Resident #16's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following:
-admission date of 07/06/23 with readmission date of 02/21/24;
-Diagnoses included chronic kidney disease, cellulitis of groin, and retention of urine.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment with an Assessment Reference Date (ARD) of 01/09/24 showed the resident was cognitively intact.
During an observation on 03/11/24, at 1:07 P.M., the resident catheter was in place and the drainage bag was on the floor.
2. Review of Resident #23's Face Sheet, located the EMR under the Profile tab, showed the following:
-admission date of 12/27/23 with a readmission date of 03/01/24;
-Diagnoses included chronic kidney disease, retention of urine, and heart failure.
Review of the resident's admission MDS assessment with an ARD of 01/03/24, showed the resident was severely cognitively impaired.
During an observation and interview on 03/12/24, at 9:00 A.M., the resident was in bed. His/her catheter bag was lying flat on the floor, urine side down. The bag was noted to be 1/2 full and appeared cloudy. Registered Nurse (RN) 1 confirmed that the bag was on the floor and shouldn't be.
3. During an interview on 03/13/24, at 4:30 P.M., the Regional Nurse Consultant (RNC) said catheter bags should not be on the floor. It is the expectation that they should be hung up appropriately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to failed to document a diagnosis and rationale for the use of an antipsychotic medication for one of five residents (Resident #...
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Based on observation, interview, and record review, the facility failed to failed to document a diagnosis and rationale for the use of an antipsychotic medication for one of five residents (Resident #22) reviewed for unnecessary medications. A sample of 18 residents was selected. These failures placed residents at risk for unrecognized side effects and a diminished quality of life.
Review of the facility's policy titled, Antipsychotic Medication Use, dated 03/22, showed the following:
-Residents will not receive medications that are not clinically indicated to treat a specific condition;
-Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions).
Review of the facility's policy titled, Behavioral Assessment, Interventions and Monitoring, dated 03/19, showed the following:
-The IDT (Interdisciplinary Team) will monitor for side effects and complications related to psychoactive medications such as .abnormal involuntary movements.
1. Review of Resident #22's Face Sheet, showed the following:
-admission date of 11/29/22;
-Diagnoses included Alzheimer's disease.
Review of the resident's Physician Orders, located in the Orders tab of the EMR, showed the following:
-An order, dated 10/13/23, for Risperidone (an antipsychotic) one milligram (mg) by mouth every day;
-The order did not show a diagnosis for the use of the antipsychotic medication.
Review of the resident's annual MDS, located in the MDS tab of the EMR with an ARD of 12/04/23, showed the following:
-Resident had severely impaired cognition;
-Received an antipsychotic medication daily during the observation period and no gradual dose reduction (GDR) attempted.
Review of the resident's February 2024 and March 2024 electronic Treatment Administration Record (eTAR) showed staff did not document monitoring for specific behaviors related to the use of the Risperidone.
Review of the resident's Progress Notes in the Progress Notes tab of the EMR showed no documentation regarding having tried to GDR the Risperidone.
During an interview on 03/13/24, at 11:32 AM, Pharm D was asked what the diagnosis was for the use of the Risperidone. She said Major depressive disorder. Pharm D was asked if this was an appropriate diagnosis for the use of Risperidone without monitoring for specific behaviors. She said I was getting ready this month to go over those residents with antipsychotic medications to ensure appropriate diagnoses. I would have liked to have more of a definitive diagnosis and monitoring for specific behaviors. Pharm D further said the physician was given a recommendation to GDR the Risperidone in July 2023 and in December 2023, but it was declined as he did not want to attempt it due a failed trial in the past.
During an interview on 03/13/24, at 12:11 PM, LPN1 asked what the prescribed diagnosis for the use of the Risperidone was. LPN1 said, The resident came to us with this medication. LPN1 was asked if the physician had attempted a GDR on the Risperidone. She said, No, I do not believe it has been attempted. LPN1 was asked if the resident had underlying diagnoses of mental illness such as schizophrenia or bipolar depression. He/she said, No.
During an interview on 03/14/24, at 10:44 A.M., the Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) said staff have risk meetings every Wednesday and staff review admissions, diagnosis, and behaviors. What should have happened would be to monitor the behaviors and speak to the physician. If a GDR has failed, then staff need to have documentation of whether the behaviors are getting better or worse.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure adequate steps had been put into place to prevent accidents when the staff failed to document fall investigations were complete and ...
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Based on record review and interview, the facility failed to ensure adequate steps had been put into place to prevent accidents when the staff failed to document fall investigations were complete and included a root cause analysis for three of four residents (Residents #8, #21, and #12) reviewed for falls of 18 sampled residents. This failure placed the resident at risk for unmet care needs and a diminished quality of life.
Review of the facility's policy titled, Fall Risk Assessment, dated 03/18, showed staff staff will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan.
1. Review of Resident #8's Face Sheet, showed the following:
-admission date of 12/27/23;
-Diagnoses included atrial fibrillation (irregular heart rhythm) and major depressive disorder.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 01/03/24, showed the following:
-Resident had severely impaired cognition;
-No fall history;
-Had not sustained any falls in the facility since admission.
Review of the resident's Resident Incident Report, dated 02/18/24, showed the following:
-Nurse was sitting at nurses' station talking with another resident when a loud noise was heard down the hallway. This nurse ran down the hallway and saw resident laying on stomach on the floor just out of the bedroom doorway. Resident was breathing heavy and not responding to questions with eyes open. Nurse call 911 and when the nurse returned to resident he/she was talking. The resident said I don't know when asked what happened. The resident's nose was bleeding. Due to the way the resident was laying it was unsafe to try and move resident until EMS (Emergency Medical Services) arrived. Unable to assess resident for wounds;
-Staff did not document a root cause analysis or resident-specific interventions to keep the resident safe when he/she returned from the hospital.
2. Review of Resident #21's Face Sheet, showed the following:
-admission date of 11/22/22;
-Diagnoses included dementia.
Review of the resident's Nursing Progress Note, dated 11/12/23, located in the Progress Notes tab of the EMR, showed a CNA (certified nurse aide) observed resident on floor next to bed lying on bed spread. Staff asked resident if he/she fell out of bed. Resident responded I don't know. Resident assessed and assisted to standing position with max assist times two. Resident was having difficulty following simple commands assisted to bed no apparent injury. Noted to have old bruise to left hip from a previous fall about a week ago. (Staff did not document a root-cause analysis or what interventions were put into place to prevent future falls.)
During an interview on 03/14/24, at 10:49 A.M., the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant (RNC) said staff do the post fall 24-hour report however, they did not do an investigation to determine a root cause analysis and any interventions.
3. Review of Resident #12's admission Record, under the Resident Profile tab of the EMR, showed the following:
-admission date of 03/01/22 with readmission date of 03/07/24;
-Diagnoses included anxiety, adult failure to thrive, and dementia.
Review of the resident's quarterly MDS assessment located under the MDS tab of the EMR with an ARD of 01/17/24, showed the resident had severe cognitive impairment.
Review of the resident's Progress Note, located under the Progress Notes tab in the EMR and dated 11/20/23 at 2:30 PM, showed the resident was in his/her room and resident in room next door heard yelling for help. Staff went to room and found resident on the floor resting on his/her right side with his/her right arm in front of her and head against the wall. (Staff did not document a root cause analysis or any steps taken to prevent future falls.)
Review of Resident #12's Resident Incident Report, dated 11/20/23, showed staff did not document a root cause analysis or steps taken to prevent future falls.
During an interview on 03/12/24, at 4:08 P.M., the RNC said there was no investigation and the facility had not been conducting root cause analysis 24 hour follow up.
4. During an interview on 03/14/24, at 10:44 A.M., the Administrator and RNC said the expectation was to have investigations after each fall and new interventions added to the care plan.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility failed to maintain appropriate infection control practices to prevent the risk of contamination and spread of infection while transpo...
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Based on observations, interviews, and record review, the facility failed to maintain appropriate infection control practices to prevent the risk of contamination and spread of infection while transporting clean laundry uncovered throughout the facility. This had the potential to affect 26 of 27 residents in the facility.
Review of the facility's policy titled, Policy and Procedure Regarding Laundry and Bedding Soiled, issued 09/22 and reviewed 03/14/24, showed clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.
