Every finding on record at Aspire Senior Living Warsaw

Based on interview and record review, facility staff failed to keep two residents (Resident #1 and #2) free from physical abuse when Certified Nurse Aide (CNA) A forcefully transferred the residents from their beds to their wheelchairs. The facility census was 83.The administrator was notified on 10/29/25 of past Non-Compliance, which occurred on 10/22/25 when staff reported the allegation. Staff immediately suspended CNA A pending the results of the investigation; assessed the resident for physical and psychological harm; investigated; in-serviced staff on abuse, neglect, proper transfer techniques, and resident rights; and terminated the employee on 10/28/25. 1. Review of the facility's Abuse & Neglect Policy and Procedure, revised 04/16/24, showed the purpose of the policy is to ensure residents are free from abuse, neglect, misappropriation of resident's property, and exploitation. 2. Review of the facility's investigation, dated 10/22/25, showed the administrator documented CNA B and CNA C notified Licensed Practical Nurse (LPN) D they witnessed CNA A transfer the residents in a forceful manner, and without the use of a gait belt. Review of the facility's investigation, dated 10/22/25, showed LPN D's signed statement dated 10/22/25. LPN D documented CNA B and CNA C notified him/her CNA A was rough while getting Resident #1 and Resident #2 up for breakfast. He/She documented CNA B and CNA C were, visibly upset, and CNA C was tearful. He/She documented they immediately notified the administrator. Review of CNA B's signed statement, dated 10/22/25, showed he/she documented he/she witnessed abuse by CNA A to Resident # 2 on 10/22/25 between 6:15 A.M. and 6:30 A.M. He/She tried to give report to CNA A on 'A' hall and witnessed him/her out of anger swiftly put Resident #2 into his/her chair, like as in seconds the resident was from bed to chair and then CNA A went to Resident #1 and attempted to transfer him/her in the same way when Resident #1 fought back and was swinging on CNA A and trying to bite him/her when at that point CNA A said to Resident #1, If you hit me again, I'll walk out.'Review of CNA C's signed statement, dated 10/22/25, showed he/she documented CNA A was, extremely aggravated and behaving aggressively, speaking very angrily about how his/her residents were not up. He/She documented CNA A, CNA B, and he/she, entered Resident #1's and Resident #2's room, and without notifying or at all speaking to Resident #2, CNA A immediately grabbed him/her under his/her shoulders and violently yanked him/her out of bed, twisted Resident #2 around and dropped him/her into a wheelchair. He/She then lowered the back of the wheelchair and grabbed Resident #2 underneath his/her shoulders again, and very roughly and suddenly yanked resident #2 again to pull him/her farther into the wheelchair. During all of this, Resident #2 was visibly and verbally confused and upset, and most of all frightened. CNA A immediately went to go and get up Resident #1 and pull him/her out of bed and into the wheelchair. Review of CNA A's signed statement, dated 10/22/25, showed CNA A documented he/she came on duty on 10/22/25 at 6:11 A.M. He/She documented he/she, got to grab Resident #2, got him/her up, and go over to Resident #1 who had taken his/her brief off. CNA A documented he/she refastened the brief. He/She documented Resident # 2 is very contracted. It's a struggle a lot of times to get him/her to roll and move around. I finally got his/her clothes on and brief go to sit him/her up in sitting position resident bit me and when I got him/her in chair he/she punched me a few times. I knew I should have left him/her in bed, but he/she is a resident who needs assist with feedings and is not allowed to eat in bed. Review of the facility's investigation, dated 10/28/25, showed the administrator documented he/she terminated CNA A on 10/28/25 for roughness with resident transfer, violating safety rules by transferring Resident #1 and Resident #2 without a second person, and resident rights. The administrator documented Resident #1 stated CNA A hurt his/her arm. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/22/25, showed staff assessed the resident with cognitive impairment, totally dependent for toileting and bathing, substantial assistance required for dressing, hygiene, and transfers and uses a wheelchair. Review of the resident's Face Sheet showed diagnoses of Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Anxiety Disorder, Osteoarthritis (a degeneration of joint cartilage and the underlying bone causing pain and stiffness), and Major Depressive Disorder. Review of the resident's care plan, updated 10/14/25, showed staff assessed the resident with pain, alteration in vision, anxiety, impaired cognition, and needed assistance with activities of daily living (ADL's). Review of the resident's care plan showed staff are directed to observe the resident for complaints of pain; observe for non-verbal signs and symptoms of pain (moaning, groaning, facial grimacing); explain procedures prior to performing to decrease anxiety or fear; allow opportunity to make choices and participate in care; use gentleness when working with resident; observe for nervous, anxious, or fidgeting behavior; assist with ambulation, toileting, and mobility as needed; transfer requires assist of two staff members with a mechanical lift; observe for non-verbal signs of pain (facial expressions, pulling away, fighting).Review of the resident's nurses' notes showed staff documented on 10/22/25, staff obtained an order for an x-ray of the resident's right shoulder due to the resident's complaints of pain. 4. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, and totally dependent for eating, toileting, bathing, dressing, and transfers. Review of the resident's Face Sheet showed diagnoses of Osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue), Major Depressive Disorder, Anxiety Disorder, and Dementia.Review of resident's care plan, updated 09/23/25, showed staff assessed resident with pain, anxiety, impaired cognition, and needed assistance with ADL's. Review of the resident's care plan showed staff are directed to provide comfort measures/pain management when needed, allow resident to make choices when possible, transfers require extensive assist of two staff, identify self on each encounter, observe for pain during mobility, explain care and procedures before and during care, use gentleness when working with resident, assist with ambulation, toileting, and mobility as needed, observe for non-verbal signs of pain.Review of the resident's nurses' notes showed staff documented on 10/22/25, staff administered as needed morphine (an opioid analgesic used to treat moderate to severe pain) due to moaning. During an interview on 10/28/25 at 1:15 P.M., the resident said a staff member was mean to him/her. He/She said the staff member rolled him/her in bed really hard, and tried to break his/her ribs. He/She said the staff member did not use a gait belt and, He/She should be fired. During an interview on 10/28/25 at 12:51 P.M., CNA C said on the morning of 10/22/25, CNA A appeared angry and agitated. He/She said CNA A just grabbed the resident and yanked him/her under the resident's arms, in a forceful manner, and without the use of a gait belt, and dropped the resident into the resident's wheelchair. He/She said the resident woke up and appeared to be startled and frightened. He/She said he/she was scared, and walked out of the room. 5. During an interview on 10/28/25 at 10:50 A.M., the administrator said CNA B notified him/her that CNA B had witnessed abusive behavior by CNA A towards Resident #1 and Resident #2. He/She said CNA B told him/her CNA B witnessed CNA A roughly grab Resident #1 under the resident's arms, without the use of a gait belt, and throw the resident into his/her wheelchair. CNA B then witnessed CNA A roughly grab Resident #2 under the arms, without use of a gait belt, and throw them into his/her wheelchair. The administrator said he/she suspended CNA A pending the investigation and terminated him/her after completing the investigation. The administrator said he/she interviewed Resident #2 on 10/22/25, and the resident told him/her CNA A hurt his/her arm. The administrator said he/she obtained an x-ray, with negative results for any injury. During an interview on 10/28/25 at 12:20 P.M., CNA B said when CNA A came on duty the morning of 10/22/25, CNA A appeared agitated. He/She said CNA A went into the residents' room to get them up for breakfast. CNA B said CNA grabbed Resident #2 and threw the resident into the resident's wheelchair. CNA B said CNA A put her hands under Resident #2's arms in a forceful manner, and without the use of a gait belt, threw Resident #2 into the resident's wheelchair so quickly, CNA B was, in shock. CNA B said CNA A then went to Resident #1, grabbed Resident #1 around the waist in a forceful manner, and without the use of a gait belt, and threw Resident #1 into the resident's wheelchair. CNA B said Resident #1 attempted to hit and bite CNA A during the transfer. During an interview on 10/28/25 at 12:33 P.M., CNA A said he/she was irritated when he/she came on duty the morning of 10/22/25 because the night staff had not gotten Resident #1 and Resident #2 up for breakfast. He/She said he/she does not use a gait belt to transfer the residents because he/she lifts them up fast and quickly pivots them into their wheelchairs. He/She said he/she transfers the residents by lifting them up under their arms and twisting to put them in their wheelchairs. During an interview on 11/04/25 at 9:08 A.M., LPN D said CNA B and CNA C notified him/her they witnessed CNA A transfer Resident #1 and Resident #2 in a forceful manner. He/She said he/she instructed CNA B and CNA C to contact the administrator. #2649674

Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Facility staff failed to conduct an annual review of its Infection Prevention and Control Program (IPCP) and update their program, as necessary. Facility staff failed to implement Enhanced Barrier Precautions (EBP) for two residents (Resident#13 and Resident #49) out of four sampled residents who required EBP, and failed to provide colostomy (an external bag attached to a surgically created stoma on the abdomen to collect stool after the colon is redirected due to a medical condition) care in a manner to prevent the spread of infection during care for one resident (Resident #75) out of three sampled residents. The facility census was 81.1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed:-The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.-Facilities must have water management plans and documentation that, at a minimum, ensure each facility: *Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;*Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit;*Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's policy titled Water Management Program, dated February 19, 2020, showed:-A water management program shall be implemented to manage the risk of legionellosis for the facility's water system;-The program team shall include the administrator; maintenance director and Director of Nursing/Assistant Director of Nursing (DON/ADON) and the team shall have knowledge of the building water system design and water management as it relates to legionellosis;-Facility staff will survey their building and conduct a systematic risk analysis of hazardous water conditions in the building water systems and determine the locations in the system where control measures are required;-For each control measure at each control measure location the facility will determine the limits including but not limited to a maximum value, a minimum value, or a range of values within which a chemical or physical parameter must be monitored and maintained;-The following corrective actions are to be taken when monitoring indicates control parameters are outside of established control limits;--Coordinate with corporate chain of command--Issue a work order on the TELS (facility management software) work order system--Take necessary actions to bring the measures back into control limits;--Document correction on work order;-The water management team is to review and confirm that all of the program elements are being implemented as designed during morning meeting after completion of preventative maintenance. Review showed the program did not contain facility specific risk areas or corrective actions to take when control measures were not within specified ranges. Review of the facility's TELS Water Management documentation for the period of September 2024 through September 2025 showed:-Nursing staff were to conduct a daily water flow test on all faucets, toilets and showers in resident care areas;-Maintenance staff were to conduct a daily water flow test on all faucets, toilets and showers in resident care areas;-Maintenance staff were directed to check pH and free chlorine levels every six months and make corrections per water management program. Review showed results of chlorine testing completed on 06/30/25 indicated 24 of 38 areas sampled were outside of the specified range. Review showed the records did not contain documentation of corrective action or review with water management team. During an interview on 09/03/25 at 2:45 the maintenance director said he/she was not aware of the facility specific Legionella related policies, and he/she was not familiar with the water management team. The maintenance director said he/she was not familiar with facility specific water management risk areas. The maintenance director said he/she followed TELS task lists related to the facility water systems. The maintenance director said all resident rooms, including showers which were not in use, were not being flushed on a routine basis. The maintenance director said he/she performed a one-minute water flush on two or three rooms per hall as part of bi-monthly room checks. The maintenance director said he/she did not run water in resident room showers if the shower contained resident belongings. The maintenance director said he/she checked the water pH, hardness and chlorine levels twice per year and would adjust the water softeners to adjust water hardness. The maintenance director said he/she was not aware of any corrective actions if chlorine levels were out of range.During an interview on 09/04/25 at 9:05 A.M., the DON said participation in the Water Management Program was part of his/her duties. The DON said since he/she started in the position about two weeks ago he/she was not familiar with the facility specifics of the program.During an interview on 09/04/25 at 12:15 P.M., the administrator said he/she was aware of the requirement to have a water management program but was not familiar with the specific components of the program. The administrator said the maintenance director is responsible for the facility water systems. 2. Review of the facility's policies titled, Infection Prevention and Control Manual, Hand Hygiene, dated 06/11/20, Nursing Procedure Manual, Colostomy/Ileostomy Care, dated 10/01/10, and Nursing Procedures Manual, Enhanced Barrier Precautions, dated 04/29/24, showed the policies did not contain documentation staff had reviewed and updated the polices as necessary. During an interview on 09/05/25 at 11:15 A.M., the administrator said the corporate office is responsible to review and update the policies on an annual basis. He/She said the corporate office sends an updated copy of the policies if something is revised. He/She said there is not an audit system in place to ensure the policies are reviewed and updated, since the corporate office is responsible to complete the annual review.3. Review of the facility's policy titled, Nursing Procedures Manual, Enhanced Barrier Precautions, dated 04/29/24, showed:-Enhanced Barrier Precautions (EBP) are an approach to the use of Personal Protective Equipment (PPE) as a strategy to decrease transmission of the Centers for Disease Control and Prevention (CDC)'s targeted multi-drug-resistant organisms (MDRO)s when contact precautions do not apply. -A sign indicating the EBP should be placed on the residents' door and if it is a semiprivate room, it should be labeled for which bed;-EBP requires the donning of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing;-EBP is employed while performing high contact resident care activities, including, transferring, providing hygiene, device care or use: urinary catheter (tube placed in the bladder to drain urine), feeding tube (tube placed in the stomach to deliver nutrition), tracheostomy (tube placed in the windpipe to ensure adequate oxygenation) and wound care.4. Review of Resident #13's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 06/17/25 showed staff assessed the resident as cognitively intact, and had a tracheostomy and feeding tube. Observation on 09/02/25 at 12:42 P.M., showed the resident door with an EBP sign. Observation showed Licensed Practical Nurse (LPN ) A suctioned the resident's tracheostomy tube and did not wear a gown. Observation on 09/05/25 at 9:43 A.M., showed LPN A administered medication through the resident's feeding tube and flushed the tube without a gown or gloves on. 5. Review of Resident #49's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact, required substantial/maximal assistance for transfers, and had a surgical wound. Review of the resident's care plan, dated 08/18/25, showed staff documented the resident is on enhanced barrier precautions per wound care. The care plan showed staff documented the resident has skin breakdown.Review of the resident's Physician Order Summary (POS), dated 09/05/24, showed an order for EBP precautions due to the surgical incision. The POS showed an order to cleanse the surgical site with normal saline, pat dry, apply Medi honey (wound gel) to wound bed, and cover with bordered gauze dressing. The POS showed an order for a diabetic foot ulcer to cleanse the left foot with normal saline, pat dry, apply Medi honey to tissue, apply alginate (wound dressing) to wound bed, cover with abdominal pad, wrap with stretch gauze wrap and secure with tape.Observation on 09/03/25 at 10:31 A.M., showed the resident's room did not have EBP signage. Observation showed Certified Nurse Aide (CNA) C assisted the resident with a mechanical lift transfer and did not wear a gown or gloves. Observation on 09/4/25 at 10:30 A.M., showed the resident's room did not have EBP signage. CNA A, CNA B and CNA C assisted the resident with a mechanical lift transfer and did not wear gloves or a gown. During an interview on 09/04/25 at 10:32 A.M., the ADON said he/she did not see EBP signage on the door. The ADON said staff should have worn gloves and a gown during the transfers because the resident requires EBP. During an interview on 09/04/25 at 11:09 A.M., CNA D said there is not EBP signage on the resident's door and he/she did not know the resident required EBP. During an interview on 09/04/25 at 1:44 P.M., the Infection Preventionist (IP) said he/she is responsible to ensure EBP signage is visible to the resident, staff and visitors and the sign for the resident door had been posted but must have fallen off the door. The IP said he/she conducted an in-service about a month ago on the use of personal protective equipment (PPE). He/She said staff were provided a list of residents on EBP and are aware of what qualifies a resident to be placed on EBP, including a resident with a catheter, wounds, tracheotomy and/or feeding tube. The IP said staff are directed to use gloves and gowns when providing care for a resident on EBP. During an interview on 09/05/25 at 11:15 A.M., the administrator said staff put signs on the residents' doors that require EBP, and staff had been educated regarding EBP and when it is required. He/She said staff are directed to ask the nurse if they do not know what precautions the resident requires. He/She said the concern with not following EBP is the potential to spread infections. During an interview on 09/05/25 at 11:16 A.M., the DON said staff put signs on the residents' doors that require EBP. He/She said staff are knowledgeable regarding which residents require EBP by education from other staff, care plan and orders. The DON said if staff are unsure, they should ask the nurse. The DON said the concern with not following EBP precautions is the potential to spread infections. 6. Review of the facility's policy titled, Nursing Procedure Manual, Colostomy/Ileostomy (opening in the abdominal wall connecting the small outside the body) Care, dated 10/01/10, showed:-Wash hands thoroughly before and after providing care;-Remove drainage bag;-Apply clean drainage bag;-Discard soiled drainage bag and gloves into a disposable bag and appropriate receptacle;-Wash hands;-The policy did not contain direction for staff regarding a clean barrier for supplies and/or hand hygiene during care.Review of the facility's policy, Infection Prevention and Control Manual, Hand Hygiene, dated 06/11/20, showed staff were directed to:-To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections;-Hand washing should be performed between procedures with resident based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents;-Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene before and after direct resident contact and after contact with resident mucous membranes and body fluids or excretions;-Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.7. Review of Resident #75's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not contain document the resident used a colostomy bag.Review of the resident's POS, dated 09/05/25, showed an order for colostomy care and to monitor the stoma.Review of the resident's care plan, dated 07/31/25, showed the resident has a colostomy related to colon cancer.Observation on 09/04/25 at 10:08 A.M., showed CNA C gathered the resident's colostomy care supplies and placed the supplies directly on the bed without a barrier. The CNA put on gloves, removed the resident's colostomy bag, provided colostomy care, and with the same soiled gloves, picked up the clean bandage, used a pair of scissors to cut the bandage to fit around stoma, applied the clean bandage to the colostomy bag and then applied the bag to the resident. The CNA removed his/her gloves, touched the resident's clothing and put the unused supplies on the resident's nightstand. The CNA picked up the dirty scissors and placed them on top of the medication cart. During an interview on 09/04/25 at 11:09 A.M., CNA C said he/she should have performed hand hygiene and glove changes after he/she removed the colostomy bag and bandage and before he/she touched the clean supplies. The CNA said he/she should not have placed clean supplies on the resident's bed, and he/she should have cleaned the scissors before placing them back on the cart. The CNA said he/she was training new staff and just did not think about it. The CNA said the issues is infection control and the possibility of transferring bacteria from resident to resident. During an interview on 09/04/25 at 1:44 P.M., the IP said staff are educated to perform hand hygiene when entering and exiting a resident room. The IP said staff should wash hands and apply clean gloves from all dirty to clean tasks. Colostomy care supplies should be placed on a clean surface or a barrier, and contaminated supplies should be thrown away or cleaned before leaving the resident's room. The concerns are spreading infection. Staff were recently in-serviced on infection control, including glove changes and hand hygiene.During an interview on 09/05/25 at 11:15 A.M., the administrator said staff should perform hand hygiene upon entering and exiting a resident's room. Staff should perform hand hygiene and glove changes after providing care, or encountering contaminated items, and before moving from a dirty to clean task. Colostomy care supplies should be placed on a clean surface or a protective barrier. Scissors should be cleaned after use in resident rooms. During an interview on 09/05/25 at 11:16 A.M., the DON said he/she expected staff to perform hand hygiene upon entering and exiting a resident's room, with glove changes, after providing care, after encountering contaminated items, and from dirty to clean tasks. Staff should have cleaned the scissors before leaving the resident's room and the clean supplies should have been placed on a barrier or clean surface.

Based on interview and record review, facility staff failed to refund resident funds within 30 days of discharge for 16 residents (Resident #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) out of 50 sampled residents. The facility census was 81.1. Review of the facility's policy titled Resident Trust, dated October 2022, showed the facility will convey refunds upon death or discharge of a resident within 30 days or within the timeframe prescribed by the state regulation.2. Review of the facility's aging report (report showing outstanding invoices and balances), dated 09/03/25, showed the following residents had money in the facility's operating account:Resident Amount Held in Operating Account#82 $235.00#83 $400.00#84 $2,040.00#85 $1,938.00#86 $529.01#87 $174.40#88 $5,704.00#89 $520.00#90 $240.00#91 $4,512.39#92 $634.46#93 $20.00#94 $240.00 #95 $140.00#96 $20.00#97 $231.00Total $17, 578.26 3. During an interview on 09/04/25 at 02:00 P.M., the Financial Specialist Assistant (FSA) said he/she oversees resident funds and petty cash. He/She said there are discharged residents with delayed refunds, and he/she is trying to get caught up. He/She said some may be waiting for copay finalization and others are just behind.During an interview on 09/04/25 at 02:20 P.M., the Financial Specialist said he/she oversees the facility funds and is aware they are behind on processing resident refunds. He/She said the facility is behind because there is only one person processing refunds and with other business and summer vacations, it has gotten behind. He/She said it is not a result of extraordinary events.During an interview on 09/05/25 at 12:02 P.M., the Administrator said funds should be refunded to residents within two weeks to 30 days from discharge and after copays have been finalized. He/She said the Financial Specialist Assistant is responsible for conveying refunds. The Administrator said he/she knew they were behind on some refunds, but not aware some discharges dated as far back as December 2024. He/She said that is an excessive number of days.

Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #3), received an accurate insulin dosage, failed to accurately transcribe a verbal insulin order in the electronic medication administration record (eMAR) for one resident (Resident #36), and failed to document an appropriate diagnosis for psychotropic medication use for one resident (Resident #101). The census was 81.1. Review of the facility's policy titled General Dose Preparation and Medication Preparation, dated 01/01/13, showed staff are instructed to confirm the MAR reflects the most recent medication order and follow manufacturer medication administration guidelines. Review of the facility's policy titled Subcutaneous Injection with Lantus SoloStar Pen, dated 2009, showed staff are instructed to perform a safety test by priming the insulin pen with two units of insulin to remove air bubbles and ensure the needle and pen are working properly.Review of the manufacturer's guidelines for Lantus insulin pen Solostar, dated 2022, instructed users to perform a safety check after attaching the needle to expel trapped air by dialing a test dose of two units of insulin. Press the injection button and check to see that insulin comes out of the needle. If no insulin comes out, repeat the test two more times. If no insulin comes out, change the needle. Always perform the safety test before each injection and never use the pen if no insulin comes out after using a second needle. 2. Review of Resident # 3's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 08/01/25, showed staff assessed the resident had a diagnosis of diabetes mellitus and received insulin. Observation on 09/05/25 at 8:20 A.M. showed Licensed Practical Nurse (LPN) A attached a needle to the resident's insulin pen, primed the needle with two units of insulin, removed the primed needle, applied a new needle and administered the resident's insulin. The LPN did not prime the new needle before he/she administered the resident's insulin During an interview on 09/05/25 at 8:28 A.M., LPN A said he/she was trained to replace the insulin pen needle after priming. He/She said the purpose of priming the needle was to expel air. LPN A said he/she never questioned it, but it is not good practice. During an interview on 09/05/25 at 9:00 A.M., the Assistant Director of Nursing (ADON) said insulin pen needles should not be changed in between priming, because that defeats the purpose of priming the needle. During an interview on 09/05/25 at 10:15 A.M., the Director of Nursing (DON) said the purpose of priming insulin pen needles is to dispel air bubbles. He/She said changing a needle after it has been primed and applying a new needle is not standard practice. The DON said the risk is dispensing an inaccurate dose of insulin.During an interview on 09/05/25 at 11:16 A.M., the administrator said she believes insulin administration is part of the facility staffs annual competency testing. He/She said not properly priming the insulin needles could cause inaccurate dosing.3. Review of the facility's policy titled Verbal and Facsimile Orders, dated 10/01/10, showed staff are instructed to enter verbal orders in the medical record and read the order back to the physician to ensure accuracy.4. Review of Resident # 36's Annual MDS, dated [DATE], showed staff assessed the resident had a diagnosis of diabetes mellitus and received insulinObservation on 09/05/25 at 08:58 A.M. showed LPN B administered 17 units of insulin to the resident.Review of the resident's electronic physician order set (POS) showed an order dated 07/02/25 for 20 units of insulin aspart (fast acting insulin). A special instruction note read: Administer 20 units after meals, hold if he/she eats less than 60%. Review of the resident's paper POS, dated 07/15/25, showed an order for 17 units of insulin aspart. A special instruction note read: Administer 20 units after meals, hold if he/she eats less than 60%. During an interview on 09/05/2025 at 9:18 A.M. LPN B said a verbal order was received on 07/15/25 that changed the insulin dose from 20 units to 17 units. LPN B said he/she had not noticed the special instructions to give 20 units was not removed when the order changed. LPN B said the resident's insulin order had two different dosages. He/She said there is not a progress note from the time of the order, and it was entered directly into the electronic record. During an interview on 09/05/25 at 10:15 A.M., the Director of Nursing (DON) said new medication orders are reviewed by the Interdisciplinary Team (IDT). The DON said a progress note should be written when verbal orders are received by the nurse. The DON said he/she expects orders to be reviewed by the nurse for accuracy and prior to medication administration.During an interview on 09/05/25 at 11:16 A.M., the administrator said medication orders are documented in the computer system by the nurses when received by a physician. He/She said nurses are expected to accurately transcribe and review medication orders, and any errors should be noticed in the morning IDT meeting.4. Review of Resident #101's Face Sheet, undated, showed the resident admitted to the facility on [DATE].Review of the resident's POS, dated 09/05/25, showed an order for 0.5 milligrams (mg) of Lorazepam (used to treat anxiety) for the treatment of depression. The POS did not contain documentation of an anxiety diagnosis.During an interview on 09/04/25 at 1:44 P.M., the Infection Preventionist (IP) said staff are required to obtain an appropriate diagnosis for prescribed medication. He/She said staff are directed to contact the doctor if there is not an appropriate diagnosis.During an interview on 09/05/25 at 11:15 A.M., the administrator said the IDT team reviews medications to verify appropriate diagnoses, when a resident is admitted to the facility. He/She said the resident was admitted from the hospital with a physician's order for Lorazepam. He/She said there is not an appropriate diagnosis for the use of the medication, but staff wanted to keep the resident on the medication until he/she was acclimated to the facility. He/She said staff scheduled an upcoming appointment for the resident with a psychiatrist.During an interview on 09/05/25 at 11:16 A.M., the DON said when a resident is admitted to the facility, the IDT team reviews their medication list to determine if there is an appropriate diagnosis for each prescribed medication. He/She said the resident was admitted to the facility from the hospital with a prescription for Lorazepam. He/She said he/she knew the resident did not have an appropriate diagnosis for the medication, but staff did not want to discontinue the medication until the resident became acclimated to the facility. He/She said staff scheduled an appointment for the resident with a psychiatrist for the upcoming week.

Based on interviews and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical and sexual abuse when Certified Nursing Assistant (CNA) B pinched the resident's chest. The facility's census was 86. The administrator was notified on 06/20/25 of past Non-Compliance, which occurred on 06/12/25 when staff reported the allegation. Staff immediately suspended CNA B pending the results of the investigation, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 06/18/25. 1. Review of the facility's policy titled, Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, revised 10/24/22, showed: -The facility strictly prohibits the abuse of residents; -This policy protects against abuse, neglect, exploitation and misappropriation of resident to include abuse by facility staff; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately (not inadvertently or accidentally), not that the individual must have intended to inflict injury or harm; -Physical abuse includes hitting, slapping, pinching, and kicking; -Sexual abuse is a non-consensual sexual contact of any type with a resident/guest and includes, but is not limited to sexual harassment, sexual coercion, or sexual assault; -Any sexual contact between staff and resident/guest unless staff and resident/guest had a prior sexual relationship before admission or married to each other (even in a consensual relationship), will be considered an abuse of power; -Sexual contact can include touching of breasts, genitalia, groin, inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. 2. Review of the facility's investigation, dated 06/12/25, showed Nursing Assistant (NA) C and NA D reported to the administrator they both witnessed CNA B pinch and twist the resident's chest on 06/11/25. Staff assessed the resident and did not have injury and all necessary parties were notified. The administrator immediately suspended CNA B pending the investigation, documented based on the corroborating statements of two eyewitnesses, the facility verified Resident #1 was physically and sexually abused by CNA B since it involved an intimate area of the resident's body. The administrator terminated CNA B on 06/18/25. 3. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/20/25, showed staff assessed the resident as follows: -Severe cognitive impairment; -Behavioral symptoms not directed towards others such as hitting/scratching self, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes; -Impairment to one side upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot); -Diagnoses to include Traumatic Brain Injury. Review of the resident's care plan, revised 05/02/25, showed staff assessed the resident with behaviors of biting, hitting, kicking, grabbing, exposing chest, inappropriate comments and sexual inappropriateness. Staff are directed to redirect the resident's attention to other things, allow opportunity to make choices and participate in care, talk in calm voice when behavior is disruptive, when resident becomes combative, leave and try to approach later. During an interview on 06/20/25 at 10:51 A.M., NA C said he/she had called for staff assistance to lay they resident in bed and got help from NA D. He/She said CNA B entered the room, asked what help was needed, told the resident to be nice to the NAs, then stood next to the bed and pinched the resident's chest. He/She said he/she did not think it was sexual in nature but saw it as a form of physical abuse. During an interview on 06/20/25 at 11:25 A.M., CNA B said he/she is aware of the allegations. CNA B said he/she stood next to the resident's bed and the resident grabbed his/her buttock. He/She said he/she playfully tickled the resident's face and told him/her to stop, but did not touch the resident on his/her chest or any other body part. He/She denied any physical or sexual abuse, or inappropriate touching towards the resident. During an interview on 06/20/25 at 12:55 P.M., NA D said when CNA B entered the resident's room the resident was already in bed and CNA B did not assist with providing care to the resident. He/She said CNA B stood next to the bed, the resident grabbed at CNA B and CNA B pinched and twisted the resident's chest in a playful manner, but it was inappropriate, and he/she considered it a form of sexual abuse. During an interview on 06/20/25 at 1:45 P.M., the administrator said when NA C reported the allegation and NA D confirmed he/she witnessed CNA B pinched the resident's chest, he/she immediately suspended CNA B pending the investigation and terminated him/her after the investigation was completed to ensure all residents remained safe. MO00255721

Based on interview and record review, facility staff failed to properly assist one resident (Resident #1) up in bed, when Nursing Aide (NA) B wrapped his/her arms around the resident and moved the resident up in bed, which results in a injury. The facility census was 87. The administrator was notified on 11/1/24 of past Non-Compliance which occurred on 10/24/24. On 10/24/24 it was reported NA B wrapped his/her arms around Resident #1 on 10/23/24, and moved him/her up in bed which resulted in bruising to his/her left and right sides. Upon discovery on 10/24/24, staff started an investigation, inserviced staff on proper techniques for assisting residents while in bed, notified the physician and suspended the NA. Staff corrected the deficient practice on 10/24/24. 1. Review of the Facility's Moving a Resident with a Sheet/Pad Policy, dated 11/1/2001, showed staff are directed to grasp the lift sheet/pad with both hands and lift the resident toward the head of the bed. 2. Review of the facility's investigation, dated 10/24/24, showed Registered Nurse (RN) A reported to Licensed Practical Nurse (LPN) C, Resident #1 had bruising to his/her left side. Review showed LPN C notified the Director of Nursing (DON) was and an investigation was started. The resident said NA B bear hugged him/her to move him/her back up in bed. He/She said he/she felt discomfort when NA B moved him/her. Review showed staff documented NA B immediately suspended and staff were in-serviced, on 10/28/24, on abuse and neglect, positioning a resident, turning a resident, moving a resident with a sheet/pad. Review showed as of 11/1/24 all staff had not been inserviced. 2. Review of Resident #1's Discharge Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/19/24, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Osteoporosis (a condition in which bones become weak and brittle); -Required two staff assistance for transfers. Review of the resident's care plan, dated 11/2024, showed the care plan did not contain direction for on how to assist the resident in bed. Review of the nurses notes, dated 10/24/24, showed RN A documented bruising to the residents left and right sides. Review of the resident's nurses notes, dated 10/27/24, showed the physician ordered X-rays of the residents left side and ribs. Review of the residen'ts xray results showed fractures to the residents left sixth and seventh rib. During an interview on 11/1/24 at 10:10 A.M., the DON said he/she was made aware of the resident's bruising, on 10/24/24, by LPN C and started an investigation. He/She said NA B was suspended immediately. He/She said the resident said the NA moved him/her up in bed by himself/herself. He/She said staff were in-serviced for abuse and neglect, positioning, cares, and moving a resident up in bed and they were ongoing. He/She said staff are to use two people and a draw sheet to move a resident up in bed. During an interview on 11/1/24 at 10:50 A.M., the resident said NA B laid the bed flat and grabbed him/her under his/her arms and pulled him/her up in the bed. He/She said normally two staff use the draw sheet to move him/her up in the bed. During an interview on 11/1/24 at 12:15 P.M., LPN C said it was reported to him/her on 10/24/24, by RN A, the resident had bruising to his/her right underarm and left side. He/She said the DON was contacted on 10/24/24 and an investigation was started. During an interview on 11/1/24 at 12:20 P.M., RN A said he/she went into the resident's room with NA D and noticed bruising to the resident's right underarm and left side. He/She said the resident complained of discomfort to his/her left side. He/She said he/she told LPN C about the bruising and an investigation was started. He/She said the resident should have two people and be moved up in bed using the draw sheet. During an interview on 11/1/24 at 12:55 P.M., NA D said the resident had complaints of pain to his/her left side on 10/24/24. He/She said he/she did not notice any bruising the day before on 10/23/24. He/She said the resident said NA B pulled him/her up in bed by pulling under his/her arms. NA D said staff are expected to use a draw sheet and two staff to move a resident up in bed. During an interview on 11/1/24 at 1:14 P.M., NA B said he/she did not assist the resident up in bed but did help the resident with turning. He/She said he/she did not bear hug the resident. NA B if the resident needed to be moved up in bed he/she would use the draw sheet and another person. He/She said he/she received training on positioning and moving a resident up in bed because of the allegations of the complaint. During an interview on 11/4/24 at 8:01 A.M., Certified Nurse Aide (CNA) F said he/she worked the night of 10/23/24, but did not assist NA B with moving the resident. He/She said staff are expected to use two people and a draw sheet to move residents up in the bed. He/She said if a draw sheet was unavailable staff are expected to get one before trying to move the resident if the resident is unable to help. During an interview on 11/4/24 at 8:42 A.M, the physician said he/she was made aware of the bruising to the resident and ordered an xray of his/her left side. He/She said the xray results revealed a fracture to the resident's sixth and seventh rib. He/She said moving the resident up in bed by bear hugging him/her and his/her comobidities could have cause the rib fracture. During an interview on 11/4/24 at 10:09 A.M. the administrator said staff are expected to move a resident up in bed using two person assist and a draw sheet. If there was not a draw sheet staff are expected to get one before moving the resident. MO00244080

Based on observation, interview and record review, the facility staff to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff failed to maintain the kitchen ceiling in good repair to prevent the potential contamination of food. These failures have the potential to affect all residents. The facility census was 77. 1. Review of the facility's Handling Serviceware / Silverware policy, dated February 1, 2002, showed serviceware should be air dried and stored turned upside down, or covered. 2. Observation on 06/11/24 at 10:54 A.M., showed Dishwasher Q removed clean plate covers, plates, and cups from a rack on the drain board and placed the items on a service cart and a shelf above the drain board. Observation showed the items were stacked while still wet. Observation on 06/11/24 at 11:18 A.M., showed eight sheet pans stacked under the prep table while wet. Observation on 06/11/24 at 11:20 A.M., showed Dishwasher Q stacked service trays and plate warmers on a service cart. Observation showed the trays and warmers were stacked while wet. Observation on 06/12/24 at 1:45 P.M., showed Dishwasher Q removed plates from a dish machine rack and stacked the plates in a plate warmer. Observation showed the plates were stacked while wet. Observation on 06/12/24 at 1:45 P.M., showed a shelf on the clean side of the dish machine contained two service trays which contained stacks of small plastic serving bowls. Observation showed the bowls were wet. During an interview on 06/12/24 at 2:00 P.M., the Registered Dietician (RD) said the biggest problem in the kitchen was stacking items when wet and not allowing them to air dry. The RD said the facility purchased new shelving three or four weeks ago, but the shelving had not been installed. 3. Review of the facility's building maintenance policies showed the policies did not contain a policy related to the kitchen ceiling. Observation on 06/11/24 at 11:31 A.M., showed an open crack along the sheetrock seam on the ceiling above the steam table and food prep counter. During an interview on 06/11/24 at 11:32 A.M., Cooks R said they told maintenance about the crack but did not complete a paper work order to have the crack repaired. During an interview on 06/13/24 at 9:30 A.M., the maintenance director said he/she was aware of the ceiling crack in the kitchen. The maintenance director said the crack in the ceiling was there since he/she started one year ago but he/she had not fixed it because it was hard to work in the kitchen since staff were cooking all the time. The maintenance director said he/she was not aware of new shelving for the kitchen. During an interview on 6/13/24 at 1:45 P.M., the administrator said kitchen wares should not be stacked wet. The administrator said the dishwasher is responsible, but other kitchen staff tried to help when they could. The administrator said maintenance staff were responsible for maintain the facility ceilings and he/she was not aware of the ceiling crack above the food prep area.

Based on observation, interview, and record review, facility staff failed to prevent the spread of bacteria for three residents (Resident #21, #62, and #81) of four sampled residents when staff did not wash hands and change gloves during the provision of care, failed to prevent the spread of bacteria when staff did not wear the appropriate Personal Protective Equuipment (PPE) for one resident (Resident #21) of one sampled resident who had a wound and failed to post precaution signs on the doors of resident rooms to alert staff and visitors of the needed precautions for three residents (Resident #17, #82, and #244) of four sampled residents who required Enhanced Barrier Precautions (EBP). The facility census was 77. 1. Review of the facilty's Hand Hygiene policy, dated June 2020 directed staff to perform hand hygiene: -When hands are visibly soiled; -Before and after entering isoation precautions settings; -Before and after assisting a resident with personal care; -Upon and after coming in contact with a resident intact skin; -Before and after assisting a resident with toileting; -After contact with a resident body fluids or excretions; -After handling soiled or used linens or catheters/urinals; -After removing gloves. Review of the facility's perineal care policy, dated November 2001, directed staff to: -Remove any fecal matter or urine wiping with tissue from front to back; -When wash clothes and soap are used, the water should be changed before rinsing the resident; -Wash perineal area first, using a different corner or a new wipe area with each wipe; -If the resident has an indwelling catheter, gently wipe the catheter from the insertion site, down the catheter approximately three inches being careful not to pull the catheter and rinse well; -Turn the resident on to his/her side and wipe from front to back wiping from inner buttocks extending over buttocks, changing wipes or corners as needed. Review of the facility's EBP policy, dated April 2024, showed: -A sign indicating the enhanced barrier precautions should be placed on the resident's door and if it is a semiprivate room, it should be labeled for which bed; -EBP requires donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms (MDRO) to staff hands and clothing; -EBP is indicated for residents with wounds or indwelling medical devices even if resident is not known to be infected or colonized with MDRO; -EBP is employed while performing high-contact resident care activities such as: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, devices care or use (central line, urinary catheter, feeding tube, tracheostomy (artificial opening to the throat), and wound care (any skin opening requiring a dressing); -EBP is intended for the length of the resident' stay or until resolution of the wound or discontinuance of the indwelling device that placed them at a higher risk. 2. Review of Resident #21's Quarterly Minimum Date Sheet (MDS), a federally mandated assessment, dated 05/08/24, showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for toilet hygiene; -Always incontinent; -Diagnosis of hip fracture and Alzheimer disease. Review of the resident's wound healing progress report, showed on 06/06/24 staff documented the presence of an unstageable (cannot see the base of the wound) suspected deep tissue injury to the resident's right hip. Observation on 06/12/24 at 09:15 A.M., showed a sign on the residents door explained everyone must clean hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, devices care or use central line, urinary catheter, feeding tube, tracheostomy (artificial opening to the throat), and wound care. Observation on 06/12/24 at 9:15 A.M., showed Certified Nurse Aide (CNA) F entered the residents room to provide care and did not apply a gown. With gloved hands the CNA pushed a soiled brief down between the resident's legs, provided pericare, rolled resident to his/her side, removed the soiled brief from under the resident and did not change his/her gloves or wash hands. With same soiled gloves, the CNA applied a clean brief, lowered the bed with the bed control, applied a sheet over the resident, gathered soiled linens and trash and removed his/her gloves. Observation showed the CNA did not wash his/her hands. During an interview on 06/12/24 at 9:30 A.M., CNA F said staff should perform hand hygiene when going in a room, when leaving a room and when removing his/her gloves. He/She said he/she was nervous being watched and the resident was being resistive during care and did not know the resident was on the EBP until the other day. He/She said he/she should have worn the gown because the resident has a wound, but didn't think about it. 3. Review of Resident #62's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Used catheter: -Occasionally incontinent of bowel; -Required substantial/maximum assist of staff for toilet hygiene. Observation 06/14/24 at 10:23 A.M., showed CNA N entered the resident room and applied gloves. Observation showed teh CNA wiped bowel movement off the resident's buttocks. The CNA removed his/her gloves and did not perform hand hygeine before he/she put on clean gloves to wipe the catheter tubing from insertion area toward the bag. During an interview on 06/14/24 at 3:05 P.M., CNA N said hand hygiene should be performed between glove changes. CNA N said he/she did not do it because he/she was in a hurry to complete the task. 4. Review of Resident #81's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Independent with toilet hygiene; -Occasionally incontinent; -Diagnosis of dementia. Observation on 06/13/24 at 6:06 A.M., showed CNA F and CNA G entered the room to provide care. CNA F applied gloves and assisted the resident to the restroom. Observation showed CNA F continued to wear the same soiled gloves and removed the brief, applied a clean brief and clean pants. CNA F removed his/her gloves, did not perform hand The mattress under the sheets was visibly wet. CNA F did not clean the wet bed mattress and applied a bed pad turned upside down over the wet area of the mattress. CNA G put clean linens over the pad on the mattress and CNA F assisted the resident to bed. CNA F and CNA G left the room and did not perform hand hygiene. During an interview on 06/13/24 at 6:15 A.M., CNA F said staff should perform hand hygiene when going in a room, when leaving a room and when removing his/her gloves. He/She said the resident was not feeling well so was trying to hurry to get him/her to bed. During an interview on 06/13/24 at 6:22 A.M., CNA G said staff are supposed to wash their hands when entering a room and before leaving a room and between glove changes. He/She was getting ready to leave for the day and trying to help where he/she could and didn't think about washing, but did sanitize when entering the room with the linen barrels. He/She said there is so much to do in twelve hours that staff need to do the best they can. 5. Review of Resident #17's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitive loss/Dementia; -Did not have surgical wounds; -Received an antibiotic. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed an order, on 06/08/24, to change peripherally inserted central catheter ((PICC) a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart) line dressing change every 72 hours. Review showed an order, on 06/12/24, for wound vac (uses negative pressure to help heal wounds) dressing change every three days. Observation on 06/11/24 at 11:03 A.M., showed the resident in bed with a PICC to right upper arm. A wound vac machine on the floor by the bed. Observation showed the resident door did not have a EBP sign. Observation on 06/13/24 at 1:17 P.M., showed the resident in bed with a PICC to right upper arm. A wound vac machine on the floor by the bed. Observation showed the resident door did not have a EBP sign. Observation on 06/13/24 at 2:04 P.M., showed CNA M placed resident on the bedpan and did not wear EBP. Observation on 06/14/24 at 9:04 A.M., showed CNA M transfered the resident from the wheelchair to the bed, placed the resident on the bed pan and did not wear EBP. 6. Review of Resident #82's Admission MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -The resident had a pressure ulcer. Review of the resident's POS, dated June 2024, showed an order for dressing changes to the resident's left heel pressure ulcers in two different areas and two areas of the resident's sacrum. Observation on 06/11//24 at 10:59 A.M., showed the resident's door did not contain a EBP sign. Observation on 06/13/24 at 8:44 A.M., showed the resident's door did not contain a EBP sign. 7. Review of Resident #244s Admission MDS, dated [DATE], showed assessed the resident as follows: -Cognitive; -Bilateraly upper extremity impairment; -Surgical wounds. Review of the resident's Physician Order Sheet, dated June 2024, showed an order on 06/01/24 for EBP related to wounds. Review of the resident's care plan, dated 06/07/24 showed direction to initiate and follow isolation precautions as ordered. Observation on 6/11/24 at 11:19 A.M., showed the resident with a dressing to his/her right leg, left foot, and a dressing to his/her left and right arm. Observation showed the resident's door did not have a Enhanced Barrier Precaution sign. Observation on 06/12/24 at 10:21 A.M., showed the resident had a dressing to his/her left foot, right below the knee amputation, left arm, right arm and right ear. Observation showed the resident's door did not contain a EBP sign. Observation on 06/14//24 at 01:15 P.M., showed the resident's door did not contain a EBP sign. 8. During an interview on 06/14/24 at 2:30 P.M., the Director of Nursing (DON) said staff are expected to perform hand hygiene when entering a room, before leaving a room and between glove changes to decrease the risk of infection spread. He/She said staff are expected to post signs on the resident doors indicating they are on EBP for wounds, catheters and ostomies and is the responsibility of the wound nurse, but he/she is new so it would fall on the DON to make sure they are there. Staff are expected to follow the guidance on the signs including wearing of gowns during provisions of care and wound care. He/she did not know why the signs were not posted. During an interview on 06/14/24 at 3:07 P.M., the administrator said residents with EBP precautions should have a sign on the door indicating the precautions needed. He/She said if staff do not follow the guidance there is a potential for the spread of infection. The administrator said any resident with a wound should have an EPB sign on their door. The staff should then be aware that proper PPE should be used during resident care. 43327 50753

