Every finding on record at Aspire Senior Living Webb City

Based on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were not used more than four months without completing required training and evaluations when the facility did not have an effective process in place to ensure certified nurse aide (CNA) training programs were completed timely for NAs resulting in eleven NAs (NA Q, NA T, NA I, NA K, NA AA, NA B, NA W, NA S, NA R, NA C, and NA U) working longer than four months in the facility without completing the CNA training course. The facility census was 106.Review of facility policy titled, Hiring of Non-Certified Nurse Aides (Missouri), undated, showed the following:-Trainees must enroll in a Missouri-approved CNA program totaling 175 hours, which consist of 75 hours classroom instruction and 100 hours on-the-job clinical training;-Trainees must successfully complete the initial 16 hours of required training before any direct resident contact;-Trainees must pass the Missouri CNA exam within the required timeframe following course completion;-The facility may not permit trainees to continue working in resident care if they fail to meet certification timelines or exam requirements;-Trainees who do not complete training, fail exams, or demonstrate unsafe care practices must be removed from resident care and may be subject to termination. 1. Review of NA Q's personnel file showed the following:-Date of hire of 11/26/24 (one year and thirteen days prior);-Staff documented NA Q enrolled in the online nurse aide training program on 10/04/25;-Staff did not have documentation NA Q had completed the nurse aide training program. 2. Review of NA T's personnel file showed the following:-Date of hire of 01/15/25 (ten months and twenty-four days prior);-Staff documented NA T enrolled in the online nurse aide training program on 10/17/25;-Staff did not have documentation NA T had completed the nurse aide training program. During an interview on 12/09/25, at 12:35 P.M., NA T said he/she started the online CNA class in the middle of November. Staff can come into the facility Monday through Friday from 8:00 A.M. to 5:00 P.M. on their days off to work on the class. 3. Review of NA I's personnel file showed the following:-Date of hire of 01/15/25 (ten months and twenty-four days prior);-Staff documented NA I enrolled in the online nurse aide training program on 10/17/25;-Staff did not have documentation NA I had completed the nurse aide training program. 4. Review of NA K's personnel file showed the following:-Date of hire of 02/21/25 (nine months and eighteen days prior);-Staff documented NA K enrolled in the online nurse aide training program on 10/04/25;-Staff did not have documentation NA K had completed the nurse aide training program. 5. Review of NA AA's personnel file showed the following:-Date of hire of 03/06/25 (nine months and three day prior);-Staff documented NA AA completed the online nurse aide training program on 07/30/25, however failed the exam. During an interview on 12/05/25, at 11:47 A.M., NA AA said the following:-He/she was previously a CNA, however let his/her certification expire;-He/she watched 17 hours of videos and completed three days of on the job traning with a CNA;-He/she completed the nurse aide training program approximately four months ago, however failed the test. 6. Review of NA B's personnel file showed the following:-Date of hire of 03/12/25 (eight months and twenty-seven days prior);-Staff documented NA B enrolled in the online nurse aide training program on 10/04/25;-Staff did not have documentation NA B had completed the nurse aide training program. During an interview on 12/05/25, at 2:51 P.M., NA B said the following:-He/she was hired in March 2025;-He/she has not worked on his/her class in a couple of months, as it is hard to complete because they can only work on it on their days off. 7. Review of NA W's personnel file showed the following:-Date of hire of 03/19/25 (eight months and twenty days prior);-Staff documented NA W enrolled in the online nurse aide training program on 09/18/25;-Staff did not have documentation NA W had completed the nurse aide training program. During an interview on 12/09/25, at 12:30 P.M., NA W said he/she was hired in March 2025, and started NA classes a couple of months ago. 8. Review of NA S's personnel file showed the following:-Date of hire of 03/06/25 (eight months and three days prior);-Staff documented NA S enrolled in the online nurse aide training program on 10/12/25;-Staff did not have documentation NA S had completed the nurse aide training program. During an interview and observation on 12/09/25, at 12:40 P.M., NA S said the following:-NA S was providing showers to residents;-He/she was hired in January 2025;-He/she started online CNA classes three months ago;-Staff must complete the class on their days off and he/she hasn't worked on it in about a month;-He/she received on-the-job training by following a CNA for about a week;-He/she did not have to have a competency test after completing OJT;-He/she is currently the only shower aide for the facility. 9. Review of NA R's personnel file showed the following:-Date of hire of 05/14/25 (six months and twenty-five days prior);-Staff documented NA R enrolled in the online nurse aide training program on 10/04/25;-Staff did not have documentation NA R had completed the nurse aide training program 10. Review of NA C's personnel file showed the following:-Date of hire of 06/25/25 (five months and fourteen days prior);-Staff documented NA C enrolled in the online nurse aide training program on 10/17/25;-Staff did not have documentation NA C had completed the nurse aide training program. During an interview on 12/05/2025, at 11:49 A.M., NA C said the following:-He/she watched videos and received two weeks on the job training with another CNA;-He/she independently provides cares for residents, unless they are a two-person assist;-He/she has been employed with the facility for approximately five to six months;-He/she is supposed to be enrolled in CNA classes but does not know why he/she is not. He/she has mentioned it to management. During an interview on 12/09/25, at 12:45 P.M., NA C said the following:-The Staff Development Coordinator (SDC) told him/her if staff do not complete the online CNA class by February 2026, they will be terminated;-The Corporate Nurse is supposed to be enrolling him/her in the online CNA class. 11. Review of NA U's personnel file showed the following:-Date of hire of 08/07/25 (four months and two days prior);-Staff documented NA U enrolled in the online nurse aide training program on 10/04/25;-Staff did not have documentation NA U had completed the nurse aide training program. During an interview and observation on 12/04/25, from 10:29 A.M. to 11:50 A.M., NA U said the following:-He/she was pushed one resident in his/her wheelchair down the hall after assisting the resident with a shower;-He/she provided incontinent care for another resident;-He/she started at the facility three or four months ago;-He/she was informed the facility enrolled him/her in the online NA class today (12/04/25). 12. During an interview on 12/09/25, at 12:55 P.M., LPN X said the following:-He/she was unsure when NA's have to start class by, but knows there is a date;-NA's receive training from most experienced CNAs;-He/she was unsure if there is check list or if the NA's must be signed off by nursing staff or management on competency;-If a CNA had a concern with a NA they can talk to a nurse or the Staff Development Coordinator (SDC). During an interview on 12/09/25, at 1:00 P.M., the SDC said the following:-He/she started the position as the SDC in August 2025;-He/she just received his/her credentials in October 2025 to start enrolling staff in CNA training;-The Corporate Nurse had enrolled the most recent NA's in CNA classes;-The facility did not have a sign off or check off list to ensure competency of the NA's after receiving their on-the-job training;-The SDC only completed a competency evaluation of NA's if there has been a complaint;-Current Medical Records Staff (MRS) previously was responsible for enrolling staff in CNA classes;-NA staff should be enrolled immediately in the online CNA class upon hire;-NA's have 120 days to complete the online program. Staff must work on the classes Monday to Friday, from 8:00 A.M. to 5:00 P.M., when management is in the building;-The SDC and the Corporate Nurse are responsible of monitoring the NA's progress in the class. 14. During an interview on 12/09/2025, at 2:00 P.M., LPN O said the following:-Upon hire, NA's follow a CNA around for approximately a week;-LPN O has previously (a year ago) reviewed NA competency, but currently MR is responsible for competency checks;-NA's complete online CNA classes. During an interview on 12/09/25, at 2:10 P.M., LPN N said the following:-NA's must complete a CNA class either 120 days after employment or after 120 hours on the job;-NA's complete on the job training;-He/she was unsure if there is a competency check off. During an interview on 12/09/25, at 2:50 P.M., MRS said the following:-NA staff have to complete 16 hours of orientation before they can start on the floor;-After the orientation, they are enrolled in online CNA class;-NA's received OJT with a CNA or a NA that is already enrolled in class;-MRS or LPN O used to review NA's for competency;-MRS has not checked a NA for competency since June or July 2025 and has not enrolled a NA in online CNA classes since August 2025;-He/she does not know when the NA's work on their online classes. During an interview on 12/09/25, at 3:43 P.M., the Director of Nursing (DON) said the following:-NA's complete their orientation, and then are placed with a CNA for on the job training;-The DON is unsure how long the NA shadows the CNA;-NA's should be enrolled in CNA classes as soon as they complete their shadowing;-NA's must complete the CNA class and be tested within 120 days of employment;-The CNA classes are online, and staff can work on their class Monday through Friday when management is available; -The SDC and the Corporate Nurse track staff's class progress and completion. During an interview on 12/09/25, at 4:12 P.M., the Administrator said the following:-NA's were paired with CNAs for on the job training;-He/she was unsure if there is a competency check by management;-NA's should be enrolled in CNA classes as soon as possible;-The SDC and the Corporate Nurse are responsible for enrolling NA's in the CNA class;-The CNA class must be complete within 120 days of employment;-He/she was unsure of when NA staff work on their online CNA class;-The facility had NA staff who have worked at the facility longer than 120 days and have not completed their CNA class.