1. During an observation and interview on 03/12/24, at 2:55 P.M., Laundry Aide (LA) 2 was observed pushing a clothes cart down the hallway. LA2 said that he/she delivered the clothes to the residents. When asked should the clothes be covered, LA2 did not respond.
During an interview on 03/14/24, at 9:12 A.M., LA1 said no one had ever told him/her that clean clothes should have been covered when transported and delivered back to residents' rooms. He/she said that the only clean items that he/she covered were linen and bath towels.
During an interview on 03/14/24, at 10:45 A.M., the Infection Preventionist (IP) confirmed that residents' clean clothes should have been covered when transported down the hallways and delivered back to the residents.
During an interview on 03/14/24, at 11:24 A.M., the Administrator said clean clothes should have been covered when transported back to the residents.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to timely report an allegation of staff to resident abuse, when one resident (Resident #1) alleged a staff member hit him/her, t...
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Based on observation, interview, and record review, the facility failed to timely report an allegation of staff to resident abuse, when one resident (Resident #1) alleged a staff member hit him/her, to the state survey agency (SSA - Department of Health and Senior Services (DHSS)) . The facility census was 31.
Review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, showed the following:
-If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual;
-All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator or his/her designee to the state licensing/certification agency responsible for surveying/licensing the facility immediately, but not later than two hours, if the alleged violation involves abuse or has resulted in serious bodily injury, or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.
1. Review of Resident #1's face sheet showed:
-admission date of 07/20/23;
-Diagnoses of acute kidney failure, history of falling, aphasia (loss of ability to understand or express speech) following cerebrovascular disease (medical condition affecting the blood vessels of the brain and cerebral circulation, most commonly presents as a stroke), dementia, and major depressive disorder.
Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/31/23, showed the resident had moderate cognitive impairment.
Review of the resident's progress note dated 10/17/23, at 4:14 A.M., showed Licensed Practical Nurse (LPN) A documented the following:
-Resident resting in bed with eyes closed until 4:00 A.M. Resident turned on the call light and a certified nurse assistant (CNA) left the nurses' station to check on the resident. The resident stated that an employee was just beating on him/her and it resulted in his/her right arm and right chest being sore. This nurse and the CNA assessed the resident's arm and chest and found no apparent marks. The resident was yelling at the nurse and CNA, claiming he/she did not know whether he/she felt safe with the nurse and the CNA. The CNA took the resident into the bathroom to change the resident and for the resident to use the bathroom. The resident refused to allow the CNA assistance with changing. This nurse and the CNA were unable to calm the resident or redirect the resident at this time.
Review of the resident's progress note dated 10/17/23, at 5:53 A.M., showed LPN A documented the following:
-This nurse checked on the resident and the resident was still adamant that an employee beat him/her in his/her sleep. This nurse asked the resident if there was a possibility that the resident had a dream about the incident and the resident said, How could I beat my own back? The resident is very upset about the situation and stated that he/she is going to get out of here and that he/she doesn't feel safe. This nurse asked the resident if he/she needed anything and the resident stated that he/she wanted ice water. The nurse brought ice water to the resident and the resident told the nurse to get out.
During an interview on 10/24/23, at 4:00 P.M., LPN A said the following:
-He/she worked from the evening of 10/16/23 to the morning of 10/17/23;
-He/she said one other staff member, CNA B worked that night;
-The resident reported the allegation of staff to resident abuse at approximately 4:00 A.M.;
-The nurse said he/she and the CNA had been charting at the nurses' desk prior to the incident and there were no other staff in the facility and no wandering residents;
-The nurse assessed the resident and the resident complained of pain to his/her right arm and chest area, but the nurse found no visible signs of injury;
-The resident said he/she did not notify DHSS of the allegations because he/she was trying to work with the resident to keep him/her from escalating in anger.
Review of the resident's progress note dated 10/17/23, at 3:18 P.M., showed the Director of Nursing (DON) documented the following:
-This nurse assessed the resident upon arrival to work and noted no visual signs of injury, redness, bruising, or scratches noted to any of the areas. The resident voiced being beaten. The resident said they pulled on him/her and beat him/her on the back when he/she was getting up to the bathroom. The resident was unable to describe who this person was and was unsure if it was a male or female. The Administrator and Regional Nurse were notified. The Regional Nurse came to the facility and assessed the resident. The resident's next of kin came to the facility and spent approximately two to three hours with the resident. Staff notified the resident's physician.
During an interview on 10/24/23, at 10:10 A.M., the DON said the following:
-On 10/17/23, he/she arrived to the facility at 6:00 A.M., and the night nurse (LPN A) reported to the DON that at 4:00 A.M. the resident told staff that an employee had just beaten him/her on the back, chest, and arm;
-LPN A said the resident indicated this abuse occurred right before the staff arrived in the room;
-LPN A said the resident was unable to describe the alleged perpetrator;
-The resident had periods of confusion;
-The DON assessed the resident's body and found no visible injuries. The resident said his/her back was sore;
-The Regional Nurse also assessed the resident for any injuries and found none;
-The DON began an investigation, interviewing other residents and staff;
-The facility staff notified the resident's physician and the resident's next of kin of the alleged incident;
-The DON said he/she submitted an online report to the Missouri Department of Health and Senior Services (DHSS), the state survey agency (SSA), at approximately 8:15 A.M. (over four hours after the allegation was made);
-The DON said the facility policy was to notify DHSS within two hours of any allegations of abuse and this was an allegation of abuse;
-The DON said he/she thought the two hour reporting timeframe started when the DON was notified of the allegation.
Review of DHSS Records showed DHSS staff received the allegation of possible abuse on 10/17/23 at 9:36 A.M.
During an interview on 10/24/23, at 11:35 A.M., LPN C said the following:
-If he/she were informed of an allegation of resident abuse or observed resident abuse, he/she would ensure the resident's immediate safety, and then notify the DON and Adminstrator immediately;
-The facility has two hours to notify DHSS of all allegations of abuse.
During an interview on 10/24/23, at 1:20 P.M., the Administrator said the following:
-He/she was out of the facility on 10/17/23, the morning of the alleged incident;
-He/she advised the facility nurse by phone to contact the corporate nurse for instructions on reporting the allegation of resident abuse;
-The nurse should notify the Administrator and DON immediately of any allegation of abuse;
-Staff are trained on reporting of abuse;
-The facility should notify DHSS of all allegations of abuse within two hours;
-He/she would consider the resident's statement to be an allegation of abuse.
Complaint # MO00225994
Sept 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed monitor all resident wounds per standards of practice when facility st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed monitor all resident wounds per standards of practice when facility staff failed to document weekly comprehensive wound assessments for wounds of two residents (Resident #1 and Resident #2) potentially causing a delay in identification of a decline in a wound. The facility census was 25.
Record review of the facility's policy titled, Wound and Skin Care Protocols and Procedures, dated June 2021, showed the following:
-The purpose is to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown;
-The wound care protocols are written to treat stages of wounds. Not all wounds are from pressure and not all wounds can be staged. The protocols will serve as a reference for selecting appropriate dressings based on the wound assessment;
-The Director of Nursing (DON) will be responsible for reviewing the weekly wound report and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice;
-Always assess, wound etiology (cause), resident's overall condition, nutritional needs, pain control/pain, need for pressure reducing devices, management of infection/bacterial burden and knowledge level of resident, family and staff managing the resident with wound;
-A complete wound assessment and documentation will be done weekly on all pressure injuries until healed. The criteria including, site/location, stage, size, appearance of the wound bed, surrounding skin, drainage (exudate), and odor.
1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information:
-admission date of 09/19/23;
-Diagnosis included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (plaque buildup causes the inside of the arteries to narrow over time), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and Type II diabetes mellitus.
Review of the resident's Treatment Administration Record (TAR), dated September 2023, showed an order, dated 09/19/23, for skin audit to be done weekly, record zero for no new skin problems or one new skin problems. Follow up in the form under skin and wounds.
Review of the resident's Initial Care Plan, dated 09/19/23, showed skin care of dressing, change to left foot daily.
Review of the resident's Medicare Skilled Daily Note dated 09/19/23, at 4:43 P.M., showed the following:
-The resident has an existing wound/skin condition;
-Skin/wound issue type of surgical incision and amputation;
-Amputation of left great toe.