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 77. 1. Review of the facility's Dietary Manager / Food Services Director job description, reviewed 06/30/03, showed the individual must be a Certified Dietary Manager (CDM) in good standing or in training to satisfactorily complete the requirements to become a CDM. During an interview on 06/11/24 at 10:21 A.M., the Dietary Supervisor (DS) said he/she worked in the facility for 8 months and started as DS about two months ago. The DS said he/she had not started CDM classes yet and had never taken other food safety manager courses. The DS said he/she had food safety handling classes four or five years ago. The DS said he/she was not given a training completion timeline and had not received CDM course enrollment paperwork. During an interview on 06/12/24 at 2:00 P.M., the Registered Dietician (RD) said the facility had not been able to find a Certified Dietary Manager to work at the facility. The RD said the facility was working toward the dietary supervisor's CDM credential. The RD said the DS was not scheduled to attend any food service manager training other than the CDM course. During an interview on 06/13/24 at 1:45 P.M., the administrator said the facility was having a hard time finding a CDM. The administrator said he/she thought the DS was allowed one year from hire date to obtain CDM credential so he/she did not look at alternatives.

Based on observation, interview, and record review, facility staff failed to provide daily activities for all residents who reside on the secured unit. The facility census was 77. 1. Review of the facility's Delegation of Activity Program Duties policy, dated March 2008, showed: -The activities program should provide stimulation or solace; promote physical, cognitive and/or emotional health; enhance to the extent practicable, each resident's physicial and mental status; and promote each resident's self-respect by providing, for example, activities that support self-expression and choice; -Activities should be designed to provide meaningful activity to each resident, consistent with their background and interests, every day. Review of the facility's Resident Daily Routines and Activities on the dementia unit policy, dated May 2002, showed: -Time not involved with activites of daily living care or formal activites can be meaningful for the resident by providing space that is safe, with objects for free exploration, such as scrapbooks, magazines, seed catalogs, memory boxes, etc.; -Activities should be age appropriate; -When helpful, use background music to create a mood conducive to activities; -Daily routines should be established for each resident, based on their level of functioning and preferences for activity; -Activities should provide an appropriate stimulation level to avoid hyperactivity or overly passive activities; -Passive activities are more appropriate in the early evening hours, to cue rest and sleep and active-participatory activites are more appropriate in early day, when it is time to be busy; -The activity department may assist in the dementia unit, but the primary caregivers should be responsible to conduct daily recreational activites. Review of the Activity Calendar, dated June 2024 posted on the secured unit showed: -On 6/11/24, at 11:30 A.M., fold laundry and at 2:00 P.M., counting numbers; -On 06/12/24, at 11:30 A.M., church service and at 2:00 P.M., fresh fruit; -On 06/13/24 at 11:30 A.M, craft/make a flag and at 2:00 P.M., ring toss; -On 06/14/24 at 11:30 A.M, Father's day social and at 2:00 P.M., iced tea time. Observation on 06/11/24 at 11:45 A.M., showed residents sat at the dining room table, wandered the halls, or were in their rooms. Staff did not provide the fold laundry activity. Observation on 06/11/24 at 2:17 P.M., showed residents sat at the dining room table, wandered the halls, or were in their rooms. Staff did not provide the counting numbers activity. Observation on 06/13/24 at 2:13 P.M., showed residents sat at the dining room table, wandered the halls, or were in their rooms. Staff did not provide the ring toss an activity. During an interview on 06/14/24 at 9:03 A.M., Certified Nurse Aide (CNA) F said activities is responsible to organize and assist with the first activity of the day and nursing is responsible for the second in the afternoon. He/She said activities don't always happen because there is usually only one staff member on the secured unit that are responsible for toileting, bathing/showers, naps, snacks, feeding and watch and deal with resident behaviors. He/She said he/she does the best they can. During an interview on 06/14/24 at 12:53 P.M., the activity director said activities assist with providing spelling bees, memory games, name that price, painting and always try new things. He/She said he/she puts a calendar on the wall for staff to use as a guide to complete activities on the secured unit. He/She said he/she reminds the staff to document the resident's participation, but knows it is not always done. He/She said the secured unit residents do not go to facility group activities very often because it is a lot for him/her to watch them. During an interview on 06/14/24 at 2:30 P.M., the Director of Nursing (DON) said activites are performed on the secured unit once or twice a day by the activity director and knows the regular staff will sometimes color with the resident or do things they like. He/She said ideally, there would be two staff on the unit, so activities could get done but right now, most of it is done by the activity director. During an interview on 06/14/24 at 3:07 P.M., the administrator said there is an activity calendar on the secured unit that are performed one time a day by the activity director. He/She said sometimes there are volunteers and churches that come in as well as TV time. The administrator said the residents are often tired by 7:00 P.M. or 8:00 P.M., and go to bed, but rise early in the morning.

Based on observation, interview and record review, facility staff failed to obtain informed consent, complete entrapment assessments, and/or complete a side rail assessment the use of side rails and/or grab bars for nine (Resident #17, #20, #21 #32, #39, #41, #54, #82, and #244 ) of nine sampled residents . The facility census was 77. 1. Review of the facility's Proper Use of Side Rails Policy, dated 10/26/22, showed side rails should be addressed in the care plan and the resident and the resident representative should give informed consent to the use of the device, prior to its use. The facility did not provide entrapment or side rail assessments upon request. 2. Review of Resident #17's Admission Minimum Data Set (MDS), a federally mandated assessment, dated 05/06/24, showed staff assessed the resident as: -Required partial/moderate assist in bed mobility; -Required partial/moderate assist in sit to stand; -Required partial/moderate assist in chair/bed to chair transfer; -Did not use side rails/restraints. Review of the resident's medical record, showed the record did not contain a signed consent, an entrapment assessment or side rail assessment for the use of side rails. Observation on 06/11/24 at 11:03 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/12/24 at 9:50 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/13/24 at 7:58 A.M. and 1:31 P.M., showed the resident in bed with bilateral quarter size side rails in the raised position. 3. Review of Resident #20's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No behaviors; -Not Applicable to assess bed mobility; -Dependent for chair to bed-to chair transfers; -Not Applicable to assess sit to stand transfers; -No restraints; -Diagnoses of Multiple Sclerosis. Review of the resident's medical record showed the record did not contain a signed consent, an entrapment assessment or side rail assessment for the use of side rails. During an interview on 06/11/24 at 11:23 A.M., the resident said he/she used the grab bars to hold him/herself in position for personal care. Observation on 06/11/24 at 11:33 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/12/24 at 8:58 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/13/24 at 10:00 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/14/24 at 9:01 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. 4. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Impaired cognition; -Required supervision for sitting to lying; -Required partial/moderate staff assist for lying to sitting; -Required substantial/moderate assistance for chair to bed-to chair transfers; -Dependent on staff for sit to stand transfers; -No restraints; -Diagnosis of hip fracture. Review of the residents medical record showed the record did not contain an entrapment assessment. Observation on 06/12/24 at 8:28 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/13/24 at 4:46 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. 5. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Partial/moderate assist is bed mobility, sit to stand, and chair/bed to chair transfer; -Did not use side rails/restraints. Review of the resident's medical record, showed the record did not contain a signed consent, an entrapment assessment or side rail assessment for the use of side rails. Observation on 06/12/24 at 08:19 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. 6. Review of Resident #39's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Independent for bed mobility, sit to stand, and transfers between the bed and chair; -Did not use restraints. Review of the resident's medical record showed the record did not contain a signed consent, an entrapment assessment, or an assessment for the use of side rails. Observation on 06/11/24 at 11:47 A.M., showed the resident sat on the edge of the bed with the bed rail in the raised position. Observation on 06/12/24 at 8:54 A.M., showed the resident sat on the edge of the bed with the bed rail in the raised position. Observation on 06/14/24 at 8:30 A.M., showed the resident sat on the edge of the bed with the bed rail in the raised position. 7. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No behaviors; -Independent with all mobility; -No restraints. Review of the resident's medical record showed the record did not contain a signed consent, an entrapment assessment or side rail assessment for the use of side rails. Observation on 06/11/24 at 11:47 A.M., showed the resident in bed with the grab bar in the raised position. Observation on 06/12/24 at 10:21 A.M., showed the resident in bed with the grab bar in the raised position. Observation on 06/14/24 at 09:34 A.M., showed the resident in bed with the grab bar in the raised position. During an interview on 06/12/24 at 9:40 A.M., the resident said he/she did not use the bed rails. 8. Review of Resident #54's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Required supervision for roll left to right and sitting to lying; -Required partial to moderate staff assistance for lying to sitting; -Required substantial/maximum assistance for sit to stand and chair/bed-to-chair transfers; -No restraints; -Diagnosis of Alzheimer's dementia. Review of the resident's medical record, showed the record did not contain a signed consent, an entrapment assessment or side rail assessment for the use of side rails. Observation on 06/11/24 at 11:02 A.M. and 2:51 P.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/12/24 at 08:36 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/14/24 at 08:39 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. 9. Review of Resident #82's Admission MDS, dated [DATE], showed staff assessed the resident as: -Partial/moderate assist is bed mobility; -Partial/moderate assist in sit to stand; -Partial/moderate assist in chair/bed to chair transfer; -Did not use side rails/restraints; Review of the resident's medical record, showed the record did not contain a signed consent, an entrapment assessement or side rail assessment for the use of side rails. Observation on 06/11/24 at 10:59 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/12/24 at 8:22 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/13/24 at 7:51 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. 10. Review of Resident #244's Entry Tracking Record dated 05/31/24, showed staff assessed the resident as follows: -Cognitive; -Bilateral upper and lower extremity impairment: -Partial to maximum assistance needed for bed mobility. Review of the resident's medical record showed the record did not contain a signed consent, an entrapment assessement or side rail assessment for the use of side rails. Observation on 06/13/24 at 1:23 P.M., showed the resident in bed with bilateral quarter size side rail in the raised position. Observation on 06/14/24 at 11:05 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. During an interview on 06/12/24 at 10:06 A.M., the resident said the bed rail assists with mobility while in the bed and getting into his wheelchair. 11. During an interview on 06/14/24 at 2:42 P.M., the Director of Nursing (DON) said side rail assessments should be done and in the electronic chart. He/She said maintenance completes the entrapment assessments, and then staff gets consents. Who monitors it is being completed and why not done? During an interview on 06/14/24 at 03:07 P.M., the administrator said it is the responsibility of maintenance and Physical Therapy to obtain the consents. He/she said the consent forms are kept in the office of the DON. She said she could not find the consent forms. 42484 43327

Based on interview and record review, facility staff failed to complete a thorough investigation when Licensed Practical Nurse (LPN) C reported he/she was accused by one resident (Resident #1) of making threats. The facility census was 84. 1. Review of the facility's policy titled, Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, revised 10/24/22, showed staff were directed to: -The facility will investigate and document all incidents and accidents involving residents/guests, certain incidents and accidents must also be reported to the appropriate state agencies; -The facility will report all alleged instances of abuse -Notify the Administrator of an unusual situation in the facility, whether reportable or not, immediately; -The Administrator or designee will report to the State Agency and all other required agencies, per regulation; -All allegations of abuse and instances that result in serious bodily injury must be reported within 2 hours; -The Administrator is responsible for conducting a thorough investigation and obtaining witness statements. 2. Review of the resident's face sheet showed: -admitted [DATE] at 9:32 P.M.; -discharged [DATE] at 9:00 A.M. Review of the resident's nurses notes showed: -On 06/01/24 at 9:23 A.M., LPN C documented staff alerted him/her the resident had requested pain medication. LPN C entered resident's room and noted resident to be visible upset. LPN C asked the resident what was wrong, and the resident responded that staff did not answer his/her call light, did not come assist her, and his/her roommate cried all night. LPN C offered the resident a room change but the resident responded that he/she had called his/her spouse. The resident said his/her spouse called an ambulance and he/she was leaving. LPN C explained to the resident if he/she left against medical advice (AMA) that he/she would be responsible for his/her room charge and LPN C could not send the resident's medications with him/her. The resident responded she didn't care then proceeded to say that LPN C was trying to kill her and threaten her with his/her medications. LPN C administered requested pain medications and left the room. Staff came and alerted LPN C about 10 minutes later that the resident's spouse was in the room and the resident told his/her spouse he/she was threatened with his/her medications. LPN C spoke to the spouse and attempted to explain what happened, but spouse interrupted LPN C and said he/she was taking the resident out of the facility. LPN C called the residents physician and left a message. LPN C asked resident's spouse to sign an AMA form which he/she did and LPN C made the spouse a copy. LPN C assisted ambulance staff to move the resident from the bed to the gurney. LPN C called the Administrator and DON after. 3. Review of the facility's investigation, dated 06/26/24, showed the investigation did not contain documentation staff started the investigation until 06/26/24 at 11:50 A.M. 4. During an interview on 06/26/24 at 1:25 P.M., the Regional Nurse said the Director of Nursing (DON) and him/her were completing random chart audits and discovered a nurse's note written on 06/01/24 by LPN C. LPN C and the Administrator were suspended immediately when the note was discovered today until the investigation is completed. He/She got a statement from LPN C about the incident. During an interview on 06/26/24 at 1:25 P.M., the DON said he/she and the Regional Nurse were doing random chart audits and discovered a nurse's note written on 06/01/24 by LPN C. The DON said this incident was reported to the Administrator but not to Department of Health and Senior Services (DHSS). The DON said he/she remembered LPN C called him/her about the resident leaving AMA but did not tell him/her about the resident's comment. The DON said he/she found out about the comment with the chart audit. During an interview on 06/27/24 at 8:42 A.M., the Administrator said the day the resident was admitted he/she left at 5:00 P.M. for vacation. The Administrator said he/she did not meet the resident as the resident was admitted after he/she left. The Administrator said he/she does not remember the conversation with LPN C on 06/01/24. The Administrator said he/she would have referred LPN C to the DON since he/she was on vacation. The Administrator said he/she has not had any previous concerns or reports regarding LPN C. The Administrator said if allegations of threats or abuse are reported to him/her then he/she is responsible to complete an investigation and report it to the DHSS within two hours. During an interview on 06/27/24 at 8:51 A.M., LPN C said he/she was the charge nurse on 06/01/24 the day the resident left AMA. After the resident left he/she called the Administrator and reported the whole story to him/her. LPN C said the Administrator was on vacation and asked LPN C to contact the DON. He/She called the DON and just told her the resident left AMA. He/She did not tell the DON the whole story. LPN C said he/she received abuse/neglect training upon hire, monthly in the staff meetings, and as needed. LPN C said the Regional Nurse did abuse/neglect and medication training at discharge with him/her on 06/26/24 too. If he/she knows of abuse/neglect happening he/she would report it to the Administrator or DON. LPN C said any abuse/neglect must be reported to DHSS within two hours. LPN C said anyone can make a report to DHSS but generally the Administrator or DON make those reports. MO00238182