Based on record review and interviews, the facility failed to implement an antibiotic stewardship program that develops, promotes, and implements a facility wide system that monitors the use of antibiotics, reduces the risk of adverse events associated with antibiotic use, and failed to develop and implement protocols that ensure residents prescribed an antibiotic are utilizing the appropriate one. The facility census was 106.Review of a facility policy titled Infection Prevention and Control Program, dated October 2025, showed the following:-The policy of the facility is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;-The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, and surveillance, and investigations of exposures of infectious diseases;-A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff;-An antibiotic stewardship program will be implemented as part as the overall infection prevention and control program;-Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program;-The infection preventionist, with the oversight of the Director of Nursing (DON), serves as the leader of the antibiotic stewardship program.1. Review showed the facility did not provide information regarding an antibiotic stewardship program.Review of the facility infection control binder showed the following:-The last weekly infection analysis review occurred on 05/20/25;-The last antibiotic usage review occurred on 05/20/25.During an interview on 12/09/25, at 4:10 P.M., Licensed Practical Nurse (LPN) O said he/she was the wound care nurse and was not on a committee for infection control or antibiotic use. During an interview on 12/09/25, at 2:13 P.M., the DON said the following:-Antibiotic stewardship program should monitor the number of infections and any reoccurring infections in the facility;-The staff should have in-services and training based upon antibiotic findings;-The Assistant Director of Nursing (ADON) highlighted resident infections in a binder to assess clusters of infections in the facility;-The binder did not appear to be up to date upon his/her review;-Antibiotic usage is reviewed weekly in the infection control meeting;-The wound care nurse and ADON had infection control meetings, but he/she did not attend.During an interview on 12/09/25, at 4:12 P.M., the Administrator said he/she did not know about antibiotic stewardship. Infection control is reviewed in Quality Assurance and Performance Improvement (QAPI) meetings. Nurses should be conducting daily meetings that address a variety of topics.

During an interview on 12/09/25, at 4:12 P.M., the Administrator said he/she did not know about antibiotic stewardship. Infection control is reviewed in Quality Assurance and Performance Improvement (QAPI) meetings. Nurses should be conducting daily meetings that address a variety of topics. Review of a facility policy titled Infection Prevention and Control Program, dated October 2025, showed the following:-The policy of the facility is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;-The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, and surveillance, and investigations of exposures of infectious diseases;-All staff are responsible for following all policies and procedures related to the program;-A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff;-The infection preventionist serves as the leader in surveillance activities, maintains documentations of incidents, findings, and corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee;-The infection preventionist, with the oversight of the Director of Nursing (DON), serves as the leader of the antibiotic stewardship program;-The infection preventionist shall coordinate screening procedures in case of widespread exposure of staff to any infectious disease.Review showed the facility did not provide a certificate of infection preventionist training for the DON or Assistant Director of Nursing (ADON).During interviews on 12/09/25, at 11:45 A.M., and on 12/09/25, at 2:04 P.M., the corporate nurse said the ADON was the infection preventionist until he/she quit on Monday. The DON was the infection preventionist until the facility hired someone else. He/she was the corporate nurse and is not in the facility much, so he/she was not the infection preventionist. He/she was available to provide guidance to the DON related to infection preventionist role. He/she was not involved in any infection control planning or committees.During an interview on 12/09/25, at 1:37 P.M., the Administrator said the infection control nurse was the ADON, but he/she quit on the day of surveyors' arrival. The corporate nurse was overseeing the DON who had currently taken over as the infection preventionist until another nurse could be hired for position. He/she had not informed the DON of new infection control position yet. He/she did not know if the DON had any infection control training. The corporate nurse was trained in infection control and had always been overseeing it at the facility. During an interview on 12/09/25, at 2:13 P.M., the DON said the following: -He/she had not been advised he/she would be the infection preventionist;-The ADON quit on Monday, and he/she assumed the infection preventionist role would fall on her;-The corporate nurse or Administrator had not advised him/her they would be the new infection preventionist;-He/she signed up to take an infection prevention course today;-He/she was not aware that the ADON was not trained for infection preventionist role prior to quitting.