Review of the resident's medical record showed there was no initial comprehensive assessment (including site/location, stage, size, appearance of the wound bed, surrounding skin, drainage, and odor) documented for the left incisional wound great toe amputation.
Review of the resident's nurse's note dated 09/22/23, at 11:47 A.M., showed the following:
-Resident admitted to the facility on [DATE] from the hospital;
-The nurse assessed skin and completed a head-to-toe assessment;
-One surgical site at left groin approximately 4.6 millimeter (mm) by 0.2 mm;
-One surgical site al left knee approximately 12.4 mm x 0.2 mm;
-An amputation of the greater toe on the left foot;
-Resident also has bruising from previous IV site on left wrist.
(Staff did not document complete assessments (including site/location, stage, size, appearance of the wound bed, surrounding skin, drainage/exudate, and odor) of each wound.)
Review of the resident's Medicare Skilled Daily Note dated 09/24/23, at 1:37 P.M., showed the following:
-The resident has an existing wound/skin condition;
-Surgical incision and amputation;
-Amputation of left great toe;
-Type of dressing: stump wrap removed and reapplied.
(Staff did not document complete assessments (including site/location, stage, size, appearance of the wound bed, surrounding skin, drainage/exudate, and odor) of each wound.)
Review of the resident's September 2023 TAR showed staff documented the ordered skin audit was completed on 09/25/23.
Review of the resident's Skilled Daily Note dated 09/25/23, at 2:32 P.M., showed the following:
-The resident has an existing wound;
-Surgical incision;
-Surgical incision on left foot
(Staff did not document complete assessments (including site/location, stage, size, appearance of the wound bed, surrounding skin, drainage/exudate, and odor) of each wound.)
Review of the resident's Medicare Skilled Daily Note dated 09/26/23, at 2:44 P.M., showed the following:
-The resident has an existing wound/skin condition;
-Surgical incision, left.
(Staff did not document complete assessments (including site/location, stage, size, appearance of the wound bed, surrounding skin, drainage/exudate, and odor) of each wound.)
2. Review of Resident #2's face sheet showed the following:
-admission date of 09/12/23;
-Diagnoses included cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of the right and left lower limb, altered mental status, and hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time);
Review of the resident's initial care plan, dated 09/12/23, showed the following:
-Skin care to bilateral lower extremities (legs), kerlix (bandage rolls provide wicking action, aeration and absorbency) xerofoam ( made for use on low draining wounds) non-adherent foam and tubigrip (Tubular Bandages are used to provide tissue support during treatment of strains and sprains, soft tissue injury and swelling);
-Able to communicate;
-Poor short term memory.
Record review of the residents wound/skin assessment, dated 09/12/2023, showed the following:
-Wound type: Lesion;
-Location: Right lateral shin;
-Date wound identified: 09/12/2023;
-Present upon admission with cause unknown;
-Measurements: Length 1 cm and width .5 cm;
-Symptoms of infection: Erythema;
- Drainage: Serosanguineous, small;
-Infection treated: yes;
-Surrounding skin: red, indurated
- Wound bed: Granulation (granulation tissue is pink in color and is an indicator of healing) tissue: 50%, Eschar (a dry, dark scab or falling away of dead skin)
50.00% ;
-Wound edges: Border definition- distinct, outline clearly visible. Normal healthy skin;
-Physician notified, pending treatment orders.
Review showed staff did not document a comprehensive wound assessment to include site/location, stage, size, appearance of the wound bed, surrounding skin, drainage/exudate, and odor, was not completed weekly on 09/19/23 or 09/26/23.
3. During an interview on 09/28/23, at 11:33 A.M., Licensed Practical Nurse (LPN) B said the following:
-He/she completes wound care to residents as ordered by the physician. He/she then marks on the TAR that it was completed. He/she has completed wound care on Resident #1 and Resident #2 and as far as she knows they were being assessed.
-Any changes in a wound should be assessed and documented;
-Wound assessments should be completed at lease weekly to include what the wound looks like, measurements and signs of infection. He/she thinks the DON does weekly assessments on the residents;
-The assessment is usually documented in the nurse's notes or skilled charting notes.
4. During an interview on 09/28/23, at 3:14 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said the following:
-Resident wounds should be assessed weekly. This should be a comprehensive assessment that includes, measurements, a detailed description, odor, color, drainage, if it is blanchable, if there is any changes there should be a note. Wound care assessments should be completed according to the facility policy.
5. During interviews on 09/28/23, at 1:26 P.M. and 2:30 P.M., the DON said the following:
-Wound assessments should be done when the nursing staff does wound care on the residents;
-There is no specific person designated to do the wound care assessments, however, he/she is in charge of doing wound measurements;
-All resident wounds should have an assessment that includes the description of the wound, drainage, measurements, and any signs/ symptoms of infection.
6. During an interview on 09/28/23, at 2:56 P.M., the Administrator said the following:
-Nursing staff should document the assessment of wounds per the facility policy. All resident wounds should receive an assessment. He/she was not aware that a comprehensive assessment was not documented for Resident #1 or Resident #2.
MO00225064
Apr 2022
5 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to complete criminal background checks (CBC), employee disqualification list (EDL) checks, and/or Nurse Aide (NA) registry (a registry that in...
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Based on record review and interview, the facility failed to complete criminal background checks (CBC), employee disqualification list (EDL) checks, and/or Nurse Aide (NA) registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) for a federal indicator prior to starting employment and continued resident contact for four staff (Business Office Manager (BOM) A, Certified Nursing Assistant (CNA) B, Housekeeping (HK) C, and HK D). The facility census was 17.
Record review of the facility's policy titled Abuse Prevention Program, revised September 2021, showed the following information:
-The facility will not hire or maintain in employment a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities;
-Background checks will be done at the time of hire in accordance with the facility background check policy. Staff will not be hired who have been found guilty, or plead nolo contendere (no contest), of abuse, neglect, mistreatment of residents, or misappropriation of resident property by a court of law. Such a determination will not be limited to residents, but shall include any known abusive acts against others;
-The nurse aide registry will be checked prior to employment for each state where a nurse aide has shown to have worked, or has listed certification. Nurse aides will not be hired whose name is on any state abuse registry. Verification of background checks, nurse aide registry checks and reference checks will be maintained in the personnel file of each employee.
Record review of a facility policy entitled Compliance and Ethics - Screening Employees, Contractors and Volunteers, revised December 2020, showed background screening and investigations are conducted prior to employment to ensure that employees meet at least the following criteria:
-Current licensure is in good standing in the state of practice;
-The individual has not been found guilty of abusing, mistreating or neglecting residents;
-He or she has not been excluded from participating in Medicare or Medicaid programs; and
-The individual has not been found to have a criminal record.
Record review of the facility's New Hire Checklist, dated 6/1/2015, showed the following information:
-References checked;
-Criminal Background Check;
-Employee Disqualification List checked;
-Family Care Safety Registry checked;
-Professional License or Certification;
-Check CNA Registry for all new hires.
1. Record review of CNA A's personnel record showed the following information:
-Hire/start date of 9/16/2020;
-The facility did not complete a CBC for CNA A.
2. Record review of HK B's personnel record showed the following information:
-Hire/start date of 10/1/2020;
-The facility did not complete a CBC for HK B.
3. Record review of BOM C's personnel record showed the following information:
-Hire/start date of 1/3/2022;
-The facility did not complete a CBC, EDL or NA registry check for BOM C.
4. Record review of HK D's personnel record showed the following information:
-Hire/start date of 1/4/2022;
-The facility did not complete a CBC or NA registry check for HK D.
5. During an interview on 4/7/2022, at 6:20 P.M., the Director of Nursing (DON) said the facility should complete a CBC, EDL, and NA registry check for all new employees prior to them starting work.
6. During an interview on 4/7/2022, at 6:45 P.M., the Administrator said the facility should complete a CBC, EDL and NA registry check for all new employees prior to them starting work. The BOM was responsible for completing background checks; the corporate office completes the exclusionary list checks. The current BOM is still in training to take over those duties , but was not in that role at the time the background checks were required to be completed for CNA A, HK B, BOM C, and HK D.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a procedure in place to ensure staff changed oxy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a procedure in place to ensure staff changed oxygen equipment per professional standards and failed to care plan the need to change oxygen equipment for three residents (Resident #6, #10, and #11) and failed to obtained a physician's order to change oxygen equipment for one resident (Resident #10). The facility census was 17.