Based on observation, interviews, and record review facility staff failed to provide appropriate personal hygiene, bathing, and incontinence care for seven (Resident #3, #20, #21, #47, #52, #54, and #81) out of 18 dependent sampled residents. The facility census was 77. 1. Review of the facility;s Hygiene and Grooming policy, dated 11/01/01, showed good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity Review showed staff care to include: A.M. Care to include: a) Offer bedpan, urinal or assistance to the bathroom; b) If the resident is incontinent of urine or stool, provide perineal care; c) Wash hands after returning utensils to proper place; d) Get a basin of warm water, and take to bedside for the resident to wash face and hands . Assist the resident as needed; e) Gather oral hygiene supplies, and take to bedside for the resident to brush teeth. Assist the resident as needed; f) Wash hand after returning utensils to proper place; g) Assist the resident to dress in desired clothing for breakfast; h) Assist the resident to comb an brush hair, as needed; i) Assist the resident to the dinning room, when appropriate. Position the resident in comfortable sitting position, when eating in the room. Be sure call light is within reach, when the resident remains in the room. P. M. Care to include: a) Offer bedpan, urinal assistance to the bathroom; b) If the resident is incontinent of urine or stool, provide perineal care; c) Wash hands after returning utensils to proper place; d) Get a basin of warm water, and take to beside for the resident to wash face and hands. Assist the resident as needed; e) Apply lotion as needed; f) Gather oral supplies, and take to the beside for the resident to brush teeth. Assist the resident as needed; g) Wash hands after returning utensils to proper place. Review of the facility's Shaving the Resident policy, dated November 2001, showed male and female residents are shaved daily or as needed. Review of the facility's Nail Care policy, dated November 2001, showed nail care is a routine part of grooming each day. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 05/14/24, showed staff assessed the resident as follows: -Cognitively intact; -Bathing substantial assistance. Review of the resident's care plan, dated 03/20/24, showed staff were directed to provide assistance with toileting, ambulation, and other personal needs; Review of the resident's care summary, dated 04/01/24 through 06/11/24, showed staff documented the resident received a shower on 04/12/24, 05/03/24, 05/24/24, and 06/04/24. Observation on 06/12/24 at 10:33 A.M., showed the resident in his/her room with his/her hair loosely pulled back in a ponytail greasy and disheveled. Observation on 06/14/24 at 9:00 A.M., showed the resident had greasy disheveled hair pulled back loosely in a ponytail. During an interview on 06/12/24 at 10:38 A.M., the resident said he/she had not received a shower in over two weeks and that it was frustrating for him/her to have to wait so long. 3. Review of Resident #20's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for toilet hygiene and personal hygiene. Review of the resident's care plan, dated 03/18/24, showed the care plan did not address the resident's need for assistance to complete daily activities of care. Observation on 06/11/24 at 11:33 A.M., showed the resident with body odor, long fingernails with dark residue underneath, greasy uncombed hair, and facial hair. Observation on 06/12/24 at 11:11 A.M., showed the resident with body odor, long fingernails with dark residue underneath, greasy uncombed hair, and facial hair. Observation on 06/13/24 at 10:00 A.M., showed the resident with body odor, long fingernails with dark residue underneath, greasy uncombed hair, and facial hair. Observation on 06/14/24 at 09:01 A.M., showed the resident with body odor, long fingernails with dark residue underneath, greasy uncombed hair, and facial hair. During an interview on 06/12/24 at 11:11 A.M., the resident said he/she was not offered a bed bath frequently enough. The resident said he/she liked to be clean and without facial hair. The resident said he/she felt unpleasant to him/herself and others. 4. Review of Resident #21's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -No behaviors or rejection of care; -Dependent on staff for toilet hygiene and personal hygiene; -Diagnosis of Alzheimer disease. Review of the resident's care plan, dated 05/9/24, showed staff assessed the resident required assistance to complete daily activities of care safely. Review of the Resident Care summary, dated 04/14/24 through 05/14/24, showed staff documented the resident received three showers. Review of the Resident Care summary, dated 6/14/24, showed staff documented the resident received five showers during the 30-day look back peroid. Observation on 06/11/24 at 12:21 P.M., showed the resident with long fingernails, long facial hair and uncombed hair. Observation on 06/12/24 at 08:28 A.M., showed the resident with long facial hair with a red stain around the mouth, long fingernails and uncombed hair. Observation on 06/13/24 at 4:45 A.M. through 6:25 A.M., showed the resident in bed with a visibly saturated brief and smelled of urine. Observation on 06/13/24 at 1:53 P.M., showed the resident with long facial hair and long fingernails. Observation on 06/14/24 at 8:25 A.M., showed the resident with long facial hair and long fingernails. His/her hair was uncombed. During an interview on 06/13/24 at 1:52 P.M., the family said the resident did not have facial hair in the past and would not let his/her nails get so long. He/She said that his/her nails could scratch his/her skin and maybe get a tear. During an interview on 06/13/24 at 6:30 A.M., Certified Nurse Aid (CNA) G said the resident can be resistive during care at times but is not an excuse. He/She said he/she is on the hall by him/herself a lot and do the best they can. 5. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required set-up for showers; -Diagnosis of Parkinson's Disease and depression. Review of the resident's care plan, dated 04/08/24, showed the care plan did not address the resident's need for assistance to complete daily activities of care. Review of the Resident Care summary, dated 03/14/23 through 04/11/24, showed staff documented the resident received one bed bath. Review of the Resident Care summary, dated 04/15/23 through 05/15/24, showed staff documented the resident received one shower. Review of the Resident Care summary, dated 05/16/24 to 06/22/24, showed staff documented the resident received three showers. Observation on 06/11/24 at 3:11 P.M., showed the resident's hair was greasy and with facial hair. Observation on 06/11/24 at 10:20 A.M., showed the resident's hair was greasy and with facial hair. During an interview on 06/11/24 at 10:20 A.M., the resident said he/she was upset because showers were not regularly available. The resident said he/she wants to appear clean and does not want facial hair. 6. Review of Resident #52's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent for personal hygiene; -Total dependence bathing; -Diagnosis of alzheimers, and dementia. Review of the resident's care plan, dated 05/23/24, showed staff were directed as follows; -Assess skin daily with routine care; -Full skin assessment with bath/shower: -Hair done during activities. Review of the resident's care summary, dated 04/01/24 through 06/1/24, showed staff documented the resident received a shower on 05/06/24, 05/23/34, and 06/08/24. Observation on 06/11/24 at 2:50 P.M., showed the resident's hair was very disheveled and dry in appearance. Observation on 06/14/24 at 10:20 A.M., showed the resident's hair was uncombed and disheveled. 7. Review of Resident #54's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -No behaviors or rejection of care; -Dependent on staff for personal hygiene; -Required substantial/maximum assistance for dressing; -Diagnosis of Alzheimer disease. Review of the Resident Care summary,dated 03/16/24 through 06/13/24, showed staff documented the resident received eight showers. Review of the resident's care plan, dated 07/12/23, showed: -The resident required assistance to complete daily activities of care safely; -Bath per schedule; -Assist with shaving; -Assist with hair; -The care plan did not contain direction or guidance for dressing. Observation on 06/11/24 at 11:02 A.M., showed the resident wore a blue shirt with pale blue sweatpants. The shirt and paints contained stains and debris and hair was disheveled. Observation on 06/11/24 at 12:44 P.M., showed the resident in the dining room for lunch with stains and debris on his clothing and hair was uncombed. During an interview on 06/13/24 at 6:30 A.M., CNA G said that the resident can do a lot of things by himself but should not be wearing soiled clothing or have uncombed hair. Staff should help the resident if he/she cannot do the task. He/She said he/she is often on the hall by him/herself and does the best they can. 8. Review of Resident #81's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Independent with personal hygiene and toileting; -Required supervision with dressing; -Diagnosis of dementia. Review of the residnet's care plan, dated 04/08/24, showed: -Provide pericare after each incontinent episode; -Dressing with one person assist; -Bathing per schedule with one person assist; -Toilet with one person assistance. Review of the Resident Care summary, dated 03/16/24 through 06/13/24, showed staff documented the resident received ten showers. Observation on 06/12/24 at 8:35 A.M., showed the resident wore green pants with a black shirt with a white logo across the front. Observation on 06/13/24 at 6:06 A.M., showed the resident up ambulating the hallway wearing green pants with a black shirt with a white logo across the front. He/She smelled of urine and his/her pants were visibly wet. The resident's sheets and mattress were wet, hair was uncombed. During an interview on 06/13/24 at 06:30 A.M., CNA G said that the resident normally takes themself to the bathroom and does not know why they were so wet. He/She said the resident was last checked on around 4:15 or 4:30 A.M. 9. During an interview on 06/14/24 at 9:52 A.M., CNA M said we do not have enough staff to get the showers done and we often stay over time to try and finish them. During an interview on 06/14/24 at 9:58 A.M., CNA N said we do showers at least every three days but he/she did not think they were all getting done due to low staff numbers. During an interview on 06/14/24 at 10:07 A.M., Licensed Practical Nurse (LPN) P said showers should be done at least twice a week. He/She said we are not currently able to always do that and it is inappropriate. The residents are not receiving showers. During an interview on 06/14/24 at 10:34 A.M., the Director of Nursing said showers should be done twice a week, nails and hair are done in the morning. Incontinence care should be done as soon as possible and all grooming finished before a resident leaves their room. The memory care unit may not be getting this task done because we do not currently have two staff in the unit. During an interview on 06/14/24 at 3:07 P.M., the Administrator said staff should shower/bathe residents twice a week at least. All morning care like brushing teeth, washing faces, and changing clothes should be be done. Typically it is done but not always in the morning because staff are to busy. All facility staff can help get hygiene finished. We schedule showers by room numbers. 42484 43327

Based on observation, interview and record review, facility staff failed to provided a safe, clean, comfortable, and homelike environment when facility staff did not repair damage in resident rooms and bathrooms. The facility census was 77. 1. Review of the facility's Federal Rights of Residents, dated 11/01/01, showed facility will provided a safe, clean, comfortable, and homelike environment. Review showed staff are directed to: -Clean beds and bath lines that are in good condition; -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 2. Observation on 06/11/24 at 10:15 A.M., showed occupied room [ROOM NUMBER]'s bathroom door with a large plastic scratch guard hung loose on one side with sharp edges and a heavily stained bathroom floor. Observation on 06/11/24 at 11:02 A.M., showed occupied room [ROOM NUMBER] doorframe with chipped paint, shower floor with brown stained tile, stained caulk around the toilet and privacy curtain partially torn. Observation on 06/11/24 at 11:07 A.M., showed occupied room [ROOM NUMBER] shower floor with stained tile and call light tapped to the wall with bandage tape. Observation on 06/11/24 at 11:22 A.M., showed occupied room [ROOM NUMBER] wall behind the residents bed with a gouge, the baseboard by the shower wall loose, the shower floor stained and a rust-colored ring in the sink bowl. Observation on 06/11/24 at 12:21 P.M., showed occupied room [ROOM NUMBER] wall behind the resident's beds with multiple areas of gouges and chipped paint. Observation on 06/12/24 at 8:16 A.M., showed occupied room [ROOM NUMBER] bathroom floors with areas of lifted and cracked floor tiles. Observation showed the bathroon floor tiles with heavy black stains in the grout lines. Observation on 06/14/24 10:23 at A.M., showed resident occupied room [ROOM NUMBER]'s door did not close and latch with ease. Certified Nursing Assistant (CNA) N attempted to shut the door and shoved the door closed with force. Observation on 06/14/24 at 11:03 A.M., showed resident occupied room [ROOM NUMBER]'s bedroom floor tiles chipped around the perimeter of the bed with gray stains between the beds, black residue between the tiles under the heating/cooling unit. Observation of the resident bathroom showed the base of the toilet discolorwd and the bathroom door scratched. Observation on 06/14/24 at 11:05 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom sink pipes wrapped in black tape and a tub under the pipe filled with gray water. The bathroom door contained gouges, and the baseboard missing with crumbled drywall. The bathroom tiles in the bathroom had yellow stains and the caulk with black residue. Observation on 06/14/24 at 11:08 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom with yellow stains on the tiles, and black residue in the caulking. Observation on 06/14/24 at 11:10 A.M., showed resident occupied room [ROOM NUMBER]'s wall by both beds with areas drywall and paint peeled. Observation of the bathroom showed the tiles behind the toilet with black residue. Observation on 06/14/24 at 11:08 A.M., showed the 400-hallway floor tiles cracked, chipped tiles, and with multiple stains. 3. During an interview on 06/14/24 at 9:50 A.M., Certified Nurse Aid (CNA) M said he/she tells the maintenance supervisor verbally if they find damaged items in a residents room. He/She said they were aware of the damage to the resident rooms. During and interview on 06/14/24 at 10:02 A.M., CNA N said if damage is noticed to a resident room he/she tells the Maintenance supervisor directly. He/She said they have told the maintenance supervisor about the damage in the rooms. During an interview on 06/14/24 at 10:17 A.M., Housekeeper C said many of the floors need to be replace because they can not be cleaned correctly due to the damage on them. He/She said they report damage to the housekeeping supervisor and to the maintenance department. During an interview on 06/14/24 at 11:09 A.M., the maintenance supervisor said staff should use the maintenance tracking computer software (TELS) to report repairs needed so it can be tracked, but chose to report it verbally instead. He/She was aware of the rooms that needed to be fixed. During an interview on 06/14/24 at 2:37 P.M., the Director of Nursing said staff should tell the maintenance supervisor through the electronic maintenance system, not verbally so it can be tracked. Maintenance is responsible for the repairs to resident rooms. During an interview on 06/14/24 at 3:17 P.M., the administrator said the maintenance supervisor is responsible for repairs to the building and that they were aware of the damage. Staff should report damage in the electronic system not verbally alone. Any immediately dangerous damage should be fixed right away. 43327

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs for five (Resident #17, #20, #21, #82 and #244) of sixteen sampled residents. The facility census was 77. 1. Review of the facility's Nursing Assessment's policy, dated August 2018, showed: -The facility conducts, a comprehensive, standardized assessment of each resident's functional capacity necessary to develop a person centered care plan and to modify the care plan and care services based the resident's status and resident goals and preferences, future discharge; -Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident's condition; -The comprehensive person-centered care plan is established with input from the resident/resident representative and upon completion of a comprehensive Minimum Data Set (MDS) assessment, a federally mandated assessment tool completed by facility staff, by the interdisciplinary team (IDT); -The initial nursing assessment on admission should include a baseline plan of care to be completed within 48 hours of admission; -The comprehensive assessment should include an IDT plan of care developed within 21 days of admission; -The quarterly nursing assessment should include a quarterly update of the IDT care plan; -A significant change of condition assessments should include an update to the plan of care to reflect the change of condition; -Information in the medical record, as documented by nursing personnel aids in the development of accurate plans. 1. Review of Resident #17's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/06/24, showed staff assessed the resident as: -Inattentive and disorganized thinking that fluctuates; -Use of a walker or a wheelchair; -Required parital/moderate staff assistance for sitting to lying; -Required partial/moderate staff assistance for lying to sitting; -Required partial/moderate assistance for chair to bed-to chair transfers; -Required partial/moderate assistance for sit to stand transfers; -Did not use bed rails. Review of the resident's care plan, dated 06/10/24, showed the care plan did not contain direction for the following: -Use of bed rails; -Cognitive loss/demenia; -Activities of daily living (ADL) function; -Urinary incontenence; -Psychosocial well-being; -Behaviors; -Activities; -Dehydration; -Surgical wounds; -Enhanced Barrier Precautions. Observation on 06/11/24 at 11:03 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/12/24 at 9:50 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/13/24 at 7:58 A.M. and 1:31 P.M., showed the resident in bed with bilateral quarter size side rails in the raised position. 2. Review of Resident #20's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No behaviors or rejection of care; -Dependent on staff for all mobility and hygiene; -Had an indwelling catheter; -Diagnosis of Multiple Sclerosis (MS), anxiety, and depression. Observation on 06/11/24 at 11:33 A.M., showed the resident in bed with raised bed rails. Observation on 06/14/24 at 09:01 A.M., showed the resident in bed with raised bed rails. Review of the resident's care plan, dated 3/1824, showed the care plan did not contain direction for the following: -Activities of daily living (ADL) function; -Catheter care; -Use of bed rails. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Inattentive and disorganized thinking that fluctuates; -Required supervision/touching for sitting to lying; -Required partial/moderate staff assist for lying to sitting; -Required substantial/moderate assistance for chair to bed-to chair transfers; -Dependent on staff for sit to stand transfers; -No restraints; -Diagnosis of hip fracture, Alzheimer's disease, anxiety and depression. Review of the resident's care plan, dated 05/09/24, showed the care plan did not contain use or direction for use of bed rails. Observation on 06/12/24 at 8:28 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. Observation on 06/13/24 at 4:46 A.M., showed the resident in bed with grab bars on both sides of the bed in the up position. During an interview on 06/13/24 at 6:06 A.M., Certified Nurse Aide (CNA) G said he/she did not know what it said regarding the side rails for the resident. During an interview on 06/14/24 at 9:03 A.M., CNA F said he/she did not know what it said regarding the side rails for the resident, but knows they are on the bed. 4. Review of Resident #82's Admission MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Inattentive and disorganized thinking that fluctuates; -Use of a wheelchair; -Required supervision/touching for sitting to lying; -Required partial/moderate staff assistance for lying to sitting; -Required parital/moderate assistance for chair to bed-to chair transfers; -Dependent on staff for sit to stand transfers; -Has pressure ulcers; -No restraints. Review of the resident's care plan, dated 05/29/24, showed the care plan did not contain direction or intervention for the following: -Use of bed rails; -Cognitive loss/demenia; -Activities of daily living (ADL) function; -Urinary incontenence; -Psychosocial well-being; -Behaviors; -Nutrition; -Enhanced Barrier Precautions. Observation on 06/11/24 at 10:59 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/12/24 at 8:22 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Observation on 06/13/24 at 7:51 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. 5. Review of Resident #244s Admission MDS, dated [DATE], showed staff did assessed the resident as follows: -Cognitive; -Bilateral upper and lower extrimity impairment; -Surgical wounds; -Used wheelchair. During an interview on 06/12/24 at 10:06 A.M., the resident said the bed rail assists with mobility while in the bed and getting into his wheelchair. Observation on 06/13/24 at 1:23 P.M., showed the resident in bed with bilateral quarter size side rail in the raised position. Observation on 06/14/24 at 11:05 A.M., showed the resident in bed with bilateral quarter size side rails in the raised position. Review of the resident's care plan, 06/07/24, showed the care plan did not contain direction for the use of bed rails. 6. During an interview on 06/13/24 at 06:06 A.M., CNA G said the care plans are in the computer and in a book off the secured unit. He/she has access to them but does not always have time to read them. During an interview on 06/14/24 at 09:03 A.M., CNA F said the care plans are in the computer and in a book off the secured unit. He/she has access to them and include specialized care needs such as call lights, assistance level, behavioral interventions, skin breakdown and falls. During an interview on 06/14/24 at 01:44 P.M., Licensed Practical Nurse (LPN) A said CNA's on the secured unit would have to ask the charge nurse and therapy how to care for a resident if its not in a care plan. He/She said the care plans are kept in a book at the nurse station and CNA's that work on the secured unit would have to come out to review them and someone would have to cover for them while they are off the unit. During an interview on 06/14/24 at 2:30 P.M., the Director of Nursing (DON) said residents should have a baseline care plan completed within 48 hours then a comprehensive after the admission MDS is completed. He/She said it is the responsibility of the MDS nurse to complete/accurate and update the care plans to include: activities of daily living, risk for elopement, potential for weight variations, potential for skin breakdown, falls, code status, incontinence and anything that would trigger on the MDS assessment. He/She said it is the DON's responsibility to ensure staff are following the care plans. During an interview on 06/14/24 at 3:07 P.M., the Administrator said care plans should be initiated by the MDS nurse and should include falls, infection, anything that changes with the resident, wounds, interventions for prevention of skin breakdown, special diets and infection prevention such as Enhanced Barrier Precautions (EBP). He/She said the IDT staff review the daily nurse notes and can update the care plans at that time with any changes. 43327 50753

Based on observation, interview, and record review, facility staff failed to safely propel two residents (Resident #25, and #52) out of two residents in wheelchairs. Facility staff failed to ensure the residents' environment remained free of accident hazards when staff did not ensure access to a key for the employee bathroom on the secured unit was available and the door locked at all times to keep residents from entry. The facility census was 77. 1. Review of the facility's policies showed staff did not provide a policy for the use of wheelchairs. 2. Review of Resident #25's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/15/24, showed staff assessed resident as: -Severely cognitively impaired; -Required no assistance for locomotion short distances and partial assistance for long distances; -Wheelchair used as a mobility device. Observation on 06/12/24 at 07:14 A.M., showed Licensed Pratical Nurse (LPN) O propelled the resident in his/her wheelchair from the hallway to the dining room without foot pedals. 3. Review of Resident #52's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Total dependence transfer; -Total dependence wheelchair; -Diagnosis of Alzheimer disease, and dementia. Observation on 06/11/24 at 12:25 P.M., showed LPN K propelled the resident in his/her wheelchair from the dinning area to a common area and one foot dragged on the floor. During an interview on 06/11/24 at 12:30 P.M., LPN K said he/she should have put the residents foot on the footrest before moving the resident in the wheelchair because it is not safe to do otherwise. 4. During an interview on 06/14/24 at 2:33 P.M., The Director of Nursing (DON) said staff should not propel residents in wheelchairs without footrests because they could be injured. During an interview on 06/14/24 at 3:14 P.M., the administrator said staff should have the footrests on wheelchairs when propelling residents to prevent injury to the resident. 5. Review of the facility's Dementia Unit Characteristics policy, dated October 2003, showed the same safety features as if a house was child proofed should be used. Review showed doors to hazardous areas closed and locked and hazardous objects or substances kept in locked closets. Observation on 06/11/24 at 12:32 P.M., showed a room labeled employee break room on the secured unit. Observation showed the room employee break room unlocked and contained a linen barrel, a mop bucked with the mop and water, and a toilet. The call light did not have a string to alert staff if a resident wandered into the room and the door locked from the inside. Observation on 06/13/24 at 4:48 A.M. and 1:55 P.M., showed a room labeled employee break room on the secured unit. Observation showed the room employee break room unlocked and contained a linen barrel, a mop bucked with the mop and water, and a toilet. The call light did not have a string to alert staff if a resident wandered into the room and the door locked from the inside. Observation on 06/14/24 at 08:35 A.M., showed a room labeled employee break room on the secured unit. Observation showed the room employee break room unlocked and contained a linen barrel, a mop bucked with the mop and water, and a toilet. The call light did not have a string to alert staff if a resident wandered into the room and the door locked from the inside. During an interview on 06/12/24 at 4:58 A.M., Certified Nurse Aide (CNA) G said residents often go to the employee bathroom and open it up and try to go in it. He/She said there had not been a key for it since the locks were changed a while ago. CNA G said if a resident would go in the room and lock the door, staff would have to call maintenance to get them out. During an interview on 06/14/24 at 03:07 P.M., the administrator said he/she was not aware the door did not lock to the employee bathroom on the secured unit. He/She said if the door does not lock, a resident could wander in there and get hurt. 42484

Based on record review, the facility administration failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes when facility staff failed to have an unlimited year history on the Criminal Background Checks (CBC) through the Missouri Highway Patrol for all new employees. The facility census was 77. 1. Review of the facility's Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation Policy, dated 10/24/22 showed the facility will search the appropriate registries and will conduct a background investigation to determine whether a finding of abuse, neglect, mistreatmnet, exploitation or misappropriation [NAME] been entered against a potential employe. This search will include all registries that the facility believes may have information. 2. Review of the contracted company for CBC checks letter, dated 6/12/24, showed the contracted company is to provide background screening services for pre-employment purposes. Review showed the company will search within a seven year timeframe for misdemeanor records. Felony convictions are reported out as far back as the state allows. In the state of Missouri, our statewide criminal search uses the online court search website to find criminal records. During an interview on 06/13/24 at 2:53 P.M., Financial Specialist Assistant said he/she is responsible for completing the CBC. He/She enters the potential employees name in the to the contracted company to complete the checks. This system has been used for about a year and started after the last survey. He/She was not aware the CBC checks only goes back seven years and did not know it had to be unlimited. He/She said he/she uses what corporate tells him/her to use.