Based on interview and record review, the facility failed to fully implement their abuse and neglect prevention policies, when the facility failed to complete a criminal background check (CBC), an employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) check, and a Nurse Aide (NA) Registry (list of individual with a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility) check for ten sampled staff (Certified Nursing Assistant (CNA) A, Nursing Assistant (NA) B, NA C, Registered Nurse (RN) D, Dietary Aide (DA) E, Certified Medication Technician (CMT) F, Licensed Nurse Practitioner (LPN) G, Laundry Aide (LA) H, NA I, and Dietary Manager (DM)). The facility census was 106.Review of the facility policy titled Background Investigations, dated 10/01/25, showed the following:-Job reference checks, drug screenings, licensure verifications, and criminal conviction record checks are conducted on all personnel making application for employment with this company;-The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied;-For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing. 1. Review of CNA A's personnel record showed the following:-Hire date of 08/21/24;-A check of the Family Care Safety Registry (includes a CBC check) and EDL was complete on 12/05/25;-The facility did not have verification showing a check of the NA Registry was complete. 2. Review of NA B personnel record showed the following:-Hire date of 03/12/25;-A check of the Family Care Safety Registry and EDL was complete on 12/05/25;-The facility did not have verification showing a check of the NA Registry was complete. 3. Review of Dietary Manager (DM) personnel record showed the following:-Hire date of 09/17/25;-A check of the Family Care Safety Registry and the EDL was complete on 12/05/25;-The facility did not have verification showing a check of the NA Registry was complete. 4. Review of NA C personnel record showed the following:-Hire date of 06/25/25;-A check of the EDL list was complete on 06/23/25;-The facility did not have verification of a criminal background check requested or received;-A check of the Family Care Safety Registry was complete on 12/05/25;-The facility did not have verification showing a check of the NA Registry was complete. 5. Review of RN D personnel record showed the following:-Hire date of 09/17/25;-A check of the EDL list was complete on 09/16/25;-The facility requested a criminal background check on 09/12/25. No results were received;-The facility did not have verification showing a check of the NA Registry was complete. 6. Review of DA E personnel record showed the following:-Hire date of 04/23/24;-The facility received a criminal background check on 12/18/24;-A check of the EDL list was complete on 01/07/25;-The facility did not have verification showing a check of the NA Registry was complete. 7. Review of CMT F personnel record showed the following:-Hire date of 05/14/24;-The facility received a criminal background check on 12/18/24;-A check of the Family Care Safety Registry and EDL was complete on 12/05/25;-The facility did not have verification showing a check of the NA Registry was complete. 8. Review of LPN G personnel record showed the following:-Hire date of 02/03/25;-The facility received a criminal background check on 02/19/24;-A check of the EDL list was complete on 12/05/25;-The facility did not have verification showing a check of the NA Registry was complete. 9. Review of LA H personnel record showed the following:-Hire date of 09/04/24;-A check of the EDL list was complete on 09/03/24;-The facility received a criminal background check on 12/19/24;-The facility did not have verification showing a check of the NA Registry was complete. 10. Review of NA I personnel record showed the following:-Hire date of 01/15/25;-A check of the EDL list was complete on 01/07/25;-The facility received a criminal background check on 02/19/25;-The facility did not have verification showing a check of the NA Registry was complete. 11. During an interview on 12/09/25, at 12:30 P.M., the Business Office Manager (BOM) said the following:-He/she completed a check of the Family Care Safety Registry (FCSR) and the EDL list;-He/she verifies nurses have an active license and will check the NA Registry on all CNAs and CMTs;-He/she did not check the NA Registry for non-nursing staff;-All background checks were completed prior to staff orientation. During an interview on 12/09/25, at 3:43 P.M., the Director of Nursing (DON) said the following:-The BOM completed staff background checks, which include the FCSR, EDL, criminal background, NA Registry on all nursing staff, and verification of nursing licenses;-He/she was unsure if staff were permitted to work prior to receiving the results of the background check;-Staff cannot work the floor in until NA Registry and nurse license verification is received. During an interview on 12/09/25, at 4:12 P.M., the Administrator said the following:-The BOM completed the background check which consists of the EDL, FCSR, NA Registry, and nurse license check;-The facility only checks the NA registry for CNA staff;-Background checks need to be complete prior to staff working the floor.

Based on observation, interviews, and record review, the facility failed to ensure medications were labeled and stored per standards of practice when insulin pens were not properly labeled and dated, including pens for seven residents (Resident #47, #35, #4, #83, #22, #7, and #33). The facility also failed to maintain the medication storage refrigerator at the recommended temperatures, per manufactures recommendations, for multiple medications stored in the refrigerator for use. The facility had a census of 106.1. Review of a facility procedure titled Insulin Pen, dated 10/01/25, showed the following:-It is the policy of this facility to use insulin pens to improve accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for discharge;-Insulin pens contain multiple doses of insulin but are for a single resident use;-Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date;-If the label is missing, the pen will not be used, and a new pen must be ordered from the pharmacy;-Once opened, clearly labeled insulin pens may be stored at room temperature;-Insulin pens should be disposed of after 28 days or according to manufacturer's recommendations. Review of a facility policy titled Storage and Expiration Dating of Medications and Biologicals dated 06/30/25, showed the following:-Facility should ensure medications that have been retained longer than recommended by the manufacturer guidelines are stored separate from other medications until destroyed;-Facility should record the date opened on the primary medication container when the medication has a shortened expiration date once opened;-If a multi-dose vial of an injectable medication has been opened, the vial should be dated and discarded withing 28 days unless manufacturer specifies a different date;-Facility should destroy and reorder medications with soiled, illegible, worn, incomplete, or missing labels. Review of the Food and Drug Administration (FDA) package insert, dated 05/2019, for insulin glargine (long-acting insulin) showed the following: -Never share the insulin pen between patients, even if the needle is changed;-The insulin pen can be used for 28 days after being opened;-Do not use insulin pen after expiration date. Review of the Food and Drug Administration (FDA) package insert, dated 02/2015, for Novolog Flex Pen (insulin lispro - fast acting insulin) showed the following: -Never share the insulin pen between patients, even if the needle is changed;-The insulin pen can be used for 28 days after being opened;-Do not use insulin pen after expiration date. Review of the Food and Drug Administration (FDA) package insert, dated 09/2018, for Basaglar Kwik Pen (long-acting insulin) showed the following: -Never share the insulin pen between patients, even if the needle is changed;-The insulin pen can be used for 28 days after being opened; -Do not use insulin pen after expiration date. Review of the Food and Drug Administration (FDA) package insert, dated 07/2022, for Tresiba (long-acting insulin) injection pens showed the following: -Never share the insulin pen between patients, even if the needle is changed;-The insulin pen can be used for 56 days after being opened; -Do not use insulin pen after expiration date. 1. Review of Resident #47's face sheet (basic resident profile information) showed the following:-admission date of 01/28/25;-Diagnoses included diabetes mellitus (disorder where the body does not produce enough insulin, causing blood sugar levels to be high). Review of the resident's current Physician Order Sheet (POS) showed an order, dated 05/26/25, for insulin glargine insulin pen 100 units per milliliter (ml); administer 65 units subcutaneously (below the skin) twice daily for diabetes mellitus. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed the resident's insulin glargine pen had no expiration date. 2. Review of Resident #35's face sheet showed the following:-admission date of 01/28/25;-Diagnoses included diabetes mellitus. Review of the resident's current POS showed the following:-An order, dated 09/18/25, for Novolog Flex Pen insulin 100 unit per ml; administer subcutaneously before meals and at bedtime per sliding scale:-If blood sugar is 150 milligrams/deciliter (mg/dL) to 200 mg/dL, give 3 units;-If blood sugar is 201 mg/dL to 250 mg/dL, give 6 units;-If blood sugar is 251 mg/dL to 300 mg/dL, give 9 units;-If blood sugar is 301 mg/dL to 350 mg/dL, give 12 units;-If blood sugar is 351 mg/dL to 400 mg/dL, give 15 units;-If blood sugar is 401 mg/dL to 450 mg/dL, give 18 units;-An order, dated 10/09/24, for insulin glargine insulin pen 100 units per ml; administer 13 units subcutaneously at bedtime. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed the resident's insulin glargine pen had not date opened noted and no expiration date noted. The resident's Novolog insulin pen showed a date of 10/20 written on the pen in marker. Staff did not indicate if this was the date opened or date expired. 3. Review of Resident #4's face sheet showed the following:-admission date of 09/16/25;-Diagnoses included diabetes mellitus. Review of the resident's current POS showed an order, dated 09/23/25, for insulin glargine insulin pen 100 units per ml; administer 23 units subcutaneously twice daily. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed the resident's insulin glargine pen had no expiration date. 4. Review of Resident #83's face sheet showed the following:-admission date of 03/30/23;-Diagnoses included diabetes mellitus. Review of the resident's current POS showed an order, dated 09/23/25, for Basaglar Kwik Pen insulin pen; 100units per ml; administer 15 units subcutaneously at bedtime. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed resident's Basaglar insulin pen showed a date of 10/26 written on the pen in marker. Staff did not note if that was open date or expiration date. 5. Review of Resident #22's face sheet showed the following:-admission date of 08/23/22;-Diagnoses included diabetes mellitus. Review of the resident's current physician order sheet showed an order, dated 05/21/25, for insulin glargine insulin pen 100 units per ml; administer 36 units subcutaneously twice daily. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed the resident's insulin glargine pen had no expiration date. 6. Review of Resident #7's face sheet showed the following:-admission date of 06/22/23;-Diagnoses included diabetes mellitus. Review of the resident's current POS showed an order, dated 02/27/25, for insulin lispro (fast acting insulin) insulin pen; 100unit per ml; administer per sliding scale subcutaneously before meals and at bedtime:-If blood sugar is 70 mg/dL to 130 mg/dL, give 0 units;-If blood sugar is 131 mg/dL to 180 mg/dL, give 2 units;-If blood sugar is 181 mg/dL to 240 mg/dL, give 4 units;-If blood sugar is 241 mg/dL to 300 mg/dL, give 6 units;-If blood sugar is 301 mg/dL to 350 mg/dL, give 8 units;-If blood sugar is 351 mg/dL to 400 mg/dL, give 10 units;-If blood sugar is 401 mg/dL to 450 md/dL, give 15 units;-If blood sugar is 451 mg/dL to 500 mg/dL, give 18 units.-If blood sugar is greater than 500 mg/dL, call physician. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed the resident's insulin lispro pen had no expiration date. 7. Review of Resident 33's face sheet showed the following:-admission date of 03/28/25;-Diagnoses included diabetes mellitus. Review of the resident's current POS showed an order, dated 05/16/25, for insulin lispro (fast acting insulin) insulin pen; 100unit per ml; administer per sliding scale subcutaneously before meals and at bedtime:-If blood sugar is 70 mg/dL to 130 mg/dL, give 0 units;-If blood sugar is 131 mg/dL to 180 mg/dL, give 2 units;-If blood sugar is 181 mg/dL to 240 mg/dL, give 4 units;-If blood sugar is 241 mg/dL to 300 mg/dL, give 6 units;-If blood sugar is 301 mg/dL to 350 mg/dL, give 8 units;-If blood sugar is 351 mg/dL to 400 mg/dL, give 10 units;-If blood sugar is 401 mg/dL to 450 mg/dL, give 15 units;-If blood sugar is 451 mg/dL to 500 mg/dL, give 18 units;-If blood sugar is greater than 500 mg/dL, call physician. Observation of a medication cart on 12/04/25, at 9:45 A.M., showed the resident's insulin lispro pen had no expiration date. 8. Observation of a medication cart on 12/04/25, at 9:30 A.M., showed three Tresiba injection pens and one open insulin lispro injection pen were open with no resident name, physician name, date dispensed, amount to be given, frequency, or expiration date indicated. These insulin pens were in a cup with other resident insulin pens. 9. During an interview on 12/04/25, at 9:30 A.M., Licensed Practical Nurse (LPN) G said the following:-Insulin pens should have a resident name listed and be dated with an open and expiration date.;-Insulin should be thrown away 28 days after opening;-Insulin pen and vials should be dated with an open date, an expiration date, and nurse initials;-He/she would destroy a pen with no date as you would not know how long it had been opened;-Insulin pens are to be used by one resident only and should be marked with the resident name;-Any nurse can clean expired medication out the medication, there is no set cleaning schedule;-Medications should be destroyed if they are found with no name or expired. 10. During an interview on 12/04/25, at 9:45 A.M., Licensed Practical Nurse (LPN) P said the following:-Insulin pens are for individual resident use;-Pens should have a date they were opened written on them;-Insulin pens should be discarded 30 days after opening;-The nurse would not know when the pen is expired if there is no date indicated; -An insulin pen without a name or date should be discarded. During an interview on 12/09/25, at 12:35 P.M., LPN N said the following:-Insulin pens should have resident information, be dated, have expiration date, and be initialed by the nurse upon opening;-Insulin pens with no date should be destroyed;-Insulin pens should be thrown away if there is no resident name listed;-Insulin pens are to be used by one resident only. During an interview on 12/09/25, at 2:13 P.M., the Director of Nursing (DON) said the following:-Nurses should verify the resident name, date opened and expiration date on insulin pens;-Insulin pens expire 28 days after opening; -Insulin pens are to be used by one resident only;-Insulin pens should be disposed if there is no resident name listed;-Insulin pens that are not dated should be disposed of as staff would not know how long it had been opened for;-Nurses and Certified Medication Technicians (CMT) should go through the medication cart weekly and dispose of expired and discontinued medications. 11. Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, revised date 06/30/25, showed the following:-Facility should ensure medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia (USP) guidelines for temperature ranges and manufacturer guidance;-Facility staff should monitor the temperature of vaccines twice a day;-Refrigeration temperature should be between 36 degrees Fahrenheit (F) and 46 degrees F. Review of the Centers for Disease Control and Prevention (CDC) Guidelines for vaccines, dated 03/26/21, showed the following:-Never freeze refrigerated vaccines;-Ideal temperature of refrigerated vaccines is 40 degrees F;-Refrigerator temperature should be between 36 degrees F and 46 degrees F. Review of Influenza (flu) vaccine package insert, dated July 2024, showed the following:-Store all vials in refrigerator at 35 degrees F to 46 degrees F;-Do not freeze;-Discard if vaccine has been frozen. Review of Pneumococcal (pneumonia) vaccine package insert, dated March 2024, showed the following:-Should be stored between 36 degrees F and 46 degrees F;-Do not freeze. Review of Hepatitis B (protects against acute and chronic illness) vaccine package insert, undated, showed the following:-Should be stored between 36 degrees F and 46 degrees F;-Do not freeze. Review of Tubersol (used to test for tuberculosis) package insert, undated, showed the following:-The vial should be stored at 35 degrees F to 46 degrees F;-The medication should be discarded if exposed to freezing temperatures. Review of acetaminophen suppository (used to treat pain and or fever) package insert, dated February 2024, showed the following:-May keep the medication in a cool storage at 36 degrees F to 46 degrees F to prevent melting;-Do not allow to freeze. Review of the Novolog package insert, undated, showed the following:-Keep Novolog pen or vial in a cool storage at 36 degrees F and 46 degrees F;-Do not freeze. If has been frozen, discard. Review of Humalog (insulin lispro) package insert, dated March 2024, showed the following:-Keep the Humalog pen or vial in a cool storage at 36 degrees F to 46 degrees F;-Do not allow to freeze. Review of Lantus (insulin) package insert, dated December 2024, showed the following:-Keep the Lantus pen or vial in cool storage at 36 degrees F to 46 degrees F;-Do not allow it to freeze;-Do not put it next to the freezer compartment of the refrigerator or next to a freezer pack. 1. Observation and interview on 12/04/25, at 10:00 A.M., of the medication refrigerator located in the medication room with LPN G showed the following:-The thermometer in the refrigerator read 21 degrees F;-The refrigerator contained resident insulins, tuberculosis testing serum, influenza vaccine, pneumococcal vaccine, hepatitis B vaccine, and acetaminophen suppositories;-LPN G said that the temperature should be between 25 degrees F and 32 degrees F. He/she said that night shift nurse checks the refrigerator temperature and should document it on the log nightly. Observation and interview on 12/05/25, at 10:45 A.M., of the medication refrigerator located in the medication room with LPN O showed the following:-The thermometer in the refrigerator read 22 degrees F;-LPN O said that he/she was not sure what the temperature of the refrigerator should be. He/she did not know who was responsible for checking the temperature of the refrigerator and logging it;-The refrigerator contained 20 pre-filled syringes of pneumococcal Prevnar vaccine; one vial of Hepatitis B vaccine; 18 pre-filled syringes of influenza vaccine; two vials of tuberculosis testing solution, seven insulin pens; and 12 acetaminophen suppositories. Review of the refrigerator logs, obtained from a clear sleeve from the front of the refrigerator, showed staff signed and completed the logs for the following days in the month of October 2025:-On 10/03/25, staff noted the temperature was 32 degrees F;-On 10/04/25, staff noted the temperature was 32 degrees F;-On 10/05/25, staff noted the temperature was 32 degrees F;-On 10/08/25, staff noted the temperature was 32 degrees F;-On 10/09/25, staff noted the temperature was 32 degrees F;-On 10/13/25, staff noted the temperature was 33 degrees F;-On 10/14/25, staff noted the temperature was 32 degrees F;-On 10/17/25, staff noted the temperature was 33 degrees F;-On 10/18/25, staff noted the temperature was 32 degrees F;-On 10/19/25, staff noted the temperature was 32 degrees F;-On 10/22/25, staff noted the temperature was 33 degrees F;-On 10/27/25, staff noted the temperature was 33 degrees F;-On 10/28/25, staff noted the temperature was 32 degrees F;-On 10/31/25, staff noted the temperature was 33 degrees F. Review of the refrigerator logs, obtained from a clear sleeve from the front of the refrigerator, showed staff signed and completed the logs for the following days in the month of November 2025:-On 11/01/25, staff noted the temperature was 32 degrees F;-On 11/02/25, staff noted the temperature was 32 degrees F;-On 11/19/25, staff noted the temperature was 33 degrees F;-On 11/20/25, staff noted the temperature was 33 degrees F;-On 11/24/25, staff noted the temperature was 33 degrees F;-On 11/25/25, staff noted the temperature was 33 degrees F;-On 11/28/25, staff noted the temperature was 32 degrees F;-On 11/29/25, staff noted the temperature was 33 degrees F. Review of the refrigerator logs, obtained from a clear sleeve from the front of the refrigerator, showed staff signed and completed the logs for the following days in the month of December 2025:-On 12/03/25, staff noted the temperature was 32 degrees F. During an interview on 12/09/25, at 4:04 P.M., Maintenance Director said that he/she was not allowed in the medication room without a nurse. He/she did not know how often the medication refrigerator was checked and had nothing to do with checking the temperature of the refrigerator. He/she had not been notified of anything being wrong with the refrigerator. During an interview on 12/05/25, at 11:30 A.M., the Director of Nursing (DON) said the night shift nurse was responsible for checking the refrigerator temperature and charting it on the log every night. Staff should contact the DON immediately if the temperature was out of range and the DON would contact maintenance to check the refrigerator. The DON was not sure what the temperature range should be. He/she has not been auditing the temperature log but should have been. Medications were to be kept at specific temperatures and if not kept at the recommended temperature, the medication should not be used until checking with pharmacy. During an interview on 12/05/25, at 12:22 P.M. the Administrator said that the DON was responsible for ensuring that the medication refrigerator temperature was checked daily. He/she expected the DON to report any temperatures that are out of range immediately so that they can figure out how to get the refrigerator fixed. He/she said the temperature range should be between 32 degrees F to 35 degrees F.

Based on observation, interview, and record review, the facility failed to maintain a complete and effective infection prevention and control program when the facility failed to ensure staff were educated on enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities); failed to ensure staff wore appropriate protective personal equipment (PPE) when providing catheter (flexible tubing that is used to drain urine from the bladder) care for one resident (Resident #46) and when accessing a percutaneous endoscopic gastrostomy (PEG - a tube inserted through the abdominal wall in the stomach to provide nutrients) tube for one resident (Resident #62). The facility also failed to maintain an effective infection prevention and control program when the facility failed to have processes in place to ensure all new staff were screened prior to employment for tuberculosis (TB - a serious illness that mainly affects the lungs and can be spread when a person with the illness coughs, sneezes or sings) when the facility failed to fully complete TB testing for nine staff (Certified Medication Technician (CMT) F, Nurse Assistant (NA) I, Licensed Practical Nurse (LPN) G, Dietary Aide (DA) E, NA B, NA C, Laundry Aide (LA) A, Registered Nurse (RN) D, and Dietary Manager (DM)). The facility census was 106.1. Review of the Centers for Disease Control's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 07/12/22, showed the following:-Multidrug-Resistant Organisms (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs;-EBP are infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities;-EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO;-Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care;-EBP use of PPE refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing;-Examples of high-contact resident care activities requiring gown and glove use for EBP includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central line, urinary catheter, feeding tube, and tracheostomy/ventilator, and wound care on any skin opening requiring a dressing;-Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/01/25, showed the following:-The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;-All staff and responsible for following all policies and procedures related to the program;-A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents;-All staff should use PPE according to established facility policy governing the use of PPE. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 10/01/25, showed the following:-It is the policy of this facility to implement EBP for the prevention of transmission of multidrug resistant organisms;-An order for EBP will be obtained for residents with any of the following:-Wounds and indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO-Infection or colonization with a MDRO when contact precautions do not otherwise apply;-Make gown and gloves available immediately near or outside of the resident's room;-PPE for EBP is only necessary when preforming high-contact care activities and may not need to be donned prior to entering the resident's room;-Ensure access to alcohol-based hand rub in every resident room;-Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or providing care for another resident in the same room;-The infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education;-High-contact resident care activities include dressing; bathing; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use; and wound care;-Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review showed the facility did not provide a list of current residents on EBP. 2. Review of Resident #46's face sheet (basic resident profile information) showed the following:-admission date of 03/13/22;-Diagnoses included end stage renal disease (ESRD – kidneys are severely damaged and can no longer filter blood effectively), neuromuscular dysfunction of the bladder (nerve damage disrupts signals between the brain and the bladder causing issues with holding or emptying urine), and multiple sclerosis (a chronic autoimmune disease that affects the central nervous system). Review of the resident's most recent comprehensive Minimum Data Set (MDS-federally mandated assessment tool administered by staff) showed the resident had an indwelling catheter. Review of the resident's care plan, revised 11/21/25, showed staff did not care plan use of a catheter or EBP related to the catheter. Review of the resident's current Physician Order Sheet (POS) showed the following orders:-An order, dated 07/17/25, to change foley catheter every three weeks to prevent urinary tract infections per urology;-An order, dated 06/26/25, to provide foley catheter care every shift;-An order, dated 06/26/25, for a foley catheter 16 French with a 30 milliliter (ml) bulb (size) to closed urinary bag due to diagnosis of retention;-An order, dated 08/18/25, resident required EBP due to foley catheter. Observation of catheter care on 12/09/25, at 10:25 A.M., showed the following:-Certified Nurse Assistant (CNA) J and Nurse Assistant (NA) K provided catheter care to the resident and donned gloves. The CNA and NA did not don a gown;-CNA J and NA K gathered trash, washed hands, and exited room. Observation on 12/09/25, at 10:25 A.M., showed the resident had an EBP sign on the door and gowns located on the back of the door. During an interview on 12/09/25, at 10:35 A.M., CNA J said the following:-EBP is indicated by a sign on the resident's door;-Staff should wear a gown and gloves when caring for residents with open wounds, catheters, and feeding tubes;-He/she should have worn a gown when providing catheter care for resident but forgot. 3. Review of Resident #62's face showed the following:-admission date of 09/02/22;-Diagnoses included hemiplegia following cerebral infarction (paralysis of one side following a brain injury), aphasia (a communication disorder impairing the person's ability to speak), and dysphagia (difficulty swallowing foods or liquids). Review of the resident's care plan, revised 11/25/25, showed the following:-Resident had a PEG tube for nutritional support, hydration, and medication administration;-Staff should utilize EBP when providing personal cares. Review of the resident's current POS showed the following:-An order, dated 09/25/25, for Jevity 1.5 (a brand of liquid nutrition used in tube feedings) bolus feeding per PEG tube, administer 2 cans three times daily, flush with 100 ml water before and after each bolus feeding. Oservation of a tube feeding on 12/03/25, at 1:40 P.M., showed the following:-Licensed Practical Nurse (LPN) L entered the resident's room, washed his/her hands, and donned gloves to provide a feeding via PEG tube. The LPN did not don a gown;-LPN L provided the feeding to the resident, removed gloves, and washed hands. Observation on 12/03/25, at 10:40 P.M., showed the resident had an EBP sign on the door and gowns located on the back of the door. 4. During an interview on 12/03/25, at 12:04 P.M., CNA V said the following:-He/she was not sure what the EBP signs on the resident doors indicated;-He/she thought something was going on in the resident room;-He/she would not do anything different before entering a room with EBP sign on the door;-He/she did not know where the gowns were kept;-He/she was not sure if a gown and gloves would be needed to provide care to residents with a foley catheter or wound. During an interview on 12/09/25, at 12:35 P.M., LPN N said the following:-EBP was for residents with foley catheters, tube feedings, or intravenous lines;-Staff should wear gowns, gloves, and a face mask if needed, when providing direct care to residents;-There should be a sign on the door indicating resident is on EBP and gowns are located behind the door. During an interview on 12/09/25, at 3:48 P.M., CNA M said the following:-EBP were used for residents that have feeding tubes, wounds, and catheters;-Staff should wear gown and gloves for any direct contact with residents on EBP. During an interview on 12/09/25, at 2:13 P.M., the Director of Nursing (DON) said the following:-EBP were for residents with wounds and infections;-Residents with intravenous lines, tube feeding, and catheters are not on EBP;-A resident with a catheter could be on EBP if they had an infection;-EBP was for resident protection;-Staff should wear a gown and gloves for direct contact with EBP residents; -He/she did not know what residents were on EBP currently;-They did not keep a list of EBP residents. During an interview on 12/09/25, at 4:16 P.M., the Administrator said staff should be following EBP and wearing a gown and gloves. Staff should follow infection control guidelines. 5. Review of the facility policy titled, Employee Tuberculosis Testing, dated 10/01/25, showed the following:-At the time of employment, all new staff shall undergo pre-placement screening for Tuberculosis (TB), including an individual risk assessment, TB symptom screen, and a TB test;-All new staff shall receive two Mantoux Tb Skin Tests given two weeks apart (two step testing);-All initial and follow up TB tests shall be administered and interpreted (48 to 72 hours for skin tests) by a trained healthcare provider on our staff, or any licensed physician. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities showed the following:-Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit (5 TU) test;-Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained for all residents, employees, and volunteers;-All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two-step tuberculin test within one month prior to starting employment in the facility;-If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years;-It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status. 6. Review of CMT F's personnel record showed the following:-Hire date of 05/14/24;-The first step of the TB skin test was complete on 05/14/24;-Staff did not document the test was read within 48 to 72 hours;-Staff did not have documentation of completion of the second step TB skin test. 7. Review of NA I's personnel record showed the following:-Hire date of 01/15/25;-The first step of the TB skin test was complete on 01/14/25;-Staff did not document the test was read within 48 to 72 hours;-Staff did not have documentation of completion of the second step TB skin test. 8. Review of LPN G's personnel record showed the following:-Hire date of 02/03/25;-The first step of the TB skin test was complete on 01/19/25;-Staff did not document the test was read within 48 to 72 hours;-Staff did not have documentation of completion of the second step TB skin test. 9. Review of DA E's personnel record showed the following:-Hire date of 04/23/24;-The first step of the TB skin test was complete on 04/23/24;-Staff did not document the test was read within 48 to 72 hours. 