Record review of the facility's (undated) policy, titled Protocol for Care and Cleaning of Oxygen Concentrator, showed the following information:
-Oxygen concentrators require regular cleaning and proper maintenance to be able to work efficiently and to maximize the expected service life;
-Educate the staff on proper cleaning and care of the oxygen concentrator;
-Do not clean oxygen tubing, tubing connectors, nasal cannula/mask, humidifier bottle, replace every seven days and between residents.
1. Record review of Resident #6's face sheet (a document that gives information about the
resident at a quick glance) showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included shortness of breath, acute respiratory disease related to COVID-19 (condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen), and chronic atrial fibrillation (irregular and often very rapid heart rhythm, which can lead to blood clots in the heart).
Record review of the resident's care plan, last reviewed/revised on 2/10/2022, showed the following information:
-Resident had COVID-19;
-Staff to assess lung sounds, noting areas of decreased or absent ventilation, and presence of adventitious (sounds heard in addition to expected breath sounds) sounds;
-Have oxygen available as ordered and whenever needed for shortness of breath;
-Monitor vital signs, oxygen saturations and lab or x-rays when ordered and notify the physician of abnormalities.
(Staff did not care plan the frequency of when staff should change the resident's oxygen equipment and tubing.)
Record review of the resident's current physician order sheet (POS) showed the following information:
-An order, dated 3/3/2022, for oxygen 1 to 6 liters per nasal cannula to keep oxygen saturations above 90%;
-An order, dated 3/6/2022, directed staff to change oxygen tubing weekly on Sunday night.
Record review of the resident's treatment administration record (TAR), dated March 2022 and April 2022, showed staff did not document changing the resident's oxygen tubing or humidifier bottle.
Observation on 4/5/2022, at 1:28 P.M., showed the resident's oxygen unit in his/her room, dated 3/6/2022, on the tubing.
Observation on 4/6/2022, at 1:58 P.M., showed the resident's oxygen unit in his/her room, dated 3/6/2022, on the tubing.
Observation on 4/7/2022, at 8:06 A.M., showed the resident's oxygen unit in his/her room, dated 3/6/2022, on the tubing.
2. Record review of Resident #10's face sheet showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included acute respiratory disease and heart failure.
Record review of the resident's care plan, last reviewed/revised on 1/28/2022, showed the following information:
-The resident had impaired cardiovascular and respiratory status related to diagnoses of congestive heart failure (CHF-heart muscle does not pump blood as well as it should), coronary artery disease (CAD-damage or disease in the heart's major blood vessels) and hypertension (high blood pressure);
-Staff should assess breath sounds, monitor 02 saturations, observe shortness of breath with exertion, and administer oxygen as ordered.
(Staff did not care plan the frequency staff should change out the resident's oxygen equipment and tubing.)
Record review of the resident's current POS showed the following information:
-An order, dated 3/7/2021, to apply oxygen at 1 to 6 liters per minute per nasal cannula as needed for oxygen (02) below 90%.
(The POS did not include an order for frequency of changing the resident's oxygen or nebulizer equipment and tubing.)
Record review of the resident's TAR, dated March 2022 and April 2022, showed staff did not document changing the resident's oxygen tubing, humidifier bottle.
Observation on 4/5/2022, at 11:44 A.M., showed the resident in bed with his/her eyes closed with oxygen per nasal cannula. The resident's oxygen tubing did not have a date documented on it.
Observation on 4/6/2022, at 9:25 A.M., showed the resident in bed with oxygen on per nasal cannula. The resident's oxygen tubing did not have a date documented on it.
Observation on 4/7/2022, at 8:06 A.M., showed the resident's oxygen tubing did not have a date documented for when staff changed out the tubing.
Observation on 4/7/2022, at 2:45 P.M., showed the resident in bed watching television with oxygen on per nasal cannula. The tubing did not have a date documented to show when staff last changed out the oxygen tubing.
3. Record review of Resident #11's face sheet showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe, encephalopathy (a broad term for any brain disease that alters brain function or structure), diabetes mellitus (a group of diseases that result in too much sugar in the blood), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 1/20/2022, showed the resident received oxygen therapy while a resident in the facility.
Record review of the resident's care plan, last reviewed/revised on 1/21/2022, showed the following information:
-Resident at risk for complications related to COPD;
-Staff to monitor oxygen saturation as needed, oxygen as ordered.
(Staff did not care plan the frequency of when staff should change the resident's oxygen equipment and tubing.)
Record review of the resident's current POS showed the following information:
-An order, dated 3/7/2022, directed staff to check oxygen saturations as needed and notify the physician if less than 90%;
-An order, dated 3/7/2022, directed staff to change oxygen tubing weekly on Sunday night shift.
Record review of the resident's TAR, dated March 2022, showed staff did not document changing the resident's oxygen tubing or humidifier bottle on 3/6/2022, 3/13/2022, or 3/27/2022 per the weekly schedule.
Observation on 4/5/2022, at 1:07 P.M., showed the resident in bed with his/her eyes closed with oxygen on per nasal cannula and no date on the tubing to reflect when staff last changed out the tubing.
Observation on 4/6/2022, at 10:46 A.M., showed the resident in bed with eyes closed with oxygen on per nasal cannula and no date on the tubing to reflect when staff last changed out the tubing.
Observation on 4/6/2022, at 10:46 A.M., showed the resident in bed with eyes closed with oxygen on per nasal cannula and and no date on the tubing to reflect when staff last changed out the tubing.
Observation on 4/07/2022, at 8:06 A.M., showed the resident in bed with oxygen on per nasal cannula and no date on the tubing to reflect when staff last changed out the tubing.
4. During an interview on 4/7/2022, at 3:42 P.M., Certified Nursing Assistant (CNA) E said he/she has seen nurses change oxygen tubing on Sunday nights. He/she knows the tubing is supposed to be changed weekly, but does not know where this is documented. He/she is not responsible for changing oxygen tubing.
5. During an interview on 4/7/2022, at 3:50 P.M., Licensed Practical Nurse (LPN) F said night shift nursing is responsible for changing oxygen tubing every Sunday night. A piece of tape with the date changed should be placed on the tubing and the bubbler and then documented in the TAR.
6. During an interview on 4/7/2022, at 4:00 P.M., the Director of Nursing (DON) said night shift nursing is responsible for changing tubing and filters for oxygen every Sunday night, which is documented on the TAR and also with a dated sticker to be placed on the tubing. She said the stickers were lost, but she has ordered more of them.
7. During an interview on 4/7/2022, at 6:35 P.M., the administrator said the night shift nurse is responsible for changing oxygen tubing weekly on Sunday. The tubing should be labeled with a date and initials. Staff document the changing of the oxygen tubing in the TAR.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #11's face sheet showed the following information:
-admitted to the facility on [DATE];
-Diagnoses ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #11's face sheet showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe, encephalopathy (a broad term for any brain disease that alters brain function or structure), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
Record review of the resident's side rail and assessment and consent, dated 7/11/18, showed the following information:
-History of falls;
-Poor bed mobility;
-Medications requiring safety precautions;
-Resident requested the side rails not be released while sleeping;
-Bilateral assessment of potential entrapment zones;
-Signed consent by the resident.
Record review of the resident's Restraints: Bed Rail Safety Check, dated 7/12/18, showed bilateral measurements of fully raised side rails passed safety measurements.
Record review of the resident's quarterly Minimum Data Set (MDS -a federally mandated assessment instrument completed by facility staff), dated 1/25/2022, showed the following information:
-Set up only with bed mobility;
-Supervision with set up for transfer, locomotion on unit, and toilet use.
Record review of the resident's care plan, dated 1/28/2022, showed the following information:
-At risk for falls;
-Bed in low position when not providing cares;
-Remind resident to ask for assistance with all transfers;
-Required staff assist with ADLs;
-Call for assistance prior to transfers;
-Therapy as ordered.
(Staff did not care plan the use of the resident's grab bar.)
Record review of the current POS did not show an order for grab bars.
Observation on 4/5/2022, at 2:43 P.M., showed the resident had a single raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed.