Based on interview and record review, facility staff failed to report an allegation of abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe after being told the resident said a staff member tired to kill them. The facility census was 84. 1. Review of the facility's policy titled, Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, revised 10/24/22, showed certain incidents and accidents must also be reported to the appropriate state agencies. faclity staff are required to report all instances of abuse, neglect, exploitation, and misappropriation of resident/guest property, and suspicious injuries of unknown origin as required by state and federal law. Each employee has an obligation to immediately report any incident or allegation that constitute and instance of abuse, neglect, an injury of unknown origin, exploitation or misappropriation to the administrator, Director of Nurisng (DON), or department supervisor. If the report is made to the DON or department supervisor, that individual will notify the Administrator. The facility will report all alleged instances of abuse. The administrator or designee will report to the State Agency and all other required agencies, per regulation. All allegations of abuse and instances that result in serious bodily injury must be reported within 2 hours. 2. Review of Resident #1's medical record showes the resident admitted to the facility on [DATE]. Review of the resident's nurse's notes, dated 06/01/24 at 9:23 A.M., showed Licensed Practical Nurse (LPN) C documented staff alerted him/her the resident had requested pain medication. LPN C entered resident's room and noted resident to be visibly upset. Review showed staff documented the resident said his/her spouse called an ambulance and he/she was leaving. Review showed the resident said LPN C was trying to kill him/her and threaten him/her with his/her medications. Review showed staff alerted LPN C resident's spouse was in the room and the resident told his/her spouse he/she was threatened with his/her medications. Review of the facilities investigation, dated 06/26/24, showed staff documented LPN C reported on 06/01/24 at 8:29 A.M. the resident said LPN C tried to threaten the resident with his/her medications and tried to kill the resident on or around 06/01/24 at 8:23 A.M. Review of the investigation showed staff documented they notified DHSS on 06/26/24 at 1:17 P.M. During an interview on 06/26/24 at 1:25 P.M., the Regional Nurse said the DON and him/her were completing random chart audits and discovered a nurse's note written on 06/01/24 by LPN C. The Regional Nurse said the note exaplained a resident told him/her that he/she was threatening him/her with his/her medications and trying to kill him/her. The Regional Nurse said this was not report to DHSS until 06/26/24 when he/she found the note. During an interview on 06/26/24 at 1:25 P.M., the DON said he/she and the Regional Nurse were doing random chart audits and discovered a nurse's note written on 06/01/24 by LPN C which showed a resident told him/her that he/she was threatening him/her with his/her medications and trying to kill him/her. The DON said this incident was reported to the administrator the date of the incident but not to DHSS. The DON said the information was reported to DHSS on 06/26/24. During an interview on 06/27/24 at 8:42 A.M., the administrator said he/she does not remember the conversation with LPN C on 06/01/24. The administrator said he/she would have referred LPN C to the DON since he/she was on vacation. The administrator said he/she has not had any previous concerns or reports regarding LPN C. The administrator said if allegations of threats or abuse are reported to him/her then he/she is responsible to complete an investigation and report it to DHSS withing two hours. During an interview on 06/27/24 at 8:51 A.M., LPN C said he/she was the charge nurse on 06/01/24 the day. LPN C said he/she was alerted by staff that the resident requested pain medication. LPN said he/she entered the resident's room with the pain medication and noticed the resident was visibly upset. LPN said he/she asked the resident what was wrong, and the resident replied he/she couldn't get staff's help all night and was leaving the facility. LPN C said the resident told him/her, he/she had contacted his/her spouse and they called an ambulance to assist the resident to leave the facility. LPN C said he/she explained to the resident if he/she left AMA that LPN C could not send his/her medications with him/her. LPN C said the resident responded by saying LPN C was threatening him/her with his/her medications and trying to kill him/her. LPN C said the administrator was on vacation and asked LPN C to contact the DON. LPN C said he/she called the DON and just told her the resident left AMA. LPN C said he/she did not tell the DON the whole story. LPN C said he/she received abuse/neglect training upon hire, monthly in the staff meetings, and as needed. LPN C said any abuse/neglect must be reported to DHSS within two hours. LPN C said anyone can make a report to DHSS but generally the Administrator or DON make those reports. MO00238182

Based on interview and record review, facility staff failed to obtain a timely advanced directive for resident #238 who recieved CPR when he/she elected to be a DNR and failed to document residents' code status consistently as a Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for four residents (Resident #16, #42, #47 and #238) out of fifteen sampled residents. The facility census was 77. 1. Review of the facility's Advance Directives and Refusal of Treatment policy, dated [DATE], showed the resident has a right to formulate an advance directive for the management of his/her care. The resident shall have a copy of his/her advanced directive(s), if any, made a part of his/her medical record. Except in an emergency, prior to the start of any procedure or treatment, the resident shall receive the information necessary from his/her physician to give an informed consent. The information provided to the resident to obtain an informed consent shall include, but not necessarily be limited to, the intended procedure or treatment, the reason for the procedure or treatment, the potential risks, and the probable length of the disability. 2. Review of Resident # 238's medical record showed: -admitted to facility on [DATE]; -Expired in facility on [DATE]; -The record did not contain a signed DNR or Full Code directive. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed the record did not contain an order for his/her code status or advanced directive. Review of the resident's Baseline Care plan, dated [DATE], showed the care plan did not contain the resident's code status or advanced directives. During an interview on [DATE] at 02:54 P.M., the resident's physician said he/she had not had a chance to examine the resident yet and did not have expectations regarding when the code status should or should not be performed or when the code status should be obtained. During an interview on [DATE] at 10:52 A.M., the Social Service Designee (SSD) said the resident came to the facility on a Thursday and signed a DNR form which was faxed to the physician. The physician was off Friday and on Monday, when the resident was without a pulse or breath, CPR was initiated. He/She said that during the CPR, the physician faxed the signed DNR to the facility and CPR was stopped. During an interview on [DATE] at 11:01 A.M., the admissions coordinator said he/she was in the hospital during the time the resident was admitted to the facility. 3. Review of Resident #16's medical record showed: -admitted to facility [DATE]; -The record did not contain a signed DNR or Full Code directive. Review of the resident's POS, dated [DATE], showed the record did not contain an order for his/her code status or advanced directive; Review of the resident's baseline care plan, dated [DATE], showed the care plan did not contain the resident's code status or advanced directives. 4. Review of Resident #42's medical record showed: -admitted to facility on [DATE]; -The record did not contain a signed DNR or Full Code directive. Review of the resident's POS, dated [DATE], showed the order did not contain an order for his/her code status or advanced directive. Review of the Care Plan, dated [DATE] showed the baseline care plan did not contain the resident's code status or advanced directives. 5. Review of Resident # 47's medical record showed: -admitted to facility on [DATE]; -The record did not contain a signed DNR or Full Code directive. Review of the resident's Care Plan, dated [DATE], showed the care plan did not contain the resident's code status or advanced directives. 6. During an interview on [DATE] at 10:52 A.M., The SSD said it is the responsibility of the Admissions coordinator to obtain advanced directive information upon or prior to admission, if possible. The directives are signed and given to the nurse to get an order from the physician. He/She said he/she is the backup if the admissions personnel is out of the building and was on duty when the resident came in on Thursday. During an interview on [DATE] at 11:01 A.M., the admissions coordinator said he/she is responsible to obtain and review advanced directives on admission as part of the admission process. He/She then passes the information to the charge nurse who will obtain an order and ensure it gets put into the medical record. During an interview on [DATE] at 1:44: A.M., Licensed Practical Nurse (LPN) A said upon admission the nurse will review the hospital discharge or admitting paperwork to determine the residents code status. The nurse confirms it with the admissions coordinator, updates the care plan and obtains an order. During an interview on [DATE] at 03:07 P.M., the Administrator said advanced directives are reviewed and obtained during the admission process. He/she said once obtained, it is sent to the physician for review and order and would expect the process to be completed within 24 hours unless a weekend and would expect the process to be completed the next business day. 42484 43327

Based on observation, interview, and record review, the facility staff failed to manually wash dishes in the three compartment sink while the dishwasher was under repair, to use the sanitizing solution according to manufacturer's instructions, and to allow dishes to air dry completely before use. The facility staff also failed to perform hand hygiene and to change gloves as often as necessary to avoid cross contamination, to maintain a clean and sanitary environment in the kitchen, to store food in a manner to prevent contamination and outdated use, and to maintain the ice machine in a sanitary manner to prevent contamination and foodborne illness. The facility census was 77. 1. Review of the manufacturer's instructions for the facility's dishwasher showed: - Minimum wash water temperature 120 degrees ( ) Fahrenheit (F); - Minimum rinse water temperature 120 F. Review of the facility's Dish Machine Sanitization policy, dated 08/10/28, showed: - Dish machines using chemicals for sanitation may be used if the temperature of the wash/rinse water meets manufacturer's recommendations (or state and local guidelines if more stringent); - Any observation of a wash or rinse temperature that is not within the desired range, should be reported immediately to the dietary manager or supervisor and dishwashing should be suspended; - The policy did not address where staff should wash dishes until the dishwashing machine was repaired. Observation on 4/26/23 at 9:40 A.M., showed the facility's dishwasher used chemical sanitization. Observation also showed the wash water temperature in the dishwasher measured 80 F, and the rinse water temperature measured 80 F. Further observation showed Cook Z manually washed and rinsed dishes in a plastic bin before he/she placed them into the dishwasher. Further observation showed the dishes were not submerged in the soapy water or the rinse water. During an interview on 4/26/23 at 9:45 A.M., the regional dietary manager (RDM) said the kitchen hot water heater did not work, and the staff boil water on the stove to manually wash the dishes in the plastic bins. The RDM said the kitchen has a three compartment sink, but the staff do not use it since there is not a lot of room at that sink. The RDM said the staff should use the three compartment sink to manually wash dishes. During an interview on 4/27/23 at 2:45 P.M., the regional registered dietician (RRD) and the RDM said the kitchen hot water heater stopped working 3/20/23. The RRD and the RDM said the dietary staff have been using disposable containers and plastic ware for meals, but they changed to dishes and utensils a couple days ago. The RRD and RDM said the staff manually washed dishes in the plastic bins at the dish washing area due to the lack of space at the three compartment sink. The RRD and the RDM said it is expected staff would manually wash dishes in the three compartment sink when the dishwasher is not working according to manufacturer's instructions. During an interview on 4/28/23 at 9:18 A.M., the administrator said the RDM is responsible to ensure staff are washing dishes according to regulations and policies. The facility has a policy for washing dishes, and dietary staff have been trained on the policy. She said the hot water heater was not working, and it was her understanding the dietary staff utilized disposable containers and plastic ware until the repairs were completed. The administrator said staff boiled water to wash pots, pans, and serving utensils in the three compartment sink. The administrator said it is expected dietary staff would manually wash dishes in the three compartment sink. 2. Review of the facility's Three Compartment Sink Sanitization policy, dated 8/10/18, showed: - First sink is the wash sink, the second sink is the rinse sink, and the third sink is the sanitizing sink; - In the first sink, wash dishes thoroughly; - In the second sink; immerse washed dishes completely in rinse water; - Immerse rinsed dishes in sanitizer for at least one minute. Observation on 4/26/23 at 10:00 A.M., showed Cook Z washed dishes in the three compartment sink. Further observation showed the cook washed the dishes in soapy water, dipped the dishes in sanitizing solution, and rinsed the dishes under running water. During an interview on 4/26/23 at 10:05 A.M., the RDM and Cook Z said the correct order to wash dishes in the three compartment sink is to wash, sanitize, and then rinse the dishes. The RDM said she does not like to use the dishes without rinsing off the sanitizing chemicals. Observation on 4/26/23 at 10:30 A.M., showed Cook Z washed dishes in the three compartment sink. Further observation showed the cook dipped dishes into the sanitizing solution and placed them in the drying rack. The cook did not submerge the dishes in the sanitizing solution per the manufacturer's instructions. During an interview on 4/26/23 at 10:35 A.M., Cook Z said he/she did not receive training on how to use the sanitizing solution for the dishes, and he/she did not read the manufacturer's instructions. The cook did not know how long to leave the dishes submerged in the sanitizing solution. Observation on 4/26/23 at 12:10 P.M., showed Cook AA washed dishes in the three compartment sink. Further observation showed the cook washed the dishes in soapy water, dipped the dishes in sanitizing solution, and laid the dishes on the drain board. During an interview on 4/26/23 at 12:15 P.M., the RRD said the process for manually washing dishes in the three compartment sink was to wash, rinse, and sanitize the dishes. He/She said the dishes should not be dipped in the sanitizing solution. He/She said they should be submerged, but he/she was not sure for how long. The RRD said the previous dietary manager said staff had been trained on kitchen policies, but some of the staff are new and may need training on how to use the three compartment sink. During an interview on 4/27/23 at 2:45 P.M., the RRD and the RDM said it is expected staff would receive training on how to use the three compartment sink to manually wash dishes before they used it. They said the order to manually washing dishes is to wash, rinse, and sanitize. The RRD and RDDM said the dishes should be submerged in each sink, and the staff should let the dishes stay submerged in the sanitation sink for one minute. During an interview on 4/28/23 at 9:18 A.M., the administrator said the RDM is responsible to ensure staff are washing dishes according to regulations and policies. The facility has a policy for washing dishes, and dietary staff have been trained on the policy. She said the order to manually wash dishes it to wash, rinse, and then sanitize. The administrator said dishes should be submerged in each sink, and the dishes should be left submerged in the sanitizing solution for 30 seconds to one minute. The administrator said the sanitizing solution should not be rinsed off the dishes. 3. Review of the facility's Three Compartment Sink Sanitization policy, dated 8/10/18, showed staff are directed to sanitize dishes in the third sink and then allow dishes to air dry. Observation on 4/26/23 at 10:35 A.M., showed the RDM picked up a ladle out of the sanitizing solution in the three compartment sink, rinsed under water, and used the ladle on the resident's food. The RDM rinsed off the sanitizing solution, and he/she did not allow the ladle to air dry before he/she used it. Observation on 4/26/23 at 11:25 A.M., showed the RDM prepared pureed meals for the resident's lunch service. The RDM picked up the food processor bowl from the drying rack at the three compartment sink. The bowl was visibly wet, and the RDM used the bowl to prepare the pureed carrots. Observation on 4/26/23 at 11:41 A.M., showed dietary aide (DA) BB picked up silverware from the drying rack at the three compartment sink. The silverware was visibly wet, and the DA rolled the silverware in napkins for the resident's lunch service. Observation on 4/26/23 at 12:00 P.M., showed DA BB handed the RDM a scoop, and he/she touched the food surface area of the scoop. The RDM washed, rinsed, and dipped the scoop in the sanitizing solution in the three compartment sink. The scoop was visibly wet, and the RDM used the scoop to prepare resident's plates. During an interview on 4/26/23 at 12:15 P.M., the RRD said staff should are expected to allow dishes to completely air dry before using them. She said staff should not rinse off the sanitizing solution. The RRD said staff should allow the solution to completely dry before use. The RRD said the facility has a policy, and the previous DM said staff have been trained on the kitchen policies. During an interview on 4/27/23 at 2:45 P.M., the RRD and the RDM said the facility has a policy for washing dishes, but they are not sure if all the staff have received training on the policy. They said it is expected staff would allow dishes to completely air dry before they use them. During an interview on 4/28/23 at 9:18 A.M., the administrator said the RDM is responsible to ensure staff are washing dishes according to regulations and policies. The administrator said the facility has a policy for washing dishes, and dietary staff have been trained on the policy. She said dishes should be allowed to completely air dry before they are used. 4. Review of the facility's Handwashing Guidelines, dated 020/1/02, showed hands should be washed every time an employee enters the kitchen, at the beginning of shift, after returning from break; after hands have touched anything unsanitary; after hands have touched the face, nose, or hair; before beginning to work with food; While preparing food, especially when changing preparation procedures, and when working with different raw food during preparation. Review of the facility's Use of Gloves and Hairnets policy, dated 08/15/09, showed: - Gloves should be worn when handling food items; - Use utensils to handle food; - Wear gloves when direct contact between hands and food occurs; - Wash hands before and after wearing or changing gloves; - Change gloves when activities are changed, when the type of food being handled is changed, or when leaving the work station; - Change gloves after touching your face, hands, or hair with gloved hands. Observation on 4/26/23 at 10:18 A.M., showed staff washed dirty dishes in the three compartment sink. The staff touched dirty dishes and the faucet handles. Observation also showed the RDM prepared resident lunches, touched the faucet handles of the three compartment sink with her bare hands, and continued to touch food related items. Further observation showed the RDM did not perform hand hygiene after he/she touched the faucet handles and before he/she touched food related items. Observation on 4/26/23 at 10:41 A.M., showed DA BB rinsed and stacked dirty dishes, donned gloves, and put away clean dishes. The DA did not wash his/her hands when he/she moved between a dirty task and a clean task and did not wash his/her hands before he/she put on gloves. Observation on 4/26/23 at 10:45 A.M. showed DA BB wore gloves and touched dirty dishes. The DA picked up a clean cutting board and a clean knife. He/She touched the blade of the knife with his/her gloved hands. The RDM told the DA to change his/her gloves. The DA changed his/her gloves, touched his/her hat, face, and facemask. The DA opened a box of cake, placed the cake on the cutting board, and used the same knife to cut the cake for the resident's lunch. The DA touched the cake with his/her gloved hands and placed the slices on plates for the resident's lunches. The DA did not wash his/her hands wash or change gloves after he/she touched dirty dishes and before he/she touched the cutting board and knife blade. The DA did not wash his/her hands after he/she removed his/her gloves. The DA did not change gloves and did not wash his/her hands wash after he/she touched his/her hat, face, and facemask and before he/she touched the resident's cake. Observation on 4/26/23 at 11:35 A.M., showed the RDM prepared resident lunches for service. The RDM dropped plastic lids onto the floor. The RDM used his/her bare hand to pick up the lids and throw them away. The RDM continued to prepare resident lunches and touched food related items with his/her bare hand. The RDM did not wash his/her hands after he/she picked the lids up from the floor and before he/she touched other food related items. Observation on 4/26/23 at 11:41 A.M., showed DA BB touched his/her facemask with his/her gloved hands and then rolled silverware in napkins for the resident's lunch service. The DA did not change his/her gloves and wash his/her hands after he/she touched his/her facemask and before he/she touched the napkins and silverware. Observation on 04/26/23 at 11:49 A.M., showed DA BB wore gloves and prepared resident trays for hall service. The DA dropped a juice container on the floor and picked up the juice container with his/her gloved hands. The DA continued to touch food related items as he/she prepared the hall trays. The DA did not change gloves and hand wash after he/she picked up the juice container from the floor and before he/she touched other food related items. Observation on 4/26/23 at 11:53 A.M., showed Cook Z rolled silverware in napkins for the resident's meal service. The cook touched the front of his/her facemask with his/her bare hands and continued to roll silverware in napkins. The cook did not hand wash after he/she touched his/her facemask and before he/she touched the silverware and napkins. Further observation showed the cook dropped a napkin on the floor. He/She picked up the napkin, discarded it, and continued to roll silverware in napkins. The cook did not hand wash after he/she picked the napkin up from the floor and before he/she touched other food related items. Observation on 4/26/23 at 11:56 A.M., showed DA BB touched the front of his/her facemask with his/her bare hands and prepared bowls of dessert for the resident lunch service. He/She touched the food surface of the bowls with his/her bare hands. The DA touched his/her face, the food surface of the scoop, and used the scoop to place dessert in the bowls. The DA did not wash his/her hands after he/she touched his/her face mask and face and before he/she touched food related items. Observation on 4/26/23 at 11:57 A.M., showed the RDM prepared resident lunches for service. The RDM touched his/her facemask with his/her bare hands multiple times. The RDM continued to touch food related items and prepare resident plates. The RDM did not wash his/her hands after he/she touched his/her facemask and before he/she touched resident plates and other food related items. Observation on 4/26/23 at 12:25 P.M., showed Cook CC touched the front of his/her face mask with his/her bare hands and then touched clean dishes. The cook did not wash his/her hands after he/she touched his/her facemask and before he/she touched clean dishes. During an interview on 4/27/23 at 2:45 P.M., the RRD and the RDM said the facility has a policy for hand washing and glove use, and the staff have been trained on the policy. They said staff should wash their hands when they enter the kitchen, moving from a dirty task to a clean task, after touching their face or body, after touching something that is dirty, and before and after glove use. The RRD and the RDM said they consider items on the floor to be dirty, and staff should perform hand washing after touching these items. The RRD and the RDM said the faucets on the three compartment sink are dirty since staff are washing dishes in that sink, and staff should wash hands after touching the faucets. The RRD and the RDM said it is expected staff would change their gloves for one task and change them when moving to another task. The staff should also change their gloves if they become contaminated. During an interview on 4/28/23 at 9:18 A.M., the administrator said the RDM is responsible to ensure staff are washing hands and using gloves according to regulations and policies. She said the facility has a policy for handwashing and glove use, and the RDM has been training staff on the policy. The administrator said staff are expected to wear gloves any time they are handling food; and staff should change their gloves when the gloves become dirty, when moving between tasks, and after touching something that is contamination. The administrator said it is expected staff would wash their hands before and after glove use, before handling clean dishes or preparing food, when moving from a dirty task to a clean task, and after they touch their face, body, or clothes. 5. Review of the facility's Cleaning Schedules policy, dated 8/10/18, showed the dietary manager should develop the cleaning schedule, the frequency of equipment cleaning, and who is responsible for each cleaning task. Review of the facility's Cleaning of Miscellaneous Equipment and Utensils, dated 9/03/19, showed: - The policy did not list the frequency of cleaning each floor, except housekeeping will deep clean the dietary floors at least quarterly. The floor cleaning schedule to be coordinated between housekeeping and dietary manager; - Ingredient bins (sugar, flour, etc.) cleaned monthly or as needed; - Mixer cleaned after each use; - Refrigerator cleaned weekly; - Shelving cleaned monthly or as needed; - Walls and ceilings cleaned as needed; Observations on 4/26/23 at 9:45 A.M. showed: - Ceiling vent over the food service table near microwave visibly dirty with accumulation of a black substance; - The bottom shelf of the service table with crumbs. Further observation showed pitchers stored inverted on the shelf, and staff used the pitchers during resident meal service; - Snack and drink refrigerator visibly dirty with drips and spills; - Ceiling area over the coffee area visibly dirty with brown substance; - Floor under ice machine is visibly dirty with black substance, trash, and debris. Further observation showed the baseboard not attached to the wall and the studs visible; - Floor under drink service counter visibly dirty with trash and debris; - Wall at microwave and toaster visibly dirty with chunks and debris; - Bulk bins, containing powdered sugar visibly dirty with crumbs and orange spots; - Large stand mixer with white substance on table and splatters on mixer; - Bottom shelf of steam table visibly dirty with brown substance. Further observation showed pots and baking sheets stored inverted on the shelf; - Bulk container of flour with crumbs on the container; - Bulk container of sugar with brown drips on the container. Observations on 4/27/23 at 3:30 P.M., showed: - Ceiling vent over the food service table near microwave visibly dirty with accumulation of black substance; - The bottom shelf of the service table with crumbs. Further observation showed pitchers stored inverted on the shelf, and staff used the pitchers during resident meal service; - Snack and drink refrigerator visibly dirty with drips and spills; - Ceiling area over coffee area visibly dirty with brown substance; - Floor under ice machine is visibly dirty with black substance, trash, and debris. Further observation showed the baseboard not attached to the wall and the studs visible; - Floor under drink service counter visibly dirty with trash and debris; - Wall at microwave and toaster visibly dirty with chunks and debris; - Bulk bins, which contained powdered sugar, visibly dirty with crumbs and orange spots; - Large stand mixer with white substance on table and splatters on mixer; - Bottom shelf of steam table visibly dirty with brown substance. Further observation showed pots and baking sheets stored inverted on the shelf; - Bulk container of flour with crumbs on the container; - Bulk container of sugar with brown drips on the container. During an interview on 4/27/23 at 2:45 P.M., the RRD and the RDM said they have a process to clean the kitchen, and the staff have been trained on the process. They said the process includes daily, weekly, and monthly tasks. The RRD and the RDM said the mixer, work stations, and floors are cleaned daily, and the walls are cleaned weekly and monthly. The RRD and the RDM said it is expected staff would clean the bulk bins whenever they become dirty or when they put in new product. They said the kitchen area with the ice machine and drink service area is cleaned by the housekeeping staff, and the kitchen ceiling is cleaned by the maintenance staff. They do not know how often staff clean these areas, but the RDM can submit a work order to have them clean when needed. During an interview on 4/28/23 at 9:18 A.M., the administrator said the RDM is responsible to ensure the kitchen is clean and sanitary. The facility has kitchen cleaning schedule, and the RDM has been training staff on the policy. The administrator said the RDM checks the kitchen every day to ensure it is clean. She said the dietary department and the housekeeping department work in collaboration to ensure the refrigerator and floors are kept clean in the ice machine and drink service area. The administrator said the hole in the wall and the kitchen ceiling are maintained by the maintenance director. She said the facility has not had a maintenance director in the last couple weeks, but maintenance staff from other facilities come to help a couple times a week. The administrator said it is expected staff would submit work orders for the maintenance staff, and the staff have been trained on how to submit the work orders. The administrator said it is expected the kitchen would be maintained in clean and sanitary manner to prevent cross contamination. 6. Review of the facility's Leftover Food Storage and Use policy, dated 9/12/29, showed leftover foods should be covered, labeled, and dated. Review of the facility's Food Receipt and Storage policy, dated 8/23/17, showed: - Open food items should be covered, labeled, and dated; - The policy did not address bulk food storage. Observation on 4/26/23 at 10:50 A.M. of a storage shelf over the microwave, showed: - Two open boxes of baking soda undated; - Four open sprinkles undated; - Open cocoa powder undated; - Open raisins undated; - Open nutmeg undated; - Open ginger undated. Observation on 4/26/23 at 2:00 P.M., of the two door freezer, showed: - Open bag of round disks not labeled and undated; - Open bag of brown shredded substance not labeled and undated; - Open bag of square disks not labeled and undated; - Open container of ice cream undated; - Open package of round disks not labeled and undated. Observation on 4/26/23 at 2:08 P.M. of the pantry, showed: - A bulk container of flour with the scoop stored on the product; - A bulk container of sugar with the scoop stored on the product; - A bulk container of oats with the scoop stored on the product; - Open box of rice Chex cereal undated; - Six bulk containers of various cereals not labeled and undated; - Open box of Spanish rice undated; - Open bag of long grain rice undated; - Open bag of elbow noodles undated; - Open bag of spaghetti noodles undated; - Open bag of tortilla round chips undated; - Open bag of vanilla cake mix undated. Observation on 4/26/23 at 2:17 P.M., of the walk-in freezer, showed: - Two open bags of brown patties not labeled and undated; - One open bag of white meat not labeled and undated; - One open bag of breaded strips not labeled and undated. Observation on 4/26/23 at 2:25 P.M., showed: - One open package of turkey breast slices undated; - One open package of meat not labeled; - Container of white substance not labeled; - Nine containers of yellow substance not labeled. During an interview on 4/27/23 at 2:45 P.M., the RRD and the RDM said the facility has a policy for food storage, and the staff have been trained on the policy. They said opened food and leftovers should be protected, labeled, and dated. The RRD and the RDM said bulk cereal should be labeled and dated, and staff should not store the scoop for bulk food on the food product. During an interview on 4/28/23 at 9:18 A.M., the administrator said the RDM is responsible to ensure staff store food according to regulations and policies, and the RDM checks food storage daily. The facility has a policy for food storage, and the RDM has been training staff on the policy. She said food should be labeled, dated, and in a closed container. The administrator said bulk food should be stored in a labeled and dated container, and the staff should store the scoop separately and not on the food product. 7. Review of the facility's Preventative Maintenance policy, dated 03/01/10, showed: -The Facilities Maintenance Department's major goal is to schedule and perform preventative maintenance for all equipment, and the facility physical plant, so that breakdown or failure is avoided; -Preventative maintenance is maintenance done on a scheduled routine basis with the emphasis on preventing maintenance problems, rather than correcting existing problems and will lower the rate of failures, decrease severity of failures, increase efficiency, protect assets, and add to safety; -Maintenance schedules should be developed in order to prevent system failure or service interruption. Review of the facility's Ice Dispensing policy, dated 02/01/02, showed the purpose of the policy was to prevent the spread of bacteria that may cause foodborne illness. Review showed the policy directed staff to store ice transfer receptacles such as coolers and chests in a manner that protects from contamination. Review showed the policy did not address the cleaning and maintenance of the ice machine. Observation on 4/27/23 at 8:30 A.M., showed the water filter cartridge (used to filter contaminants such as algae, bacteria, viruses and parasites, from the water) connected to the ice machine in the service station between the main dining room and kitchen dated 01/26/22. Review of the label on the water filter cartridge, showed instruction to replace the filter cartridge at least every 12 months. During an interview on 04/27/23 at 11:17 A.M., the administrator said the maintenance director is responsible to clean the ice machine as needed and maintenance the machine in accordance with manufacturer specifications which would include the replacement of the water filter cartridge. The administrator said he/she just became the administrator a couple of weeks ago and the facility did not have a maintenance director. The administrator said he/she did not know the water filter cartridge on the ice machine had not been replaced in the last 12 months. During an interview on 4/27/23 at 2:45 P.M., the RRD and the RDM said an outside company inspects and maintains ice machine every six months. The RRD and the RDM said the service technician serviced the ice machine a couple weeks ago. They said it is expected the technician would inspect the water filter and change it as needed. 42484