10. Review of NA B's personnel record showed the following:-Hire date of 03/12/25;-The first step of the TB skin test was complete on 03/04/25 and read on 03/06/25;-Staff did not have documentation of completion of the second step TB skin test. 11. Review of NA C's personnel record showed the following:-Hire date of 06/25/25;-The first step of the TB skin test was complete on 07/02/25 and read on 07/05/25. 12. Review of LA A's personnel record showed the following:-Hire date of 09/04/24;-The first step of the TB skin test was complete on 08/27/24 and read on 08/29/24;-The results were not documented in millimeters;-The second step of the TB skin test was complete on 09/10/24 and read on 09/12/24;-The results were not documented in millimeters. 13. Review of RN D's personnel record showed the following:-Hire date of 09/17/25;-The first step of the TB skin test was complete on 09/10/25 and read on 09/12/25;-The results were not documented in millimeters;-The second step of the TB skin test was complete on 09/26/25 and read on 09/28/25;-The results were not documented in millimeters. 14. Review of DM personnel record showed the following:-Hire date of 09/17/25;-The first step of the TB skin test was complete on 09/17/25 and read on 09/19/25;-The results were not documented in millimeters;-The second step of the TB skin test was complete on 10/03/25 and read on 10/05/25;-The results were not documented in millimeters. 15. During an interview on 12/09/25, at 12:30 P.M., the Business Office Manager (BOM) said the following:-TB testing was complete prior to orientation;-The Staff Development Coordinator (SDC) conducted staff TB testing; however, any nurse can complete it. During an interview on 12/09/25, at 12:55 P.M., LPN X said facility nurses can administer staff or resident TB testing. The SDC is responsible for staff TB testing. During an interview on 12/09/25, at 1:00 P.M., the SDC said the following;-He/she conducted a two-step test on all new employees;-He/she provided staff an appointment card to remind them of their second step TB test and also flagged the employee in his/her appointment book;-He/she only had to indicate whether the test is positive or negative, measurements do not have to be recorded;-TB tests were read two days after administered and the second step is completed two weeks after the first step. During an interview on 12/09/25, at 2:00 P.M., LPN O said management conducted staff TB testing. TB tests were read within 48 hours and measurements had to be documented. During an interview on 12/09/25, at 2:10 P.M., LPN N said the SDC conducted staff TB testing. Tests were read within 48 to 72 hours and measurements needed to be documented. During an interview on 12/09/25, at 3:00 P.M., Medical Records (MR) said the following:-New employees receive a two-step TB test;-TB tests are read within 48 hours;-The second TB test is administered with 10 days to two weeks after the first test;-Measurements of the test results should be documented. During an interview on 12/09/25, at 3:43 P.M., the Director of Nursing (DON) said the following:-The SDC or MR conducted new hire TB testing;-A two-step test was complete;-The test was read within 72 hours, and was read during the staff's onboarding process;-The second set was complete two weeks after the first;-The results were to be documented in millimeters. During an interview on 12/09/25, at 4:12 P.M., the Administrator said the following:-New employees receive a two-step TB test;-The test was read three days from the day it was administered;-He/she was unsure when the second step was administered;-Test results were documented as positive or negative. He/she is unsure if a measurement was documented.

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made two errors out of 29 opportunities resulting in an 6.9% error rate when facility staff failed to administer one medication as ordered and administered an incorrect dosage of a medication to one resident (Resident #47). The facility had a census of 106.Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made two errors out of 29 opportunities resulting in an 6.9% error rate when facility staff failed to administer one medication as ordered and administered an incorrect dosage of a medication to one resident (Resident #47). The facility had a census of 106.Review of the facility procedure titled Safe Administration Practiced, Long-Term Care, dated 05/19/25, showed the following:-Be sure to administer daily, weekly, and monthly medications within two hours of the scheduled administration time;-Consult the practitioner if there are unresolved concerns related to prescribed medications;-Documentation associated with safe medication administration would include medication name, strength, and dose. 1. Review of Resident #47's face sheet showed the following:-admission date of 03/01/23;-Diagnoses included high blood pressure and diabetes mellitus (disorder where the body does not produce enough insulin, causing blood sugar levels to be high). Review of the resident's current Physician Order Sheet (POS) showed the following:-An order, dated 08/28/24, for metformin (diabetic medication) 500 milligrams (mg) tablet, give two tablets two times a day for diabetes;-An order, dated 09/27/24, for dorzolamide-timolol (medication to treat increased pressure in the eye) eye drops, instill one drop in both eyes two times daily glaucoma. Review of the resident's December 2025 Medication Administration Record (MAR) showed the following:-Dorzolamide-Timolol eye drops, administer one drop to each eye twice daily, noted as not given on 12/09/25 at 8:00 A.M. due to drug not available;-Metformin tablet 500 mg, administer two tablets twice a day for diabetes mellitus, noted as given as ordered on 12/09/25 at 8:00 A.M. Observation of a medication pass on 12/09/25, at 9:27 A.M., showed the following: -Certified Medication Tech (CMT) Z sanitized his/her hands and started to prepare medications to administer to the resident;-The CMT pulled the metformin card from the medication cart, and it had a dosage of 500 mg and stated to administer two tablets on the label for a total dosage of 1000 mg;-The CMT placed one metformin tablet in the medication cup to administer;-The dorzolamide-timolol was not in the medication cart and unavailable for administration at the ordered time;-The CMT locked the cart and went to the medication room to obtain the dorzolamide-timolol eye drops. The CMT returned with two boxes of eye drops and indicated they were not the correct ones and put them in the cart;-The CMT then entered the resident's room and administered the medications. During an interview and observation on 12/09/25, at 9:30 A.M., CMT Z reviewed the order for metformin and stated he/she should have given two tablets as ordered.The dorzolamide-timolol eye drops were unavailable, but he/she should have administered them as ordered. During an interview on 12/09/25, at 12:35 PM., Licensed Practical Nurse (LPN) N said physician orders should be followed, and staff should administer the correct medication dosage. It would be a medication error to omit an ordered medication or to administer the incorrect dose. Nurses or CMT's should check the medication dispensing system to see if the medication is available and if not contact the pharmacy to send it right away. During an interview on 12/09/25, at 3:30 P.M., CMT M said it would be a medication error if the wrong dose of a medication was administered. He/she would notify the charge nurse, and the nurse would contact the physician. Medications that are not given at the correct time or are not available would be a medication error. During an interview on 12/09/25, at 3:55 P.M., LPN Y said it would be a medication error if the wrong dose of a medication was given to a resident. He/she would notify the physician, family, and the Director of Nursing (DON). A medication omitted during the medication pass is an error. The CMT should notify the charge nurse if there is a medication error. During an interview on 12/09/25, at 2:13 P.M., the DON said staff should follow physician orders when administering medications. It would be a medication error if the correct dosage was not given or if a medication was not available for administration as ordered Nurses should notify the resident's family and physician for a medication error. A progress note should be entered for a medication error. During an interview on 12/09/25, at 4:16 P.M., the Administrator said nurses and CMT's should follow physician orders when administering medications.