Record review of the resident's medical record showed facility staff did not perform quarterly reviews for the use of the current grab bar since the previous assessment in July 2018 for bilateral side rails no longer in use.
During an interview on 4/7/2022, at 3:29 P.M., the resident said the grab bar was installed on the bed when he/she admitted to the facility to assist with bed mobility and transferring due to hip issues. The grab bar makes it safer because there is nothing to hang onto while getting out of bed.
4. Record review of Resident #12's face sheet showed the resident admitted to the facility on [DATE].
Record review of the resident's side rail and assessment and consent, dated 8/27/18, showed the following information:
-Alteration in safety awareness due to cognitive decline;
-History of falls;
-Poor bed mobility;
-Difficulty with balance or poor trunk control;
-Medications requiring safety precautions;
-Resident visually challenged;
-Signed consent by the Durable Power of Attorney (DPOA).
-The resident had a grab bar in place at the time of the assessment.
Record review of the resident's medical record showed the facility staff did not document completion of gap measurements.
Record review of the resident's quarterly MDS, dated [DATE], showed the following information:
-Required set up only with bed mobility;
-Required supervision with set up for transfer, locomotion on unit, and toilet use;
-Diagnoses included cerebrovascular accident (stroke), hemiparesis (mild or partial weakness or loss of strength on one side of the body), hypertension (high blood pressure), and dementia.
Record review of the resident's care plan, revised on 1/28/2022, showed the following information:
-At risk for falls related to impaired mobility and history of falls;
-Bed in low position when not providing cares;
-Remind resident to ask for assistance with all transfers;
-Keep call light within reach and answer promptly;
-Remind resident to wear non-skid footwear while transferring.
(Staff did not address the use of the resident's grab bar on his/her bed.)
Record review of the resident's current POS did not show an order for grab bars.
Record review of the resident's medical record showed facility staff did not perform quarterly reviews for the use of the current grab bar since the previous assessment on 8/27/18.
Observation on 4/6/2022, at 8:35 A.M., showed the resident had one raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed.
During an interview on 4/6/2022, at 3:24 P.M., the resident said facility staff placed the grab bar on the bed to assist him/her with transferring from the bed to the wheelchair and from the wheelchair to the bed. He/she previously hit the floor when the wheelchair rolled out from him/her while transferring to the bed. The grab bar helps him/her and is safer.
5. Record review of Resident #16's face sheet showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included cerebral infarction, hemiplegia (paralysis of one side of the body) and hemiparesis, diabetes mellitus.
Record review of the resident's annual MDS, dated [DATE], showed the following information:
-Required supervision only with one person assist for bed mobility, transfers, walk in room, and personal hygiene.
Record review of the resident's care plan, revised on 2/16/2022, showed the following information:
-At risk for falls related to history of falls, weakness, and unsteady on feet;
-Assist resident with proper wheelchair positioning;
-Encourage resident to assume standing position slowly;
-Give verbal reminders not to ambulate/transfer without assistance;
-Keep bed in lowest position with brakes locked;
-Keep call light in reach at all times.
(Staff did not care plan the use of the resident's grab bar on his/her bed.)
Record review of the resident's current POS did not show an order for grab bars.
Record review of the resident's medical record showed facility staff did not document completion of a side rail assessment or consent for the grab bar.
Record review of the resident's medical record showed facility staff did not document completion of gap measurements.
Observation on 4/5/2022, at 1:38 P.M., showed the resident had a raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed.
During an interview on 4/7/2022, at 3:27 P.M., the resident said the grab bar was already on the bed when he/she first admitted to the facility. He/she uses the grab bar for transferring back and forth from the wheelchair to the bed and the bed to the wheelchair. He/she has had no problems with the grab bar and feels it is safer to have it.
6. During an interview on 4/6/2022, at 4:00 P.M., the Maintenance Director said the facility didn't have any side rails, as they were asked to take them all off by the previous owners. The facility does, however, have assist bars. He installs them using the pre-drilled holes on the beds; therefore, no measurements are ever taken by anyone. He does not make scheduled checks of the assist bars, but does periodic checks of the bars; sometimes on his monthly walk-arounds.
7. During an interview on 4/7/2022, at 3:50 P.M., Licensed Practical Nurse (LPN) F said nursing staff is responsible for determining who needs side rails and maintenance installs them. An assessment should be completed and a consent form signed by the resident or responsible party. He/she did not know who measures them or if ongoing assessment or safety checks need to be completed.
8. During an interview on 4/7/2022, at 4:00 P.M., the Director of Nursing (DON) said the resident or the resident's family requests side rails or therapy recommends them. Maintenance is responsible for installation and measurements.
9. During an interview on 4/7/2022, at 6:35 P.M., the Administrator said nursing completes an assessment for side rails and coordinates with therapy. The resident or DPOA signs a consent form. Maintenance measures and installs side rails. The facility requires annual safety checks or if a resident has a related significant change.
Based on observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to current bed rail use and/or periodic assessments for the use of current side rails (grab bars) for five residents (Resident #7, #67, #11, #12, #16); failed to obtain informed consent for the use of bed rails for two residents (Resident #7 and Resident #16); and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Residents #7, #11, #12, and #16) ), and failed to address the use bed rails in the residents' care plans for five residents (Resident #7, #67, #11, #12, #16). The facility census was 17.
Record review of the facility's policy, titled, Assistive Devices and Equipment, dated January 2020, showed the following information:
-Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents;
-Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan;
-The resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment;
-Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reductions, less restrictive methods of restraints, or total elimination.
Record review of the guidance for industry and Food and Drug Administration (FDA) staff, Hospital Bed System Dimensional And Assessment Guidance To Reduce Entrapment, issued on 3/10/2006, from the FDA, Center for Devices and Radiological Health, showed the following information:
-The term medical bed and hospital bed are used interchangeably and include adult medical beds with side rails;
-Evaluating the dimensional limits of the gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment;
-Bed safety programs may also include plans for reassessment of hospital bed systems;
-Reassessment may be appropriate when there is reason to believe that some components are worn, such as rails wobble, rails have been damaged, mattresses are softer and could cause increased spaces within the bed system; when accessories such as mattress overlays or positioning poles are added or removed; when components in the bed system are changed or replaced, such as new bed rails or mattresses;
-Bed rails are rigid bars that are attached to the bed and are available in a variety of sizes and configurations from full length to half, one-quarter, and one-eighth length and are used as restraints, reminders, or as assistive devices;
-General testing considerations include for ease of mattress movement and measurement, and general safety, the patient should not be in the bed during the measurement procedures.
1. Record review of Resident #7's face sheet (gives basic profile information about the resident) showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included myocardial infarction (heart attack), osteoarthritis (worn down cartilage in joints), joint pain, generalized muscle weakness, Alzheimer's disease, and unsteadiness on feet.
Record review of the resident's electronic and paper medical records showed the following information:
-No documentation found related to an evaluation and risk assessment prior to the use of bed side rails;
-No documentation found related to an informed consent for the use of bed side rails;
-No documentation found reflecting safety gap measurements for bed side rails.
Record review of the resident's care plan, last updated 1/25/2022, showed staff did not document the use of bed side rails.
Record review of the physician order sheet (POS), current as of 4/7/2022, showed no order for the use of bed side rails.
Observation on 4/5/2022, at 1:51 P.M., showed the resident rested in bed. U-shaped grab/positioning bars were attached to each side of the bed in a vertical position.
During an interview on 4/7/2022, at 3:42 P.M., Certified Nursing Assistant (CNA) X said the resident used his/her grab bar when staff turned him/her in bed during personal care.
2. Record review of Resident #67's face sheet showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included cognitive, attention and concentration deficits following stroke, altered mental status, contractures of bilateral knees, generalized muscle weakness, unsteadiness on feet, major depressive disorder, insomnia, and chronic pain.
Record review of the resident's electronic and paper medical records showed the following:
-On 7/11/2018, staff completed a pre-use Assessment and Signed Consent for the use of half side rails;
-Documentation showed safety gap measurements for the then existing half rails;
-Staff did not document subsequent safety checks or safety gap measurements for u-bars.
Record review of the resident's care plan, last updated 1/21/2022, showed staff did not document the use of bed side rails.
Record review of the POS, current as of 4/7/2022, showed no order for the use of bed side rails.