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from neglect when Nurse Aide (NA) A attempted to transfer the resident, who staff assessed required assistance from two staff members for safe transfers, without assistance, and without the use of a gait belt, resulting in the resident sustaining a fractured femur. The facility census was 81. The administrator was notified on 3/06/23 of past Non-Compliance which occurred on 2/27/23. On 2/28/23, the administrator identified NA A attempted to transfer Resident #1 without assistance, or the use of a gait belt, resulting in the resident sustaining a fractured femur. Upon discovery, staff suspended NA A on 2/28/23, conducted an investigation regarding the injury of unknown origin, notified the police department and appropriate parties, and terminated NA A on 3/06/23. The Director of Nursing (DON) in-serviced all staff regarding safe transfers, where to find information for residents regarding needed assistance for transfers, and reporting incidents. The in-serves included observing return demonstrations for safe transfers. Staff corrected the deficient practice on 2/28/23. 1. Review of the facility's policy, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, and Exploitation, updated 10/24/22, showed the policy strictly prohibits the abuse, neglect, exploitation, and involuntary seclusion of resident/guest(s). The policy strictly prohibits the abuse, neglect, exploitation, and involuntary seclusion of a resident/guest by any other person including, but not limited to, any facility staff, physicians, podiatrist, physician assistants, dentists, beauticians, staff of government agencies, family member, visitors, legal guardians, other residents, intruders, and volunteers. Review showed the policy defines neglect as a failure of the facility or its employees or service providers to provide goods or services necessary, to attain or maintain physical, mental, and psychosocial well-being to avoid physical harm, mental anguish, or emotional stress when the facility knew or should have known to provide the goods or services but continued to fail to take actions necessary. Neglect may include, but is not limited to: leaving resident/guest to sit or lie in urine or feces without appropriately intervening, isolating dependent resident/guest(s) by leaving them in their rooms or other isolated locations, deliberate failure to answer call bells to provide needed assistance, and performing one person assistance to transfer a resident/guest when care planned for two person. Failure to implement an effective communication system across all shifts for communicating necessary care and information between staff, practitioners, and resident representatives may result in neglect. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/12/22, showed staff assessed the resident as follows: -cognitive impairment; -requried extensive assistance from two staff members for assistance with transfers, dressing, and toilet use; -impairment on one side, lower extremities; -used a wheelchair. Review of the resident's Plan of Care, revised 12/22/22, showed staff directed the resident required extensive assistance from two staff members for transfers, toileting, and mobility as needed. Review of the facility's investigation, dated 2/28/23, showed the resident fell on [DATE]. Review showed the staff involved gave a statement, they notified the physician and resident's responsible party, and suspended NA A. Staff documented the resident complained of knee pain at 1:00 P.M. on 2/28/23 and a mobile x-ray showed the resident had a fracture of the femur (thigh bone). Staff sent the resident to the emergency room , and the hospital confirmed the resident had a fracture. Staff documented, Patient stated he/she thinks it happened during last night's transfer. Night management is interviewing staff. Review of the facility's Follow-up Investigation Report, dated 3/01/23, showed staff documented, NA A stated NA A transferred the resident alone, lowered to the floor, then picked him/her up and put him/her to bed. He/She stated he/she told the charge nurse it was a difficult transfer but did not tell the nurse or other staff about the fall. All staff on duty at the time corroborated. Patient has fractured femur, admitted to hospital. In conclusion, it was determined the fracture occurred during transfer on 2/27/23 with NA A. Review of the resident's hospital records, dated 2/28/23, showed hospital staff documented the resident sustained a fracture of the femur of the resident's right leg. Observation on 3/06/23, at 10:37 A.M., showed the resident in his/her wheelchair, in the dining room, for an activity. Observation showed the resident's right leg in a cast, with his/her right leg elevated. Observation showed the resident was not interviewable regarding the incident. During an interview on 3/06/23, at 10:35 A.M., NA A said he/she attempted to transfer the resident without assistance. He/She said he/she had not worked that hall before. He/She said residents' care plans are located on the computer and at the nurses' station. He/She said he/she did not look at the resident's care plan, did not ask how much assistance the resident required for transfers, and did not use a gait belt. NA A said he/she attempted to transfer the resident from the resident's bed to the resident's wheelchair, when both he/she and the resident slid towards the floor, but did not end up on the floor. He/She said he/she lifted the resident, unassisted back onto the bed, and then into the wheelchair. NA A said he/she called for help. He/She said he/she reported to staff it was a difficult transfer, but did not notify staff the resident had a fall. NA A said he/she attended Certified Nurse Aide (CNA) training, and facility staff trained him/her. NA A said not using a gait belt to transfer the resident was, poor judgement. Review of NA A's personnel file showed signed copies NA A acknowledged training for reporting on-the-job incidents, dated 8/30/22; policies and procedures on resident abuse and neglect, dated 8/30/22; and how to perform safe transfers for one and two person assistance with a gait belt, and given a gait belt, dated 9/19/22, and an in-service, dated 12/21/22. During an interview on at 10:40 A.M., the administrator said staff trained NA A on care and transfers of residents. He/She said NA A told the DON, both he/she and the resident slid all of the way to the floor. The administrator said staff can find information regarding residents' required assistance for transfers in the residents' plans of care, and staff should never attempt to transfer any resident without using a gait belt. During an interview on 3/06/23, at 10:50 A.M. Restorative Aide (RA) B said the resident required two staff for transfers, prior to sustaining the injury. RA B said staff train new aides on care and transfers of residents. He/She said staff are directed to always use a gait belt during resident transfers. He/She said all staff have gait belts, some residents have gait belts in their rooms, and there are gait belts available at all times. During an interview on 3/06/23, at 11:30 A.M., CNA C said he/she and the Social Service Director (SSD)/CNA worked the night of the incident. CNA C said NA A did not notify him/her NA A lowered the resident to the floor. CNA C said the resident complains of leg pain often, so staff initially applied ice to the resident's leg. He/She said the resident continued to complain of pain, so the charge nurse notified the DON. During an interview on 3/06/23, at 11:32 A.M., the SSD/CNA said NA A did not notify him/her NA A lowered the resident to the floor. He/She said the resident requires assistance from two staff members for transfers. MO00214733

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when a Certified Nursing Assistant (CNA) A grabbed Resident #1 by the left arm, pushed the resident to the bed, and slapped his/her right hand, which resulted in bruises to the resident's arm and hand. The facility census was 83. The administrator was notified on 11/16/2022 of Past Non-Compliance which occurred on 10/31/22. On 10/31/22, the administrator identified Certified Nurse Assistant (CNA) A physically abused Resident #1 when a staff member grabbed and squeezed the resident's left arm, pushed the resident back down to his/her bed, and slapped the resident's right hand, which caused bruises. Upon discovery, staff suspended the employee, conducted an investigation, notified appropriate parties, and terminated CNA A. Facility staff reviewed their abuse and neglect policies, and in-serviced all employees on abuse and neglect. Staff corrected the deficient practice on 11/2/22. 1. Review of the facility's policy, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, and Exploitation, dated 10/24/22, showed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish and physical abuse is defined as hitting, slapping, pinching, and kicking. It also includes corporal punishment. Review showed all of the facility residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property. Review showed the facility strictly prohibits the abuse, neglect, exploitation, and involuntary seclusion of a resident by any other person including, but not limited facility staff, physicians, podiatrist, physician assistants, dentists, beauticians, staff of government agencies, family member, visitors, legal guardians, other residents, intruders, and volunteers. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/22/22, showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance and one person assistance for bed mobility; -Totally dependent on two or more person for assistance with locomotion on and off the unit, transfers, dressing, toileting, and personal hygiene. Review of the facility's investigation, dated 10/31/22, showed staff documented they notified the administrator of an incident between CNA A and the resident. Review showed CNA B reported to Licensed Practical Nurse (LPN) D an allegation of physical abuse from CNA A to the resident. LPN D notified the on call nurse, who contacted the Director of Nursing (DON) and instructed LPN D to immediately suspend and escort CNA A out of the building. It was documented the staff started an investigation and obtained written statements from the staff who worked the shift when the allegation occurred. LPN D assessed the resident from head to toe and notified all responsible parties and the resident's doctor. It was documented the administrator interviewed the resident about the incident and when asked if CNA A hurt him/her, the resident demonstrated how CNA A grabbed his/her arm on the administrator, squeezed his/her arm and pushed downward. The resident had evident bruising to his/her left arm and right hand. The staff interviewed all cognitive residents and assessed all resident for injury on 10/31/22. The administrator completed abuse and neglect in-services for all staff by 11/2/22. The employee, CNA A, was terminated on 11/7/22 over the phone by the administrator. Observation on 11/7/22 at 10:48 A.M., showed the resident's left forearm had a purple area consistent with fingerprints and hand. Additionally, the resident had a quarter sized, purple area to his/her right hand, near his/her thumb. During an interview on 11/7/22 at 10:50 A.M., Resident #1 was not understood when asked questions. Resident did nod his/her head up and down when asked if CNA A hurt him/her. When asked to demonstrate how the staff hurt him/her, he/she grabbed the surveyor's arm, squeezed hard, and pushed downward. During an interview on 11/8/22 at 9:56 A.M., the Administrator, said he/she was made aware CNA A allegedly grabbed a resident's arm, squeezed, pushed him/her to the bed, and slapped his/her right hand. He/She said it was documented CNA B made Licensed Practical Nurse (LPN) D aware of the incident and contacted on call Registered Nurse (RN) C. He/She said RN C contacted the Director of Nursing (DON) who directed LPN D to immediately escort CNA A out of the building, suspend CNA A, and started the investigation. He/She said the resident did not have evident injury immediately following the incident, but later in the day showed bruising to his/her left arm and right hand. He/She said all staff were in-serviced on abuse and neglect and all residents were interviewed and assessed for injury. He/She said the facility's investigation showed the allegation was substantiated and CNA A was terminated on 11/7/22 over the phone. During an interview on 11/8/22 at 11:48 A.M., CNA B said CNA A helped him/her perform perineal care with the resident. He/She said the resident was being combative, trying to hit and pinch. He/She said the resident struck at CNA A, and CNA A grabbed the resident by the left arm, squeezed, pushed the resident back down to the bed and slapped his/her right hand. He/she said CNA A yelled at the resident to shut up and stop. During an interview on 11/18/22 at 8:49 A.M., LPN D said CNA B reported to him/her CNA A had squeezed the resident's arm, pushed the resident into his/her bed, hit the resident's right hand, and told the resident to shut up and stop. He/She said He/she immediately removed CNA A from the floor and called the on call nurse, RN C. LPN D said he/she assessed the resident and followed the instruction given by the DON. LPN D said he/she immediately escorted CNA A out of the building, suspended CNA A, and had staff start writing statements regarding the incident. MO00209219

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1's breast inappropriately. The facility census was 85. 1. Review of the facility's policy, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, and Exploitation, dated 2/08/18, showed all of the facility residents/guests have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property. The policy strictly prohibits the abuse, neglect, exploitation, and involuntary seclusion of a resident/guest by any other person including, but not limited to, any facility staff, physicians, podiatrist, physician assistants, dentists, beauticians, staff of government agencies, family member, visitors, legal guardians, other residents, intruders, and volunteers. Additional review showed: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish; -Sexual abuse is defined as non-consensual contact of any type with a resident/guest, and includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual; if the resident/guest either appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur; -Sexual contact can include touching of breasts, genitalia, groin, inner thigh, or buttocks with intent to cause sexual satisfaction or excitement to either person. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 2/25/22, showed staff assessed the resident with short and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance and one person assist for transfers, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's plan of care, dated 11/08/21, showed staff are directed to ensure the resident resides in a safe environment in the secure unit. Review of the resident's nurse's notes, dated 3/29/22, showed staff documented the charge nurse reported Resident #2 was being sexually inappropriate with Resident #1. Review of Resident #2's MDS, showed staff assessed the resident as cognitively intact, required limited assistance and one person assist for transfers, and supervision only for locomotion on the facility unit. Review of Resident #2's plan of care, dated 07/21/21, showed the plan did not list concerns regarding behaviors towards residents of the opposite sex. Review showed staff updated the plan of care on 03/29/22 to address the resident's sexual behavior towards residents of the opposite sex. Review of the resident's nurse's notes, dated 3/29/22, showed staff documented, charge nurse came to this nurse stating Resident #2 was being sexually inappropriate with Resident #1 with dementia. Staff documented he/she interviewed Resident #2 and asked him/her if he/she was inappropriate with a resident. Resident #2 stated only once that he/she pinched his/her nipple. Review of the facility investigation, dated 3/29/22, showed staff documented a staff member reported to Licensed Practical Nurse (LPN) A he/she witnessed Resident #2 with his/her finger in Resident #1's pant waistband, and separated the residents. Review showed the Director of Nursing (DON) documented he/she interviewed Resident #2, who denied having his/her hand in Resident #1's pant, but admitted he/she pinched his/her nipple. The DON documented Resident #2 said he/she did not know why he/she touched Resident #1's breast, but he/she knew it was wrong. During an interview on 3/30/22 at 10:50 A.M., the administrator said she was informed, at approximately 4:00 P.M. on 3/29/22, a staff member notified LPN A he/she witnessed Resident #2 with his/her hand in Resident #1's waistband. She said during the investigation, Resident #2 said he/she grabbed Resident #1's breast. During an interview on 3/30/22 at 11:15 A.M., Resident #2 said, I grabbed his/her boob. That's it. I don't know why. During a telephone interview on 3/30/22 at 1:30 P.M., Resident #1's family member said Resident #1 was old school, and would have slapped the resident who touched him/her inappropriately without his/her consent. MO 137

