Inspection Reports for Moore-Few Care Center

The inspection was conducted due to a complaint investigation regarding failure to provide appropriate respiratory care and pain management for Resident #1, including failure to administer oxygen as ordered, failure to notify the physician of respiratory changes, and failure to adequately assess and manage pain.

The facility failed to provide safe and appropriate respiratory care and pain management for Resident #1, resulting in actual harm. Staff failed to administer oxygen as ordered, failed to notify the physician of respiratory changes, and failed to create a timely comprehensive care plan addressing oxygen usage. The resident experienced respiratory distress and was sent to the emergency department. Additionally, the facility failed to accurately assess, monitor, address, care plan, and notify the physician of increased and unrelieved pain, resulting in increased pain.

The complaint investigation revealed failures in respiratory care and pain management for Resident #1, including failure to administer oxygen as ordered, failure to notify the physician of respiratory changes, failure to create a timely care plan, and failure to adequately assess and manage pain. The resident experienced respiratory distress leading to emergency department transfer and had unrelieved pain that was not properly addressed.

The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements related to resident care, safety, infection control, and immunizations.

The facility was found deficient in multiple areas including failure to assess and document resident self-administration of medications, inadequate prevention of accident hazards leading to resident injury, improper respiratory care and oxygen equipment management, failure to adhere to COVID-19 transmission-based precautions, and failure to administer pneumococcal vaccination to a resident who consented to it.

The inspection was conducted following a complaint and incident involving a resident (Resident #1) who slid out of a wheelchair during transport in the facility's van due to inadequate securing and lack of seatbelt use.

The facility failed to ensure all residents were kept free from accident hazards during transport, specifically failing to secure Resident #1 with a seatbelt in the van. The incident occurred when the van had to brake suddenly, causing the resident to slide out of the wheelchair. The facility lacked a specific policy for van transportation and had not properly trained staff on securing residents with seatbelts.

The complaint investigation was triggered by an incident on 01/10/24 where Resident #1 slid out of a wheelchair during transport to dialysis in the facility van. The resident was not secured with a seatbelt, although the wheelchair was strapped down. The facility investigated, educated staff, and initiated new competency checklists for drivers. Staff A received a written warning for failing to comply with Missouri seatbelt laws.

The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's responsible party in a timely manner after a change in the resident's health condition.

The facility failed to notify Resident #1's responsible party promptly after a health change occurred. Staff interviews confirmed that notification should occur as soon as possible, but the family was not contacted until the day after the incident.

The complaint investigation found that staff did not notify the resident's family about an incident on 08/01/23 until the following day, 08/02/23. The resident and family expressed dissatisfaction with the delay. Interviews with nursing staff and administration confirmed that notification should have been immediate.

The inspection was conducted due to a complaint investigation regarding the facility's failure to provide protective oversight for residents during periods of increased temperature and humidity, resulting in one resident suffering non-responsiveness and sunburn after being outside for an extended period.

The facility failed to have a policy or system in place to monitor residents outdoors during heat, leading to a resident being found unresponsive with sunburn. Staff did not document monitoring or assessment of the resident while outside. The facility had no prior policy regarding residents being outside in the heat. The resident was found with elevated temperature and sunburn after prolonged exposure. The facility corrected the noncompliance by implementing a policy and educating staff.

The complaint investigation found that the facility did not have a policy or system to monitor residents outside during heat, resulting in one resident being found unresponsive with sunburn after prolonged outdoor exposure. The resident was cognitively intact but dependent on staff for mobility and care. Staff failed to monitor or document the resident's status while outside. Interviews revealed staff were unaware of any policy regarding outdoor monitoring in heat prior to the incident. The facility corrected the issue by implementing a policy and educating staff.

The inspection was conducted due to complaints regarding failure to notify residents and/or their representatives in writing about hospital transfers and bed hold policies, failure to complete timely Minimum Data Set (MDS) assessments, failure to submit discharge assessments timely, failure to develop comprehensive care plans, and failure to maintain an infection prevention and control program.

The facility failed to provide timely written notification of hospital transfers and bed hold policies to residents and/or their representatives for two residents. The facility also failed to complete annual and quarterly MDS assessments within required timeframes for some residents, failed to submit discharge assessments timely for two residents, failed to develop comprehensive care plans including key needs such as indwelling catheters, hospice involvement, and wander guard use for several residents, and failed to ensure timely completion and documentation of employee tuberculosis screening tests for four staff members.

The complaint investigation focused on issues related to resident transfer notifications, bed hold policies, MDS assessment timeliness, care plan completeness, and employee tuberculosis screening compliance.

The inspection was conducted due to complaints regarding failure to provide Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) at discharge from Medicare Part A services, inadequate catheter care, and improper use and documentation of side rails for residents.

The facility failed to provide required SNFABN or denial letters to residents discharged from Medicare Part A services, failed to provide catheter care per infection control standards for one resident with an indwelling catheter, and failed to properly assess, document, and monitor the use of side rails for seven residents, including lack of risk/benefit evaluations, safety checks, and care plan interventions.

The complaint investigation found substantiated deficiencies related to failure to provide SNFABN notices, inadequate catheter care, and improper use and documentation of side rails.