Observation on 4/5/2022, at 2:00 P.M., showed the resident rested in bed. U-shaped grab/positioning bars were attached to each side of the bed in a vertical position.
Observation on 4/6/2022, at 1:50 P.M., showed the resident rested in bed. U-shaped grab/positioning bars were attached to each side of the bed in a vertical position.
During an interview on 4/6/2022, at 2:00 P.M., the Director of Nursing (DON) said the resident no longer uses the rails to help turn him/herself.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to keep food safe from potential contamination when food...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to keep food safe from potential contamination when food contact surfaces had a buildup of grease, lint, and hair and staff did not date or label stored food after opening. The facility census was 17.
Record review of the 2013 Missouri Food Code showed the following information:
-Physical facilities shall be cleaned as often as necessary to keep them in sanitary condition;
-Clean and sanitize work surfaces, including cutting boards and food-contact equipment, between uses and consistent with applicable code.
Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information:
-Food contact surfaces and utensils shall be clean to the sight and touch.
Record review of the facility policy titled Sanitization, revised 2008, showed the following information:
-All kitchen areas shall be kept clean;
-All equipment, food contact surfaces shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions;
-For fixed equipment not fitting in the dishwashing machine, will have any removable components scraped and cleaned to remove particle accumulation and washed according to manual or dishwashing procedures;
-Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy;
-The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas;
-Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks; and,
-To clean after each task before proceeding to the next assignment.
Record review of the facility policy titled Cleaning Rotation, dated 2011, showed the following information:
-Items cleaned monthly: Refrigerators/freezers;
-Items cleaned annually: ceilings/windows.
1. Record review of the facility daily cleaning schedule for April 2022 (through 4/8/2022) showed the following information:
-The walk-in refrigerator listed as an area to be cleaned daily;
-Staff initialed each day in April, from 4/5/22 to 4/8/22, indicating it had been cleaned;
-The front of the stove was listed to be cleaned, but the schedule did not address the back of the stove or the stove knobs.
Observation on 4/05/2022, at 10:10 A.M., showed the stove, including the back, front and around the knob areas were covered in a substance of a lint/grease/grime mixture.
Observation on 4/05/2022, at 10:10 A.M., showed the ice machine's ice scoop container dirty and slimy in the bottom.
Observation on 4/05/2022, at 10:27 A.M., showed the following areas with bags of food opened and not labeled or dated:
-In the walk-in freezer: nine beef patties; two bags of hash browns; two packages of tortillas in zip lock bags; two bags of sausage; one bag of pepperoni; three bags of ham chunks; an open package of two remaining pie shells; two packages of unidentified meat; mozzarella and parmesan cheese; two bags of lettuce (one with slimy appearance); two bags of [NAME] slaw mix which had spoiled, indicated by the slimy appearance.
-The outside of the freezer had a sign asking if everything was labeled and dated.
Observation on 4/05/2022, at 10:27 A.M., showed the following in the walk-in cooler:
-The ceiling covered with dust/fuzz particles hanging loosely and a black, fuzzy substance like mold, dotting the ceiling, shelving, walls, and the refrigerating units fan;
-There were two heads of cabbage left unwrapped and in an open box, directly under the unit's fan.
During an observation and interview on 4/07/2022, at 11:41 A.M., Head [NAME] G said the following:
-Everyone pitches in to clean when they are able;
-The kitchen staff does not actually follow a cleaning schedule;
-While pointing out some of the cobwebs and grime buildup, one fell onto the face mask of the head cook;
-He/she agreed the walk-in refrigerator had black, mold-like substance, growing on the inside;
-The head cook said he/she could also smell the mold-like substance and agreed the walk-in needed an cleaning overhaul.
During an interview on 4/07/2022, at 11:48 A.M., Dietary Aide H said the following:
-There is a list for days and nights of cleaning to be done and initialed;
-It was observed that the day list was not initialed;
-Dusting (for higher areas) used to be on the list, but not any longer;
-He/she tries to cover any food in the coolers;
-He/she puts a label with the type and the date it was placed in container and the date of expiration after food is opened;
-He/she does not know who is responsible for cleaning the container for the ice scoop;
-The ice scoop is not on the list for cleaning;
-Night shift is supposed to sweep and mop the floors;
-There is no designated person to clean the stove or knobs.
During an interview on 4/07/2022, at 12:05 P.M., the Dietary Manager said the following:
-There is a cleaning list for both the aides and cooks;
-Cleaning the dust and cobwebs off surfaces above eye level should be cleaned by the aides (also not on the cleaning lists);
-He/she said they know they are supposed to do it because they have supplies to clean them;
-He/she said staff has also been told cleaning these areas needs to be done;
-No one is assigned to clean the ceiling or walls in the walk in cooler, ceiling vents or the walk in cooler;
-Cooks are responsible for cleaning the stove and knobs;
-Night staff are responsible for cleaning the floors;
-The aides are responsible for cleaning the ice machine and container for the scoop.
During an interview on 04/07/2022, at 2:58 P.M., the administrator said the following:
-He/she knew the food was not being labeled because the kitchen manager informed him/her of the issues;
-He/she expects this to be completed every time something goes back on a shelf, after it's been opened.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on interview, observation, and record review, the facility failed to maintain a sanitary environment when staff failed to keep non-contact food surfaces the kitchen area clean and free of debris...
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Based on interview, observation, and record review, the facility failed to maintain a sanitary environment when staff failed to keep non-contact food surfaces the kitchen area clean and free of debris. The facility census was 17.
Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information:
-Non food-contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris.
Record review of the facility policy titled Sanitization, revised 2008, showed the following information:
-All kitchen areas shall be kept clean;
-All equipment, food contact surfaces shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions;
-For fixed equipment not fitting in the dishwashing machine, will have any removable components scraped and cleaned to remove particle accumulation and washed according to manual or dishwashing procedures;
-Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy;
-The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas;
-Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks; and,
-To clean after each task before proceeding to the next assignment.
Record review of the facility policy titled Cleaning Rotation, dated 2011, showed the following information:
-Items cleaned monthly: Refrigerators/freezers;
-Items cleaned annually: ceilings/windows.
1. Observation on 4/05/2022, at 10:00 A.M., showed the following areas covered in a substance of a lint/grease/grime mixture:
-Baseboards throughout the kitchen;
-Wheels on the bottom of the refrigerator units and rolling carts;
-Overhead sprinklers and ceiling vents.
Observation on 4/05/2022, at 10:10 A.M., showed the following:
-The ice machine had a dusty film with cobwebs on the outside, including the top and the filter;
-The shelving under the coffee maker was dirty with a grimy film;
-The floor throughout the kitchen was dirty;
-The heating and cooling unit (HVAC) had some dust and cobwebs on the large screws that were used to brace the unit;
-The conductor or power box in the ceiling next to the HVAC system had a grimy mixture of hair and grease, loosely hanging;
-There was a shut off valve that also had this same grimy substance on it.
During an interview on 4/07/2022, at 11:41 A.M., Head [NAME] G, said the following:
-Everyone pitches in to clean when they are able;
-The kitchen staff does not actually follow a cleaning schedule.
During an interview on 4/07/2022, at 11:48 A.M., Dietary Aide H said the following:
-There is a list for days and nights of cleaning to be done and initialed;
-It was observed that the day list was not initialed;
-Dusting (for higher areas) used to be on the list, but is not any longer.
During an interview on 4/07/2022, at 12:05 P.M., the Dietary Manager said the following:
-There is a cleaning list for both the aides and the cooks;
-Cleaning the dust and cob webs off surfaces above eye level should be cleaned by the aides;
-Staff know they are supposed to do it because they have supplies to clean them;
-Staff has also been told cleaning these areas needs to be done;
-No one is assigned to clean the ceiling or walls in the walk in cooler, ceiling vents or the walk in cooler;
-Night staff are responsible for cleaning the floors.
Aug 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made three errors out of 25 oppo...
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Based on observation, interview, and record review the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made three errors out of 25 opportunities, resulting in an error rate of twelve percent. This affected three residents (Resident #1, #12, and #42). The facility census was 49.
According to Medscape website (medical reference website for healthcare professionals) showed the following:
-Rapid acting insulin can cause hypoglycemia (low blood glucose). This may occur when enough calories are not consumed after taking the insulin within the time frame;
-Older adults may be more sensitive to the side effects of low blood glucose from rapid acting insulin's.