Based on observation, interview, and record review, the facility staff failed to routinely assess one resident's skin (Resident #4) under a [NAME] brace (hard brace used to stabilize a fracture to the upper arm while leaving the elbow free, allowing motion in the forearm and hand), causing a Stage IV pressure ulcer to develop to the resident's left upper arm. Furthermore, facility staff failed to notify the resident's physician for two days after the pressure ulcer was identified to obtain treatment orders. In addition, facility staff failed to keep the resident's air mattress set at the recommended setting, causing the mattress to be too firm. Further, facility staff failed to notify the physician when one resident's (Resident #221) unstageable coccyx (tailbone) wound deteriorated and obtain a dietary consult for the resident. Additionally, facility staff failed to accurately stage, and perform complete assessments for multiple pressure injuries and failed to accurately classify a wound as a pressure injury. The facility census was 75. The administrator was notified on 3/29/21 at 12:30 P.M. of an Immediate Jeopardy (IJ) which began on 3/1/21. The IJ was removed on 3/25/21, as confirmed by surveyor onsite verification. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, defined the following: -Pressure ulcer/injury: localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful; -Stage I pressure injury: an observable, pressure-related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and/or a defined area of persistent redness; -Stage II pressure ulcer: partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or bruising. May also present as an intact or open/ruptured blister; -Stage III pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss; -Stage IV pressure ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be present on some parts of the wound bed; -Unstageable pressure ulcer: Known but not stageable due to coverage of the wound bed by slough and/or eschar. Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, -Epithelial tissue: New skin that is light pink and shiny (even in persons with darkly pigmented skin). In Stage two pressure ulcers, epithelial tissue is seen in the center and at the edges of the ulcer. In full thickness Stage III and IV pressure ulcers, epithelial tissue advances from the edges of the wound. -Granulating tissue: Red tissue with cobblestone or bumpy appearance; bleeds easily when injured; -Undermining: The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface; -Slough: Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. -Eschar: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 1. Review of the facility's Protocol for Certified Nursing Assistant (CNA) & Licensed Nurse Skin Inspections, dated 10/1/10, provided the following guidelines for staff: -CNAs will conduct body inspections of residents at risk for pressure sores on a daily basis. Results of the inspection will be documented on the body audit sheet or in Smart Charting beside appropriate resident's name; -Licensed nurses will conduct body inspection of residents at risk for pressure sores on a weekly basis. Any skin concerns will be reported to the designated treatment nurse immediately for evaluation and treatment orders. If the treatment nurse is unavailable, the nurse identifying the concern should evaluate the wound and notify the MD for initial treatment orders. -Pressure ulcers will be assessed at least weekly by a trained registered nurse (RN) as part of the interdisciplinary team review; -Residents at greater risk for development of pressure ulcers include, but is not limited to the following: history of pressure ulcer, immobility, decreased functional ability, under-nourished, malnutrition, hydration deficits, associated diagnosis/co-morbidities and skin changes; -Infections should be treated as necessary; -The physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; -The status of ulcers should be recorded on the Wound Flow Record weekly; -The Dietary Manager should be consulted to assist with interventions; actions are recorded in the dietary progress notes; -Observations pertinent to the resident's skin status should be recorded in the nurse's notes, as appropriate; -The interdisciplinary team communicates plan of care instructions to staff. The interdisciplinary team consists of the Director of Nursing (DON)/designated RN, wound care nurse, restorative nurse designee, and dietary manager. 2. Review of Resident #4's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/28/20, showed staff assessed the resident as follows: -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Short and long term memory problems; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Dependent on staff for locomotion; -One facility acquired Stage II pressure ulcer; -Always incontinent of bladder and bowel; -Weighed 114 pounds (lbs). Review of the resident's Left Arm Fracture care plan, dated 12/4/20, showed it instructed staff as follows: -Elevate affected extremity as indicated for comfort, and to decrease/prevent edema; -Observe for signs and symptoms of decreased circulation of the affected extremity; -Maintain immobilization of the affected extremity; -Observe skin condition during care rounds; -Observe site for signs and symptoms of infection; -Monitor placement of immobilizer. Review of the Skin Breakdown care plan, dated 12/17/20, showed the resident had a total of 13 pressure ulcers. Further review, showed the care plan instructed staff as follows: -Provide pillows or other supportive/protective devices to assist with positioning; -Turn and reposition per resident's individual turning schedule; -Provide pressure reducing surfaces on the bed and chair; -Assist with repositioning to avoid friction/shearing; -Avoid use of restrictive clothing; -Perform wound care as ordered; -Assess wound healing weekly; -Full skin evaluation with bath/shower; -Assess skin daily with routine care; -Assess changes in skin status that indicate worsening of pressure ulcer and notify the physician; -Maintain head of bed at less than 30 degrees; -Reassess treatment plan. If not healing within two to four weeks; -Provide incontinent care as needed. Additional review of the Left Arm Fracture and Skin Breakdown care plans showed they did not contain direction for the staff in regards to the alternating air mattress or [NAME] brace. During an interview on 3/9/21 at 5:47 P.M., the MDS coordinator said the settings for the air mattress should be on the care plan, but he/she did not know what the setting should be. He/She said the resident's [NAME] brace should have been on the care plan, but he/she did not know the resident had one. He/she is normally made aware of new orders through morning meeting and by reviewing nurse's notes, and orders. He/she said he/she did not see the order. Review of the resident's CNA New Skin Audit Report Roster, dated 11/1/20-2/28/21, showed: -Staff failed to complete a report on 11/1, 11/6, 11/11, 11/13, 11/14, 11/18, 11/30, 12/11, 12/20, 12/25/20, 1/6/21, 1/15, 2/2, 2/10, 2/17, 2/22, and 2/28/21; -On 11/10/20, the resident had a new skin problem and the nurse was notified; -Staff documented no new skin problems for all other entries. During an interview on 3/10/21 at 2:10 P.M., the Director of Nursing (DON) said staff typically put the specialty mattress on the care plan. Additionally, he/she said the [NAME] brace should have been on the care plan. During an interview on 3/5/21 at 11:55 A.M., the hospice CNA said he/she did not remove the resident's brace when he/she gave the resident a bath. Furthermore, he/she said he/she was told by a nurse at the facility to wash around the brace. Observation on 3/1/21 at 2:34 P.M., showed the resident lay on an alternating air mattress with raised edges, with his/her legs drawn up to the left side of his/her chest. The head of the bed was elevated 45 degrees. His/her back laid flat against the bed and he/she was bent at the neck. Further observation, showed the resident had a hard plastic brace on his/her left shoulder that was up towards his/her jaw. The air mattress was set to 325 lbs, and was firm to the touch. Observation on 3/2/21 at 12:00 P.M., showed the resident lay in bed. Further observation, showed a dressing on the resident's upper left arm, dated 3/1, and an immobilizer strapped around the resident's chest that held his/her left arm to his/her chest. Additional observation, showed the hard, plastic brace on the resident's bedside table, and the air mattress was set to 325 lbs. During an interview on 3/3/21 at 9:00 A.M., hospice licensed practical nurse (LPN) AA said the durable medical equipment (DME) company is responsible for setting up the air mattresses. He/she said the mattresses are set to the resident's weight, and facility staff can adjust the mattress if it needs to be softer or harder. He/she went on to say, the resident's first wound was small, and he/she was placed on an air mattress after his/her first wound was identified. LPN AA said he/she did not like the brace the facility used on the resident's left arm, because it did not seem to fit. During an interview on 3/3/21 at 4:00 P.M., LPN F said hospice is responsible for the settings on the resident's air mattress. He/she thought the setting went by the resident's weight. Furthermore, he/she said he/she had adjusted the setting on the bed before and it would be changed back when he/she would come back to the room. Review of the dietician notes, dated 3/3/21 at 3:41 P.M., showed the resident's current body weight was 91 lbs, a 29 percent weight loss in five months, most occurring in the last 60 days. During an interview on 3/5/21 at 11:45 A.M., the Hospice Coordinator, who provided the resident's air mattress, said they had not been setting up the mattresses since the pandemic. He/She said the air mattress should be set by resident weight, and needed to be turned down if the resident weighed between 90-100 pounds and the mattress was set on 325 lbs. Observation and interview with LPN F on 3/3/21 at 2:50 P.M., showed the resident lay in bed with his/her knees drawn up to the left side of his/her chest. The resident wore an immobilizer on his/her left arm and the [NAME] brace was on a bedside table. Observation showed the resident's air mattress was set on 325 lbs. The resident had a bandage on his/her upper left arm dated 3/1, approximately 12 to 15 centimeters (cm) below his/her shoulder. LPN F, the facility's wound nurse, said the bandage was new. He/she said he/she did not know what was under the bandage, and did not have a treatment order for it. LPN F removed the dressing on the upper left arm revealing a pressure ulcer, 0.7 cm L (length) x 1 cm W (width) x 0.2 cm D (depth). Bone was visible in the center of the ulcer. The area surrounding the ulcer was deformed from a previous fracture. LPN F covered the area with a foam dressing until he/she could reach the physician for further orders. Further observation, showed the resident had two pressure ulcers on his/her left outer elbow. Pressure ulcer number one was a Stage II, 0.3 cm L x 0.7 cm W, depth superficial (shallow). Pressure ulcer number two was a Stage III, 1.3 cm L x 1.8 cm W, approximately 50 percent covered with brown slough. Review of the resident's Wound Assessment Reports, dated 3/3/21, showed staff assessed the resident as follows: -Left elbow ulcer number one Stage II wound bed 100 percent granulation tissue; -Left elbow ulcer number two Stage II wound bed 100 percent covered by epithelial tissue; -Left upper arm Stage IV ulcer wound bed 100 percent granulation tissue. Review of the resident's nurse's notes showed staff documented the following: -On 3/3/21 at 5:42 P.M., the physician was notified of a wound caused by the [NAME] brace. New orders were received to discontinue the brace. The physician said he/she did not think the brace was effective. New orders were received for [MEDICATION(S)] ointment (antibiotic ointment) to wound, cover with foam, and to splint with a board splint (a strip of rigid material used for supporting and immobilizing a broken bone), and secure with gauze and Coban (self-adherent compression bandage), or ACE wrap (elastic bandage). -On 3/3/21 at 9:48 P.M., late entry: at approximately midnight of 3/2/21, the nurse was called to asses a wound found by staff after they had removed the brace on the resident's left upper arm and shoulder. The open wound was cleaned with wound cleanser (WC) and covered with [MEDICATION(S)] foam dressing. The nurse felt the wound should be assessed by an RN or another nurse better versed in designing wound treatments. Staff were advised to leave the brace off until the wound could be reassessed. Observation on 3/4/21 08:29 A.M., showed the resident lay in his/her bed, and on his/her back. Additional observation, showed the air mattress was set on 325 lbs. During an interview on 3/4/21 at 10:08 A.M., RN E said the resident got the [NAME] brace after his/her arm fracture. RN E said by the time it was fitted, staff were told to leave it on. He/She said the brace had a protective sleeve underneath it that could be taken off to wash when it became soiled. He/she did not know how often the sleeve was changed and there was not a set schedule. He/she went on to say he/she did not know if staff were looking at the skin unless the brace needed adjusted. During an interview on 3/4/21 at 9:59 A.M., CNA O said the CNAs never took the brace off, because they were told to keep it on. He/She said staff were supposed to monitor to make sure there was no skin breakdown underneath the brace, so when staff noticed the skin started to breakdown they put a cloth protector underneath it. He/She said the skin under the brace was red and starting to breakdown about a month ago. During an interview on 3/4/21 at 12:35 P.M., LPN F said it had been a while, probably December, since staff first noticed the brace on the resident's left arm was causing pressure. He/she said staff were supposed to do weekly skin checks. Furthermore, he/she said he/she was not aware of an order to remove the brace and assess the skin under the brace. During an interview on 3/4/21 at 4:50 P.M., LPN F said he/she had not called the resident's physician regarding the resident's wounds, and had not requested any treatment changes. During an interview on 3/4/21 10:49 A.M., the DON said he/she was not aware the resident had a Stage IV pressure ulcer on his/her left arm until yesterday. He/she said the nurses are supposed to let him/her know, as well as complete body audits. He/she said he/she looks at the body audits daily and there was nothing new charted on them. He/she said he/she called the nurse who put the dressing on the resident's arm on 3/1/21 and the nurse told him/her he/she forgot about it. Furthermore, he/she said the physician was made aware of the pressure sore on the resident's left arm last night. He/she said his/her expectations for skin care was the CNAs were to look for redness around the brace daily and licensed nurses were to check under it weekly and complete a weekly skin audit. He/She said staff did not document when they found the wound under the brace. Additionally, he/she said the air mattress setting should be set at the resident's weight and the nurses or hospice should adjust it when they come in. He/she said hospice was supposed to let the facility know the setting and it should be in with air mattress order. He/she was not aware the air mattress had been on 325 lbs this week. Observation during the interview, showed the DON walked to the resident's room, touched the bed, and said the resident's bed was a little firm. He/she turned the bed down to the resident's weight. During an interview on 3/4/21 at 4:15 P.M., the resident's physician said the resident originally came back from the hospital with an immobilizer and it was changed to the [NAME] brace. He/she said it took three to four weeks to get the brace after the resident was fitted for it and it did not look like the brace fit well. He/she said he/she was not aware there was any skin breakdown under the resident's brace on his/her left arm until 3/3/21. Furthermore, he/she said the nurses should have looked under the brace once a week or so. He/she said the nurses could have reached out to Physical Therapy (PT) if they did not feel comfortable messing with the brace. He/she also said he/she felt the current treatment was sufficient because the brace needed to come off. He/she said he/she suspected if the air mattress was set on 325 pounds it could have led to further skin breakdown since the resident weighed much less than that. 3. Review of Resident #221's Admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Did not exhibit rejection of care; -Required total assistance of two staff members for bed mobility, transfers, and toilet use; -Not capable of increased independence in at least some activities of daily living (ADLs); -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Three unstageable pressure ulcers; -Received insulin and antibiotics; -Received intravenous (IV) (technique that delivers medications directly into a person's vein) medications. Review of the resident's nurse's notes, dated 2/25/21 showed the resident was admitted to the facility with a suspected deep tissue injury (SDTI) on his/her right heel, an unstageable pressure ulcer on his/her left hip, and an unstageable pressure ulcer on his/her coccyx. Review of the Wound Assessment Report, dated 2/25/21, showed facility staff assessed a pressure ulcer on the resident's sacrum (tailbone). Additional review showed staff measured the wound as 10 cm L by (x) 4.5 cm W. The pressure ulcer was listed as unstageable due to slough and eschar. Review of the Resident Risk Review for Pressure Ulcers, dated 2/26/21, showed LPN CC assessed the resident had a previous skin ulcer, was debilitated (weak), and had impaired or decreased mobility and functional ability. He/She identified the resident as being at risk of developing pressure ulcers. Review of the Dietary Communication Form, dated 2/26/21, showed LPN CC ordered the resident a mechanical soft (designed for people who have trouble chewing and swallowing), consistent carbohydrate (focus is on eating the same amount of carbohydrates every day) diet. Further review, showed it did not contain communication with the Dietician, or further evaluation from the Dietary Manager (DM). Review of the resident's care plan, dated 3/4/21, showed staff were directed as follows: -Refer to dietician for evaluation of current nutritional status; -Assess changes in the resident's skin status that indicate worsening of pressure ulcer and notify the physician; -Registered Dietician consult as needed; Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] -Cleanse the sacrum with normal saline (NS) or WC, pat the site dry, apply a barrier film (waterproof barrier to protect the peri-wound (tissue surrounding a wound) skin and acts as a protective barrier against fluids, waste, perspiration, and friction), apply a thick layer of silver alginate (absorbent dressing that protects the wound from infections and maintains a moist environment that promotes quicker and more efficient healing) to wound bed, and cover with [MEDICATION(S)] (tape used to secure wound dressings) daily until healed. Review of the resident's Wound Assessment Report, dated 3/3/21, showed staff measured the sacral wound as 11.5 cm L x 7.7 cm W, and noted a moderate amount of purulent drainage. Staff identified the wound had deteriorated. Additional review showed the physician was not notified of the drainage, or the deterioration. Observation on 3/4/21 at 12:38 P.M., showed LPN F perform wound care on the resident while he/she was lying in bed. LPN F removed a green saturated dressing from the resident's sacrum. The wound had green drainage and was covered with slough and eschar. The wound had a purulent odor (pungent, foul, or musty). Review of the nurse's notes, dated 3/4/21, showed facility staff did not notify the physician of the green purulent drainage from the resident's sacral wound. Review of the Wound Assessment Report, dated 3/10/21, showed the resident's sacral wound had a moderate amount of purulent drainage. Further review showed the physician was not notified of the drainage from the wound. Review of the nurses's notes, dated 3/10/21, showed facility staff did not notify the physician of the purulent drainage. Review of the resident's Wound Assessment Report, dated 3/17/21, showed staff documented the resident's wound had deteriorated and measured 15.4 cm L x 9.7 cm W. Staff noted a large amount of exudate from the wound and the silver alginate was no longer in place and saturated with drainage. Staff contacted the resident's physician 14 days after they identified the resident's wound started to deteriorate. Review of the resident's Discharge MDS, dated [DATE], showed the resident was discharged to the hospital, three days after the facility informed the physician of the resident's deteriorated wound. During an interview on 3/23/21 at 2:47 P.M., the Social Worker (SW) at the Veteran Affairs (VA) Hospital said the resident was initially sent to [NAME] Hospital in Sedalia for complaints of shortness of breath (SOB) and chest pain. Furthermore he/she said the resident was transferred to the VA Hospital for shortness of breath secondary to [CONDITION(S)] (extreme response to infection). During an interview on 3/23/21 at 3:00 P.M., an RN at the VA Hospital said the general surgery team had been in the process of [MEDICATION(S)] (surgical removal of dead tissue) the sacral wound. He/She said the wound has become a massive, gaping hole and they are unable to stage the wound due to its depth. During an interview on 3/24/21 at 3:21 P.M., CNA J said the sacral wound became more foul-smelling as the wound got bigger. During an interview on 3/24/21 at 3:42 P.M., LPN F said the admitting nurse is responsible for documenting wound measurements, filling out the initial Wound Healing Progress Report, and entering treatment orders. LPN F said if an order is not working for a wound, he/she will change the orders after contacting the physician to discuss treatment options. He/she said on 3/17 the resident's wound was macerated (skin looks soggy, feels soft, or appears whiter than usual). He/she said the silver alginate was not being used to cover the wound bed so he/she revised the original order to say a thick layer of the silver alginate should cover the wound. LPN F said when a wound deteriorates, he/she notifies the physician and he/she notified the ADON of the resident's wound deterioration. During an interview on 3/24/21 at 4:15 P.M., the ADON said the admitting nurse is responsible for entering orders for new residents. He/she said the orders are determined based on the initial wound measurements and the facility wound protocol policy. He/she went on to say the admitting nurse is expected to assess the resident and discuss treatment options with the resident's physician. He/She said if a resident's wound deteriorates, the nurse is expected to notify the physician and find another treatment option. He/She said he/she would expect staff to involve dietary for help in treatment as well. He/she said he/she did not visualize the resident's wounds during his stay at the facility. During an interview on 3/25/21 at 12:06 P.M., the resident's physician said he/she usually allows the wound care nurse to assess a resident and contact him/her to discuss treatment options, and if a resident's wound deteriorates, he/she would recommend sending the resident to the wound clinic. Additionally, he/she said he/she would expect a dietary consult to be completed to promote wound healing. During an interview on 3/29/21 at 1:37 P.M., the Dietician said he/she had not seen the resident while he/she was at the facility and he/she was not informed this resident had wounds. He/She expects staff to inform him/her of resident's wounds and when consultations are ordered. Furthermore, he/she said he/she is available by phone if the staff need assistance with care for a resident or recommendations for care. During an interview on 3/29/21 at 2:35 P.M., the ADON said he/she does not know why dietary was not involved in this resident's care. Furthermore, the ADON said he/she expects any communication with the physician to be documented in nurse's notes or the wound assessment module. During an interview on 3/29/21 at 2:39 P.M., the Administrator said when the facility admits a new resident, the dietary manager is notified and a user-defined assessment is completed. During an interview on 3/30/21 at 3:02 P.M., the MDS Coordinator said the User Defined Assessment for dietary staff, is completed with each MDS assessment. During an interview on 3/30/21 at 3:10 P.M., the DON said the Dietary Manager usually talks to residents upon admission to the facility. He/she said the Dietary Communication Form is filled out by the admitting nurse when a new resident arrives to the facility. The DON said the Dietary Manager usually approaches a new resident after his/her admission and then he/she fills out the user-defined assessment. During an interview on 4/6/21 at 3:50 P.M., the resident's physician said he/she did not see the resident's pressure sores. He/she went on to say he/she did not know why a dietary consult would not have helped with wound healing. During an interview on 3/29/21 at 3:09 P.M., the Social Worker at the VA Hospital said the resident's family decided to pursue comfort care measures for the resident. The Social Worker said the resident was transferred to comfort care due to wound [CONDITION(S)]. He/she said the resident will be discharged with hospice care and the resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of the facility's Pressure Ulcer policy, dated 10/1/10, instructed staff as follows: -Pressure ulcers cannot be adequately staged when covered with eschar or necrotic (dead) tissue. In compliance with federal guidelines, these ulcers should be staged as unstageable and should be noted in the wound care record, unable to determine depth. However, if the wound bed is partially covered by eschar or slough, but the depth of the tissue loss can be measured, do not code as unstageable; -As wounds progress through the various stages of healing, it should be noted that they are not reverse staged, due to the requirements of the MDS, but are actually healing ulcers of the most severe stage they were previously; -Pressure ulcers will be assessed at least weekly by a trained registered nurse (RN) as part of the interdisciplinary team review; -Residents at greater risk for development of pressure ulcers include, but is not limited to the following: history of pressure ulcer, immobility, decreased functional ability, under-nourished, malnutrition, hydration deficits, associated diagnosis/co-morbidities and skin changes; -[MEDICATION(S)] (removing of dead tissue from a wound) agents should be used only when non-viable tissue is present (eschar, necrosis) and per medical doctor (MD) order; -Products should be selected based upon wound characteristics and treatment goals; -The physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; -The status of ulcers should be recorded on the Wound Flow Record weekly. Review of Resident #4's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/28/20, showed staff assessed the resident as follows: -Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; -One facility acquired Stage II pressure ulcer. Review of the resident's Wound Assessment Report, dated 12/12/20, showed staff documented a newly identified pressure ulcer on the resident's sacrum/coccyx and assessed the wound as follows: -Unstageable due to slough/eschar; -No pain with wound treatment; -No infection; -Wound bed 100 percent granulation tissue; -Measured 6.2 cm L by (x) 5.7cm W x 0.0 cm D; -Wound edges with well defined boarders and normal, healthy skin; -Moderate amount of serous (thin, watery) drainage; -Further review showed staff failed to provide an accurate stage and depth for the wound. Review of the Skin Breakdown care plan, dated 12/17/20, showed the resident had a total of 13 pressure ulcers. The resident had one on his/her left calf/Achilles (lowest part of calf extending into the ankle), two on his/her left elbow, one on his/her left heel, one on his/her left hip, one on his/her left shoulder rear axilla (underarm), three on the top of his/her left foot, one on his/her right chest axilla, one on his/her right hip, one on his/her right upper mid back, and one to his/her sacrum/coccyx (tailbone). Observation on 3/1/21 at 2:34 P.M., showed the resident lay on an alternating air mattress with raised edges, in the fetal position, with his/her legs drawn up to the left side of his/her chest. His/her back lay flat against the bed and he/she was bent at the neck. Observation on 3/3/21 at 2:50 P.M., showed the resident lay in bed in fetal position with his/her knees drawn up to the le [TRUNCATED]

Based on interview and record review, facility staff failed to notify one resident's (Resident #71's) physician in a timely manner when the resident had a change in condition. The resident had a drop in his/her blood pressure with complaints of nausea and dizziness. Staff sent a facsimile containing the resident's medication listing to the resident's physician on [DATE], but failed to follow-up with the physician for four days despite the resident's continued low blood pressure and inability to participate in therapy due to dizziness and nausea. Staff continued to administer medications to lower the resident's blood pressure despite the resident's low blood pressure and other signs and symptoms until [DATE]. The resident continued to experience low blood pressure preventing him/her from participating in therapy and the facility documented they again notified the resident's physician by facsimile on [DATE]. The resident's physician said he/she did not receive the facsimile on [DATE] and would expect staff to notify him/her of continued issues by phone in this case. The facility census was 72. 1. Review of the facility's Change in Medical Condition of Resident/Guest(s) Policy, dated [DATE], showed facility staff are directed as follows: -Notification of the physician, legal representative, or interested family member should occur promptly, according to federal regulations, when there is a change in the resident/guest(s) condition. Change in condition is defined as a significant change in the resident/guest(s) physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threating conditions or clinical complications), and a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); -Examples of a change in condition may include a drop or elevation in blood pressure, nausea, vomiting, diarrhea, and loss of appetite/unplanned weight loss or gain; -In Non-Emergent situations the staff is to call during normal office and daylight hours. If a non-emergency situations occurs after 5 P.M., or on a weekend or holiday, the physician is contacted the next day or at the schedule requested by the physician, but no later than the next day; -Documentation should include the symptoms and observations associated with the change in condition, the date and time of contact with the physician and family member/legal representative. Notes also should include comments on the care provided by nursing personnel. 2. Review of Resident #71's Admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed staff assessed the resident as follows: -Cognitively Intact; -No behaviors or refusal of care; -Required limited assistance of two staff members for bed mobility; -Required extensive assistance of one staff member for transfers, locomotion on the unit, locomotion off the unit, dressing, toilet use, and bathing; -[DIAGNOSES REDACTED]. -Received a diuretic medication; -And had an active discharge plan to return to the community. Review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME] (a medication used to lower blood pressure) 2.5 milligrams (mg) 1 tablet Daily given for hypertension; -[MEDICATION NAME] (a medication used for irregular heart rhythms that dilates blood vessels which can cause a drop in blood pressure) 200 mg 1 tablet two times per day (BID) given for [MEDICAL CONDITION](heart rate over 100 beats per minute (BPM); - Carvedilol (a medication used to lower blood pressure) 3.125 mg 1 tablet BID given for hypertension; -[MEDICATION NAME] (a medication used to decrease [MEDICAL CONDITION] that has a side effect of lowering blood pressure) 40 mg 1 tablet daily. Review of the resident's Department Notes showed the following: -On [DATE] 12:20 P.M., Licensed Practical Nurse (LPN) A documented the following: The resident walked with therapy and participated in activities. The resident said he/she felt, Kinda weak after sitting down. Staff recorded the resident's blood pressure (BP) was ,[DATE]. The resident denied pain or shortness of air. Staff notified the resident's physician's office. The resident said he/she Feels better as soon as I sit down. -On [DATE] 5:04 P.M., Certified Occupation Therapist Assistant (COTA) G documented the following: Vital signs checked after standing less than one minute with complaints of dizziness. Treatment today included BP check three times ,[DATE] with electric biceps cuff, ,[DATE] with wrist cuff and ,[DATE] with manual cuff. Nursing informed of therapist concern. -On [DATE] 2:48 P.M., LPN H documented the following: Therapy concerned regarding resident's blood pressure readings while in therapy. Attached a note from therapy along with medication list, with two hypertension (HTN) medications (used to lower blood pressure) to Dr. I. Waiting for response at this time. -Review of the resident's medical record showed a facsimile LPN H sent to Dr. I on [DATE] at 2:59 P.M. which contained a list of the resident's blood pressures provided by the therapy department on a sticky note and the resident's medication list. -On [DATE] 4:34 P.M., COTA G documented the following: Patient had complaints of dizziness and not feeling well. Vital signs checked five minutes after standing due to complaints of dizziness, treatment today included BP ,[DATE] with electric cuff. Nursing informed of therapist concern. Patient currently in room with attempts of emesis (vomiting) and unable to finish session. -Review of the resident's medical record showed nursing staff did not document they assessed the resident's condition or notified the resident's physician regarding the change in the resident's blood pressure and other signs and symptoms from [DATE]-[DATE]. -On [DATE] 3:48 P.M., COTA G documented the following: Patient has continued complaints of dizziness with transfers and has not eaten. Patient reports dizziness and nausea, aide reports weight loss and not eating. Collaboration with nursing. Concern sent to doctor Thursday and has not replied. Vital signs checked after toileting treatment today included BP of ,[DATE], nursing reports that's too low for participation in sessions. Patient endurance level very poor. Unable to finish session due to patient performance and vitals. -Review or the resident's medical record showed nursing staff did not document they assessed the resident's condition or notified the resident's physician regarding the change in the resident's blood pressure and other signs and symptoms on [DATE]. -Review of the resident's MAR, showed staff discontinued the resident's [MEDICATION NAME] on [DATE]. -On [DATE] 2:14 P.M., Physical Therapist Assistant (PTA) J documented the following: Patient refused due to feeling dizzy and vomiting all morning. Patient's BP was assessed and was ,[DATE]. Nursing was notified of blood pressure and of the patient refusing therapy. -On [DATE] 4:30 P.M., COTA G documented the following: Vital signs checked pretreatment today included BP of ,[DATE] with complaints of dizziness and emesis. Patient refuses session reporting unable to participate. Nursing informed and verifies that medication has been changed per physician request due to BP complaints. -Review of the resident's medical record showed nursing staff did not document they assessed the resident or notified the resident's physician of the change in the resident's blood pressure or the other signs and symptoms on [DATE]. -Review of the resident's medical record showed LPN H sent Dr. I a facsimile on [DATE] at 2:24 P.M., that contained a medication list, and stated the following: Therapy reporting again that patient is refusing to work with them, has complaints of dizziness and nausea, with BP of ,[DATE]. Attached medication list again for review. -On [DATE] 3:15 P.M., PTA J documented the following: Patient's blood pressure was low again today. Patient's BP was ,[DATE]. Patient had complaints of dizziness and nausea. Nursing was notified. -On [DATE] 3:21 P.M., COTA G documented the following: Vital signs checked pretreatment today included oxygen saturation (level of [MEDICATION NAME] cells in the blood with normal ranging from 90% to 100%) 77% and BP ,[DATE]. Patient reports feeling dizzy and nauseous. Patient reports he/she does not feel he/she can do anything. Patient dry heaves into pan, information passed on to nursing. -Review of the resident's medical record showed nursing staff did not document they assessed the resident, or notified the resident's physician of the resident's low oxygen saturation level therapy staff reported to nursing on [DATE]. -On [DATE] 10:43 A.M., LPN K documented the following: At 9:45 AM this nurse was called to the resident's room. Resident's face was pale. Unable to obtain apical pulse (pulse obtained by listening with a stethoscope over the chest). No respirations (breaths). This nurse and certified nursing aide (CNA) lowered resident to the floor. Verified full code status. Initiated Cardiopulmonary Resuscitation (CPR), (a life-saving technique used in emergencies). Called 911. 10:16 AM Resident expired. During an interview on [DATE] at 3:28 P.M., Certified Medication Technician (CMT) L said he/she checks residents' blood pressures before he/she administers blood pressure medications on certain residents. He/She said the computer directs them which residents to check blood pressure on. Furthermore, he/she said the nurses' and physician are responsible to enter the orders to check the resident's blood pressure. He/She said if a resident's blood pressure was low, he/she would hold the medication and speak to the nurse who is in charge. Additionally, he/she said typically the parameters for holding medications are listed in the orders. During an interview on [DATE] at 3:31 PM LPN A said that for a change in condition staff are directed to assess the resident and notify the physician immediately. He/she said that if you are unable to get ahold of the doctor you are directed to call the medical director to get an order change or whatever you need. He/She said that staff do not utilize faxes all the time. He/she said that if it's something emergent the staff should call the physician. LPN A said for a blood pressure reading of ,[DATE] with associated symptoms of nausea and vomiting the physician should be called immediately. Furthermore, he/said the staff is given no direction on how long to wait for an answer from the physician when a fax is sent. Additionally, he/she said that four days is too long to wait for a response from the physician. During an interview on [DATE] at 3:45 P.M., the Director of Nursing (DON) said that staff should not have waited four days to get an order, to change the resident's blood pressure medication. He/she said he/she would expect them to notify the physician that day. He/she said that he/she does not know why they didn't. During an interview on [DATE] at 4:00 P.M., LPN H said that he/she was aware that it was the facility's policy to call the resident's physician if a resident had a change in condition. He/she said that when he/she called the physician's office they usually directed him/her to fax the information over so he/she just sent a fax in this case. He/she said that he/she did not remember attempting to call the physician in regards to the resident. During an interview on [DATE] at 4:40 P.M., Dr. I said that he/she would have expected the staff to notify him/her by phone when the resident's blood pressure dropped even further on [DATE]. He/she said he/she would have expected a phone call sooner than four days with someone who had a low blood pressure and was exhibiting signs and symptoms of dizziness and vomiting. Furthermore, he/she said he/she did not receive any blood pressures on the first fax that was sent to his/her office on [DATE]. He/She thought the nurse was requesting a medication review due to the phone call earlier on [DATE], and that he/she was not aware that the blood pressure had gone lower. Additionally he/she said that there is no fax notification in his/her medical system for [DATE], and that he/she was unaware that the resident was still symptomatic and suffering from low blood pressures. He/she said that he/she would have expected a phone call from the facility in this case. During an interview on [DATE] at 11:08 A.M., COTA G said that his/her therapy clinical supervisor directed the therapy staff to notify the nursing staff when someone was not acting right. He/She said that the resident was having complaints of dizziness and that he/she witnessed the resident dry heaving into an emesis basin on [DATE]. During an interview on [DATE] at 11:29 A.M., Dr. I said the resident had a history of [REDACTED]. He/She said that if staff had called him/her on [DATE] he/she would have put an intervention in place, or considered sending the resident to the emergency room for evaluation. He/She said that he/she should have been notified by phone call. Dr. I said he/she could not say if any interventions would have made a difference for this resident. During an interview on [DATE] at 4:42 P.M., the DON said he/she would have expected the staff to notify the physician via phone call and would have expected the staff to follow up with the physician in regards to the resident's low pressure and the continued signs and symptoms. He/she said that he/she would expect documentation in the nurses notes.

Based on observation, interview and record review facility staff failed to assist one sampled dependent resident (Resident #9) of 15 sampled residents, with toileting on a routine basis resulting in multiple falls, one of which resulted in a fracture. The facility census was 75. 1. Review of the facility's "Tips For Bowel And Bladder Programs", revised 10/1/10, showed staff are directed to provide routine toileting (check and change) on a regular schedule for residents who cannot participate in independent toileting. 2. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/3/12, showed staff assessed the resident as follows: - Moderately impaired cognition for daily decision making; - Required extensive assistance from one staff member for bed mobility, transfers, dressing, and eating; - Required limited assistance from two staff members for walking; - Totally dependent on assistance from one staff member for toilet use, personal hygiene, and bathing; - Always incontinent of bladder and bowel; - On a toileting program to manage urinary continence; - Had Alzheimer's disease; - Had a stroke; - Had hemiparesis (weakness on one side of the body); - Had Parkinson's disease (a degenerative disorder of the central nervous system that causes shaking, rigidity, slowness of movement and in later states, cognitive decline) - Took a diuretic (medication that increases the excretion of water from the body through urination). - Had a fracture related to a fall in the last six months prior to the current admission. Review of the resident's nurses notes, dated 10/11/11, showed staff documented the resident arrived at the facility to be admitted . Review of the resident's nurses notes, dated 10/12/11, showed staff documented the resident ambulated with an unsteady gait at a faster than normal pace and the resident's family reported the resident sometimes was incontinent of urine during the night. Review of the resident's Care Area Assessment (responses to MDS items which assist the staff in the development of individualized care plans), dated 1/3/12, showed the resident at risk for falls. Review of the resident's comprehensive care plan initiated on 10/11/11, last reviewed by staff 1/14/12, showed staff identified the resident at risk for falls. The care plan directed staff to provide the following interventions for the resident: - Pharmacy consult as needed; - Encourage clutter free environment and path to the bathroom; - Assist with ambulation, toileting, and mobility; - Involve in activities as tolerated; - Review toileting program as needed; - Observe need for additional assistive devices and/or position devices; - Keep the resident/responsible party informed. - Ensure personal hygiene and toileting prior to meals; - Observe when resident needs to use the bathroom and provide care as needed; - Provide perineal care after each incontinent episode. Review of an incident log provided by the Director of Nursing (DON) showed the resident fell on [DATE] at 8:00 P.M.. Further, review of the resident's nurses notes show staff documented the following about the resident's fall: - The resident yelled out and staff found the resident sitting on the hallway floor outside his/her room with his/her pants partway down; - The resident said that he/she fell and hit his/her right elbow and back and had complaints of pain; - X-rays taken of the resident's right elbow and right hip after the fall did not show any fracture and there was no apparent injury from this fall. Review of the resident's comprehensive care plan showed the facility staff did not add any new interventions, as a result of the fall on 10/12/11, to prevent additional falls and possible injury. Review of an incident log provided by the DON showed the resident fell on [DATE] at 5:30 A.M.. Further, review of the resident's nurses notes showed staff documented the following about this fall: - Staff found the resident laying on the floor at his/her bedside; - The resident said he/she fell while trying to get to the bathroom; - The resident said he/she needed to use the restroom and would not lay still for an assessment; - Earlier in the night, staff placed a bed alarm on the resident's bed because he/she attempted to get up several times without staff assistance; - The resident did not have any apparent injuries, but complained that he/she hit his/her head and the resident "didn't feel right"; - The resident's physician sent the resident to the emergency room to be evaluated for injury and a head computed tomography (CT) scan showed no acute injury. Review of the resident's comprehensive care plan showed staff added the following interventions as a result of the fall on 10/16/11: - Bed alarm; - Physical therapy and occupational therapy to evaluate and treat. Review of the resident's nurses note, dated 10/17/11, showed staff documented the resident can be unsteady at night when he/she gets up to go to the bathroom. Review of the resident's nurses notes, dated 10/23/11 at 11:10 A.M., showed staff documented staff found the resident standing straight up on top of another resident's bed. Staff did not document any fall of injury from this occurrence, but did document "close observation among all staff is most appropriate at this time" for the resident. Review of an incident log provided by the DON showed the resident fell on [DATE] at 8:50 P.M.. Further, review of the resident's nurse's notes show staff documented the following about this fall: - Staff found the resident in another resident's room sitting on the floor; - No apparent injuries from this fall; - The resident was sitting in a recliner chair in his/her room without a chair alarm prior to the fall. Review of the resident's comprehensive care plan showed staff added the following interventions as a result of the fall on 10/26/11: - The resident is to have a chair alarm in his/her recliner at all times. Review of an incident log provided by the DON showed the resident fell on [DATE] at 2:15 P.M.. Further, review of the resident's nurses notes showed staff documented the following about the fall: - Staff found the resident lying on the floor by the bathroom door on his/her right side; - There was a skin tear to the resident's right outer forearm; - No other injuries found by staff that day; - On 11/16/11 the resident complained of left knee pain and his/her left knee was swollen and warm to touch; - An x-ray obtained on 11/16/11 showed the resident had a fractured left patella (kneecap); - The resident's physician instructed staff for the resident wear a left knee immobilizer for one month. Review of the resident's left knee x-ray report dated 11/17/11, showed the resident had a fractured patella. Review of the resident's comprehensive care plan showed staff added the following interventions as a result of the fall on 11/15/11: - Physical therapy to evaluate and treat; - The resident is to have a personal body alarm on at all times. Review of an incident log provided by the DON showed the resident fell on [DATE] at 11:15 A.M.. Further, review of the resident's nurses notes showed staff documented the following about this fall: - Staff went to the resident's room after hearing a chair alarm sounding and found the resident in his/her bathroom on the floor; - Prior to the fall the resident had been sitting in a recliner chair; - No injuries found by staff and the resident denied pain. Review of the resident's comprehensive care plan showed staff added the following interventions as a result of the fall on 11/18/11: - Offer the family option of using a merry walker (ambulation mobility device designed to increase independent ambulation while reducing the risk of falls); - Use a lap buddy (a thick flat cushion that fits over a person's lap and under the armrests of a wheelchair which helps to remind a person to ask for assistance before getting out of a wheelchair as a means of reducing the risk of injury from falls) on the resident's wheelchair; - Place a fall mat beside the resident's bed; - High/low bed. Review of an incident log provided by the DON showed the resident fell on [DATE] at 4:30 A.M.. Further, review of the resident's nurses notes showed staff documented the following about the fall: - Staff heard a bed and body alarm sounding and found the resident sliding from a recliner chair to the floor; - When the resident landed on the floor he/she hit his/her head on the edge of the bed; - Staff initially found no injuries from this fall; - Staff assisted the resident up and assisted him/her with toileting; - Later in the day, staff found a dime size elevation on the resident's back of head which resolved after staff applied an ice pack. Review of the resident's comprehensive care plan showed staff added the following interventions as a result of the fall on 11/19/11: - Removal of the resident's rocking recliner from his/her room. Review of an incident log provided by the DON showed the resident fell on [DATE] at 4:31 A.M.. Further, review of the resident's nurses notes showed staff documented the following about the fall: - After hearing an alarm sounding, staff found the resident sitting on the floor between the bed and the wall in from of his/her wheelchair with the lap buddy still in place on the wheelchair; - Staff found no injuries from this fall. Review of the resident's comprehensive care plan showed staff added the following interventions as a result of the fall on 2/5/12: - Place a pommel seat (padded seat with a hump in the seat between the legs) in the resident's wheelchair. Observation on 3/7/12 at 12:30 P.M., showed the resident eating lunch in the dining room. Observation on 3/7/12 at 1:05 P.M., showed the resident finishing lunch in the dining room. Observation on 3/7/12 at 1:15 P.M., showed Certified Nurse Assistant (CNA) B assisted the resident back to his/her room to be toileted. CNA B opened the resident's bathroom door and the resident's roommate was in the bathroom. CNA B walked the resident over to his/her wheelchair and assisted the resident to sit down in it and then placed a lap buddy onto the wheelchair. CNA B wheeled the resident in the wheelchair out into the hallway. The resident ask "Where's the bathroom?" CNA B told the resident someone else was in the bathroom. CNA B walked down the hallway and went into a different resident's room. The resident began to propel himself/herself down the hallway in the wheelchair with a lap buddy in place. Observation on 3/7/12 at 1:20 P.M., showed the resident continued to sit in a wheelchair in the hallway with a lap buddy in place, an unknown staff member walked by and gave the resident a couple of magazines to look at. Observation on 3/7/12 at 1:25 P.M., showed the resident continued to sit in a wheelchair in the hallway with a lap buddy in place looking at magazines. Observation on 3/7/12 at 1:35 P.M., showed the resident continued to sit in a wheelchair in the hallway with a lap buddy in place. The resident's chin tilted down towards his/her chest and the resident's eyes were closed. Observation on 3/7/12 at 1:50 P.M., showed the resident continued to sit in a wheelchair in the hallway with a lap buddy in place. Observation on 3/7/12 at 2:10 P.M., showed the resident continued to sit in a wheelchair in the hallway with a lap buddy in place. Observation on 3/7/12 at 2:15 P.M., showed an unidentified staff member wheeled the resident in his/her wheelchair into the dining room and placed the resident at a table with the lap buddy in place. Observation on 3/7/12 at 2:20 P.M., showed the resident continued to sit in a wheelchair in the dining room at a table with the lap buddy in place. The resident's chin tilted down towards his/her chest and the resident's eyes were closed. Observation on 3/7/12 at 2:40 P.M., showed the resident continued to sit in a wheelchair in the dining room at a table with the lap buddy in place. The resident's chin tilted down towards his/her chest and the resident's eyes were closed. Observation on 3/7/12 at 3:10 P.M., showed the resident continued to sit in a wheelchair in the dining room at a table with the lap buddy in place. The resident's chin tilted down towards his/her chest and the resident's eyes were closed. Observation on 3/7/12 at 3:20 P.M., showed the resident continued to sit in a wheelchair in the dining room at a table with the lap buddy in place. The resident had not been toileted since asking for the bathroom at 1:15 P.M.. Review of an incident log provided by the DON showed the resident fell on [DATE] at 11:16 P.M.. Further, review of the resident's nurses notes showed staff documented the following about the fall: - Staff heard an alarm and entered the resident's room and saw him/her squatting over a trash can with pants down; - The staff member ran to catch the resident but the trash can slipped out from under the resident and he/she fell ; - Staff initially found no injuries from this fall and assisted the resident to the bathroom to toilet; - The resident complained of pain to his/her clavicle area early the next morning; - An x-ray of the resident's left clavicle showed no fracture. During an interview on 3/9/12 at 9:00 A.M., the resident's family member said facility staff should assist the resident with toileting and provide incontinence care as needed. The resident's family member said they have identified clothing items, completely saturated with urine, which staff placed in the hamper for the family to wash. The resident's family member said staff members do not provide incontinence care as often as needed during the night shift. Further, the resident's family member said staff members are slow to respond to alarms that sound during the night shift. During an interview on 3/9/12 at 12:30 P.M., CNA D said when a staff member hears a resident's bed, chair, or personal alarm sounding the staff member is supposed to walk quickly or run to the area the resident is at and take care of the resident's needs so the resident does not fall. During an interview on 3/9/12 at 12:35 P.M., the DON said the following: - Staff need to toilet and check the resident for incontinence every two hours and provide incontinence care as needed; - If the resident needs to be toileted and his/her roommate is in the bathroom, there are two shower room toilets the staff can use to toilet the resident if the shower room is not in use; - When a staff member hears a resident's bed, chair, or personal alarm sounding, the staff member is to quickly locate the area the resident is at and take care of the resident's needs so the resident does not fall. During an interview on 3/9/12 at 12:50 P.M., the DON said the following: - Most of the resident's falls occurred at night in his/her room; - All of the resident's falls were a result of the resident trying to get to the bathroom unassisted.