Record review of the Novolog (rapid-acting insulin) undated manufacturer's insert showed the following:
-Novolog starts acting fast;
-A meal should be eaten within five to ten minutes of taking a dose of Novolog;
-Dosage adjustments may be needed in regards to timing of food intake.
Record review of the Humalog (rapid-acting insulin) undated manufacturer's insert showed the following:
-Humalog starts acting fast;
-A meal should be eaten within 15 minutes of taking a dose of Humalog;
-Dosage adjustments may be needed in regards to timing of food intake.
Record review of the Symbicort (a medication inhaled to relax the muscles in the airway and improve breathing) aerosol inhaler manufacturer's recommendations showed the following:
-Localized infections of the mouth and pharynx has occurred in patients treated with Symbicort.
-Patient should rinse their mouth after inhalation of Symbicort.
1. Record review of #42's face sheet (a document that gives a resident's basic information at a glance) showed the following:
-admit date d 12/15/16;
-Diagnosis of insulin-dependent diabetes mellitus (IDDM-a form of diabetes in which there is little or no ability to produce insulin and are dependent on insulin injections).
Record review of the resident's physician order dated 7/5/19, showed directed for staff to administer five units (U) of Novolog insulin before meals.
During an interview on 7/30/19 at 9:50 A.M., Licensed Practical Nurse (LPN) A said he/she starts administering resident's insulin injections at 11:00 A.M. Staff start serving lunch at 11:45 A.M.
Observations on 7/30/19 showed the following:
-At 11:15 A.M., LPN A administered five units of the resident's Novolog insulin;
-At 11:42 A.M., staff served the resident lunch in the dining room. The resident began eating 27 minutes after staff administered the Novolog insulin.
2. Record review of Resident #1's face sheet showed the following:
-admit date d 4/4/19;
-Diagnosis of IDDM.
Record review of the resident's POS showed the following:
-A physician order, dated 7/12/19, showed directed for staff to administer Humalog insulin according to a sliding scale (progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges).
-If blood glucose level is less than 40 milligrams/deciliter (mg/dL), notify the physician;
-If blood glucose level is 71-100 mg/dL, administer no insulin;
-If blood glucose level is 101-150 mg/dL, administer one unit of insulin;
-If blood glucose level is 151-200 mg/dL, administer two units of insulin;
-If blood glucose level is 201-250 mg/dL, administer three units of insulin;
-If blood glucose level is 251-300 mg/dL, administer four units of insulin;
-If blood glucose level is 301-350 mg/dL, administer five units of insulin;
-If blood glucose level is 351-400 mg/dL, administer six units of insulin;
-If blood glucose level is greater than 400 mg/dL, administer seven units of insulin and notify the physician.
Observations on 7/30/19 showed the following:
-At 11:22 A.M., LPN A administered six units of Humalog insulin according to the sliding scale (based on a blood glucose level of 360 mg/dL);
-At 11:49 A.M., staff served the resident lunch in the dining room. The resident began eating at 11:52 A.M., 30 minutes after staff administered the Humalog insulin.
3. Record review of Resident #12's face sheet showed the following:
-admit date d 1/21/19;
-Diagnosis of chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe).
Record review of the resident's physician order dated 6/28/19, showed directed for staff to administer Symbicort aerosol inhaler, one puff for COPD with special instructions to rinse mouth and spit after each use.
Observation on 7/31/19 at 8:11 A.M., showed Registered Nurse (RN) C administered the resident's Symbicort inhaler. The nurse did not instruct the resident to rinse his/her mouth after inhaling the Symbicort.
During an interview on 7/31/19 at 9:45 A.M. LPN B said the following:
-Staff should follow instructions as ordered by the physician;
-Staff should ensure the resident rinses his/her mouth after a Symbicort inhaler is administered;
-The resident should be instructed to rinse his/her mouth and to not swallow the water.
4. During an interview on 8/1/19 at 10:31 A.M., LPN B said the following:
-Resident's receiving rapid acting insulin should eat within 30 minutes after insulin is administered;
-Snacks are available and should be offered if the meal will not be served within the time frame after the insulin is administered.
5. During an interview on 8/1/19 at 2:15 P.M., the Director of Nursing (DON) said staff should follow the manufacturer's instructions for rapid-acting insulin administration and the guidelines set for providing food after insulin administration. He expects staff to provide a snack and to monitor the residents for signs and symptoms of hypoglycemia (low blood sugar) after a resident received a rapid-acting insulin if the meal will not be served within the time frame set. Resident's that use Symbicort inhalers are at risk for oral fungal infections. He expects staff to ensure the resident rinses his/her mouth after each use.
6. During an interview on 8/1/19 at 2:37 P.M., the Administrator said staff should follow physicians' orders and manufacturer guidelines for insulin administration and inhaler administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility staff failed to follow physician's orders to obtain three Hemoglobin A1c (HbA1c - test to evaluate the average amount of glucose (sugar)in the blood o...
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Based on interview and record review the facility staff failed to follow physician's orders to obtain three Hemoglobin A1c (HbA1c - test to evaluate the average amount of glucose (sugar)in the blood over the last two to three months) tests for one resident (Resident #15) with a diagnosis of diabetes mellitus (DM - condition that affects the way the body processes blood glucose). The facility census was 49.
Record review of the facility's policy, titled Laboratory, Radiology, and other Diagnostic Services, dated December, 2016, showed the following:
-The physician may order laboratory procedures according to the needs of each resident;
-The tests will be processed and completed according to the physician orders;
-The results of the ordered services will be placed in the resident's medical record.
1. Record review of Resident #15's face sheet (a document that gives a resident's information at a quick glance) showed the following:
-admit date d 1/29/18;
-Diagnosis of diabetes mellitus.
Record review of the resident's physician order dated 10/3/18 directed staff to obtain a Hemoglobin A1c test between the 4th and the 15th of every January, April, July, and October.
Record review of the resident's laboratory records showed the following:
-Dated 10/4/18, a HbA1c test was completed;
-Staff did not obtain the physician ordered HbA1c tests for the months of January, April, and July, 2019.
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/11/19 showed the following:
-Severely impaired cognition;
-Required a therapeutic diet.
Record review of the resident's care plan, dated 5/12/19, showed direction for staff to monitor the resident's laboratory tests by obtaining a HbA1c four times a year to determine the effects of the therapeutic diabetic diet.
During an interview on 8/1/19 at 10:31 A.M., Licensed Practical Nurse (LPN) B said the following:
-Staff complete laboratory request sheets for physicians' orders for laboratory tests;
-When the order is re-occurring, it is documented on the request sheet when the next test is due;
-There is no tracking system in place to assure all laboratory tests are completed as ordered.
During an interview on 8/1/19 at 2:15 P.M., the Director of Nursing (DON) said the facility has a manual located at the nurse's stations directing staff on the procedure for laboratory tests requests. He/She expects staff to follow physicians' orders. Resident #15's HbA1c order were missed and not completed in January, April, and July.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to properly label insulin medications with open dates according to manufacturer's guidelines for two residents (Resident #1 and ...
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Based on observation, interview, and record review, the facility failed to properly label insulin medications with open dates according to manufacturer's guidelines for two residents (Resident #1 and #42) and failed to dispose of the open vials of insulin according to the recommended guidelines. The facility census was 49.
Record review of the Novolog insulin undated manufacturer's package insert showed direction to discard opened multi-use vials after 28 days.
Record review of the Humalog insulin undated manufacturer's package insert showed direction for the following:
-Do not use Humalog insulin past 28 days after the first use.
Record review of the facility's policy titled Diabetic Infection Control, dated March 2015, showed all multiple dose insulin vials will be assigned to an individual resident and tabled appropriately.
Record review of the Center's for Disease Control (CDC) guidelines, updated 8/16/16, showed the following:
-Medication vials should always be discarded whenever sterility is compromised or questionable;
-If a multi-dose vial has been opened or accessed (for example, needle-punctured) the vial should be dated and discarded within 28 days, unless the manufacturer specified a different (shorter or longer) date for the opened vial.
1. Record review of #42's face sheet (a document that gives a resident's information at a quick glance) showed the following:
-admit date d 12/15/16;
-Diagnosis of insulin-dependent diabetes mellitus (IDDM-a form of diabetes in which there is little or no ability to produce insulin and are therefore dependent on insulin injections).
Record review of the resident's physician order dated 7/5/19, showed direction for staff to administer five units (U) of Novolog insulin before meals.
During observation and interview on 7/30/19 at 11:10 A.M., with Licensed Practical Nurse (LPN) A showed the following:
-Resident #42's Novolog (rapid acting insulin) multi-dose vial labeled with an open date of 5/2/19;
-LPN A said the multi-use insulin vials could be used for four months once opened.
2. Record review of Resident #1's face sheet showed the following:
-admit date d 4/4/19;
-Diagnosis of IDDM.
Record review of the resident's physician order dated 7/12/19, for staff to administer Humalog insulin according to a sliding scale (progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges).
Observations on 7/30/19 at 11:20 A.M. showed LPN A took Resident #1's undated multi-use Humalog vial out of the medication cart. The LPN prepared the insulin syringe with six units of Humalog from the undated vial and administered the insulin to the resident.
During an interview on 7/30/19 at 11:20 A.M., LPN A said the vial was not dated. He/She said frequently if the vials come from the in-house medication dispensary machine, they are not dated when opened.
3. During an interview on 7/31/19 at 9:45 A.M., Registered Nurse (RN) C said the following:
-Insulin vials should be dated when opened;
-Opened multi-use vials of insulin are used for 30 days and then discarded;
-Staff should monitor the open date on the vial at each use;
-Staff should not use the insulin if the open vial is undated or if the vial is past the time frame to use.
4. During an interview on 8/1/19 at 2:15 P.M., the Director of Nursing (DON) said the following:
-Multi-use insulin vials are only used for 28 days unless the manufacturer recommended 32 days;
-Staff should date all insulin vials when opened;
-It is the nurses responsibility to monitor the opened date on the insulin vials;
-Staff should discard and obtain a new vial if an open vial of insulin is undated or past the 28 days.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions when staff did not complete proper hand-hygiene between tasks while touching food and no...
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Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions when staff did not complete proper hand-hygiene between tasks while touching food and non-food items with bare hands; touching non-food items with gloved hands and then touching food; placed a sanitizing solution on the same surface as food and splashed the solution splashing onto the food-prep counter surface. The facility had a census of 57.
Record review of the facility's policy titled, Handwashing dated May 2015, showed the following:
-Trash cans should be located directly under each hand sink;
-All trash cans should either have a foot controlled flip-top lid or no lid to prevent re-contamination of the hands.
Record review of the facility's policy titled, Chemical Safety dated May 2015, showed the following:
-Dietary employees should be familiar with all chemicals used in the department and should have access to information about these products.
Record review of the facility's policy titled, Glove Use dated May 2015, showed the following:
-To ensure safe and proper food handling during food preparation and service. The food code states food items should not be handled with bare hands.
-Utensils or tongs should be used to serve or handle foods, both raw and cooked whenever possible.
-Handwashing, according to guidelines, should occur between each task.
-Gloves should be worn if handling food is necessary. Extra caution should be taken when multiple tasks are being completed.
-Gloves should be removed when changing or walking away from specific tasks and hands should then be washed according to guidelines.
-Hands should be washed when changing tasks and any other time deemed necessary.
1. Observations on 07/29/19 at 1:24 P.M., in the kitchen showed the following:
-Dietary aide (DA) D washed and dried his/her hands;
-The DA picked up the rim of the trash can lid to throw away the paper towel with his/her hand. The DA did not use the foot-controlled mechanism, to dispose of the paper towel.
Observations on 07/29/19 showed the following:
-At 5:25 P.M., Nurse Assistant (NA) H readjusted a resident in his/her wheelchair. The NA began assisting another dependent resident with eating. The NA did not perform hand hygiene between the residents;
-At 5:20 P.M., NA H touched a resident's cheese puffs with bare hands and placed the cheese puffs in the residents' hands. The resident began eating the cheese puffs. NA H then began feeding another resident. The NA did not perform hand hygiene between assisting the residents.
Observations on 08/01/19 at 11:53 A.M., showed the Business Manager touched Resident #46's strawberry muffin with bare hands and placed the muffin into the resident's magic cup for the resident to eat.
During an interview on 08/01/19 at 12:08 P.M., the Dietary Manager said the following:
-Facility staff should wash their hands before assisting a resident to eat and in between residents;
-He/she would expect facility staff to wash their hands after repositioning a resident and prior to feeding another resident;
-Facility staff should apply gloves or use tongs to pick up residents food. Staff should never use bare hands
During an interview on 08/01/19 at 12:32 P.M., the Director of Nursing (DON) said the following:
-Facility staff should wash their hands prior to assisting residents with feeding, going between residents or cutting up the resident's food.
-He/She would prefer nursing staff did not touch the residents food with bare hands, facility staff should wear gloves or use utensils.
2. Observations and interview on 07/31/19, during the lunch serve-out, showed the following:
-At 11:35 A.M., [NAME] E used a rag to wipe down carts where the lunch plates were sit before going out to the dining room. [NAME] E dipped the rag into container of sanitizing solution placed on the steam table prep-counter's surface. [NAME] F served out apricots and peaches, from a large plastic container also sitting on the prep-counter, into small, individual bowls. As [NAME] E dipped the rag in and out of the sanitizing solution, the solution splashed onto the plastic container and onto the prep-counter surface;
-At 11:42 A.M., [NAME] F served out small bowls of apricots and peaches. [NAME] F did not wear gloves. [NAME] F touched the counter top, the resident's paper menus, the plastic container of peaches and a few trays. [NAME] F opened and closed the refrigerator door;
-At 11:44 A.M., [NAME] F said he/she needed to go wash his/her hands;
-At 11:45 A.M., [NAME] F returned and served apricots and peaches. The cook did not put gloves on. The cook continued to open and close the refrigerator door getting more peaches out;
-At 11:47 A.M., [NAME] F grabbed some napkins, after an aide requested for a resident, and did not wash his/her hands after touching the refrigerator door and peach container;
-At 11:50 A.M., [NAME] G wore gloves and used tongs during the meal serve out. [NAME] G left the steam table and touching the refrigerator handle opened the refrigerator. The cook picked up two small bowls of lettuce, onion and tomato and returned to the steam table to continue to fix plates. [NAME] G did not change his/her gloves and touched hamburger buns.
3. During an interview on 08/01/19 at 3:09 P.M., the DM said the following:
-The cleaning solution in the bucket should not be used anywhere near food. The cleaning bucket should be on another table or a cart that is not being used for food;
-Staff should wear gloves change the gloves between touching anything else when serving out food. Staff should wash their hands whenever anything else is touched and should use tongs to serve food onto plates or trays;
-Staff should always wash their hands, dry with a clean paper towel, use the paper towel to turn the water off, use the foot pedal to open the trash can and discard the paper towel.
4. During an interview on 08/02/19 at 9:37 A.M., the Administrator said he expects dietary staff to wash their hands any time they touch anything while serving food. If they touch a door of a refrigerator, if they touch a plate, if they touch a table top, if they touch a resident, I don't care what they have touched, I expect them to continuously wash their hands.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Missouri facilities.
Concerns
- • 29 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
- • 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Adair Village's CMS Rating?
CMS assigns ADAIR VILLAGE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Adair Village Staffed?
CMS rates ADAIR VILLAGE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Adair Village?
State health inspectors documented 29 deficiencies at ADAIR VILLAGE during 2019 to 2025. These included: 2 that caused actual resident harm and 27 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Adair Village?
ADAIR VILLAGE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CIRCLE B ENTERPRISES, a chain that manages multiple nursing homes. With 120 certified beds and approximately 51 residents (about 42% occupancy), it is a mid-sized facility located in CLINTON, Missouri.
How Does Adair Village Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, ADAIR VILLAGE's overall rating (3 stars) is above the state average of 2.5, staff turnover (56%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Adair Village?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Adair Village Safe?
Based on CMS inspection data, ADAIR VILLAGE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Missouri. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Adair Village Stick Around?
Staff turnover at ADAIR VILLAGE is high. At 56%, the facility is 10 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 80%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Adair Village Ever Fined?
ADAIR VILLAGE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Adair Village on Any Federal Watch List?
ADAIR VILLAGE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.