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to manage and with in two hours to the Survey Agency (DHSS - Department of Health and Senior Services) when staff failed to report and an allegation of abuse involving one resident (Resident #1) until the following day. The facility census was 101. Review of the facility policy Abuse and Neglect, dated 10/24/22, showed the following:-Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse or neglect, or an injury of unknown origin to the Director of Nursing (DON) or the department supervisor and that individual will notify the Administrator;-Each employee should report to the supervisor and follow-up with the supervisor to confirm it has been addressed. If not, the employee should make direct contact with the Administrator;-Any staff members that witnessed, suspected, or that is reported to, are personally obligated to initiate protection and report to supervisor immediately.1. Review of Resident #1's face sheet (admission information at a glance) showed the following:-admission date of 09/11/23;-Diagnoses included fractured left hip with artificial hip joint, moderate dementia (progressive impairments in memory, thinking, and behavior which affects ability to carry out daily activities) with anxiety, type 2 diabetes mellitus (high blood sugar), chronic kidney disease, urinary tract infection, and chronic obstructive pulmonary disease (COPD - lung disease that blocks air flow and makes it difficult to breathe). Review of the resident's care plan, revised 8/23/25, showed the following:-The resident had impaired cognition/decision making ability and impaired communication related to dementia. The resident exhibited behaviors of delusions;-Explain care and procedures before and during care; -Observe for understand, and repeat information as needed;-Provide consistent caregivers as possible;-Provide simple cues, prompts, and reminders as needed;-Speak name or touch resident so they know they are being addressed;-Allow opportunity to make choices and participate in care;-Do not argue with resident;-Identify causes for behaviors and reduce factors that may provoke behaviors;-Impaired cognition;-Explain care and procedures before and during care;-Observe for changes in cognition;-Observe resident when restless, hungry, thirsty, need to use the bathroom, pain, and provide care needed;-Assist with decisions as needed and offer choices;-Provide cues, prompts, and reminders as needed;-Touch and hugs as appropriate.During interviews on 09/09/25, at 1:34 P.M., and on 09/10/25, at 10:55 A.M., Nurse Aide (NA) E said on 08/31/25, at around 4:30 A.M. to 5:00 A.M., while doing their last rounds before shift change, he/she and Certified Nurse Aide (CNA) G went into the resident's room to provide incontinence care. CNA G turned on the light and asked the resident if they could provide care. When CNA G went to take off the incontinence brief, the resident was startled, and grabbed CNA G's arm and then hit his/her arm. CNA G grabbed the resident's hands and wrists and crossed them on his/her chest to hold him/her down. CNA G had an aggressive mean voice with the resident for hitting him/her. CNA G held the resident's hands across his/her chest for about a minute. NA E didn't know what to say or do. The resident refused to let them change him/her and they left without changing him/her. He/she knows now they should have gone and told the nurse about the resident refusing and being aggressive, and to try to go back later to the resident. He/she said, It didn't cross his/her mind to tell the charge nurse right away. He/she did think about it later and then told NA F the next night on 08/31/25 to 09/01/25. NA F told him/her that he/she should report this. Then NA F went ahead and made the report. He/she was to report to the charge nurse and then make a paper report. NA F told RN A the next day before he/she got off work. He/she did not know the time frame to report an allegation of abuse and neglect and did not know the time frame to report to the state.Review of the resident's progress note dated 09/01/25, at 7:15 P.M., showed there was an allegation of abuse that had been made about the resident. The Staffing Development Coordinator (RN) A and Licensed Practical Nurse (LPN) B assessed the resident, suspended the staff member, and notified the physician, Administrator, and durable power of attorney (DPOA). Review of DHSS records showed the facility self-reported the allegation of physical abuse on 09/01/25, at 7:24 P.M. Review of the facility's written investigation, dated 09/01/25, showed it was reported that CNA G forcibly held down the resident's hands.During an interview on 09/09/25, at 11:25 A.M., CNA D said if he/she noticed any bruising on a resident, he/she would automatically tell the nurse and chart this since the aides do chart skin for redness and bruising and where it's located. If he/she saw abuse, he/she would intervene and go let nurse know. NA E mentioned the event to NA F who was told to report to RN A. NA E was a new nurse aide and said he/she didn't know who to report to. If staff see something like abuse, staff were to tell the nurse who was to report this to the Administrator. They were to report any abuse or neglect within two hours to the state.During interview on 09/09/25, at 12:57 P.M., NA F said he/she worked the night shift on 08/31/25 to 09/01/25 when night NA E told him/her CNA G was mean and aggressive towards the resident when they went to perform incontinence care to the resident. The resident smacked CNA G on his/her arm and CNA G grabbed the resident's hands , crossed them over his/her chest, and forcefully held him/her down by the arms. NA E didn't know to report this to the nurse. NA F told NA E to report this. When NA F got off work, he/she waited to report what NA E told him/her. It was already a day late so he/she thought it was okay to wait until later that day. He/she told RN A, he/she was told this information when he/she came in later that day. NA F was not sure how to report but knew he/she was to report this immediately. It was to be reported to the state within two hours. During an interview on 09/09/25, at 3:58 P.M. Certified Medication Technician (CMT) H said they were to report any abuse to the charge nurse right away and within two hours, and staff to report to the state. During interview on 09/10/25, at 9:15 A.M., LPN I said he/she would report any allegation of abuse and neglect to the DON and Administrator. He/she did not know the time period for reporting to the state.During interview on 09/09/25, at 11:20 A.M., the Activities Director said if there was any abuse such as mental, physical, emotional, verbal, sexual, or financial, staff were to go through the chain of command and go to the charge nurse and report this immediately. This was to be reported to the state within two hours.During interviews on 09/09/25, at 2:45 P.M. and 3:10 P.M., Staffing Development Coordinator (RN A) said NA F texedt him/her that NA E had witnessed CNA G being abusive toward another resident. He/she talked to NA E who said the resident had struck CNA G and CNA G grabbed the resident's arms and pushed them toward his/her own chest while NA E provided incontinence care. RN A contacted the Administrator and then came directly to the facility to go with LPN B night charge nurse to assess the resident with another aide. LPN B They contacted all the nurse aides involved and took them off the schedule. Staff were to contact the DON and Administrator if there was any abuse or neglect allegation. They were to notify staff immediately and have two hours to report to the state.During an interview on 09/10/25, at 10:10 A.M., the Assistant Director of Nursing (ADON) said he/she would expect staff to report immediately any abuse to their charge nurse. During an interview on 09/10/25, at 11:45 A.M., the DON said staff were to report any abuse and neglect immediately and the Administrator had two hours to get the report in to the state. Staff were to call her and not text her. The staff can call her, the ADON, and the Administrator at any time.During an interview on 09/10/25, at 2:20 P.M., the Administrator said she had orientation that discussed Abuse and Neglect and reporting immediately to the charge nurse or the DON, and herself as administrator. Complaint 2604516

Based on observation, interview, and record review, the facility failed to promote and facilitate each resident's right of self-determination through support of resident choice when staff failed to honor resident preferences for showers for three residents (Resident #1, #2, and #3). The facility census was 103.Review of the facility policy titled, Hygiene and Grooming, dated 10/01/10, showed the following:-Good hygiene and grooming help prevent the spread of infection and promote the resident's feeling of self-worth and dignity;-Guidelines for provision of hygiene and grooming services are shower, tub, or complete bed bath, as needed; and hair and scalp shampoo, as needed;-Services may be provided on a varying schedule, when a physician's order or recommendation exists, or when the resident needs services more frequently;-Resident preferences for time of day, type of bath, and frequency of bath should be honored, to the extent possible.1.Review of Resident #1's face sheet showed the following:-admission date of 02/09/24;-Diagnoses included congestive heart failure (CHF - a condition in which the heart doesn't pump blood as efficiently as it should), dependent on oxygen, muscle weakness, unsteadiness on feet, major depression, and general anxiety disorder.Review of the resident's care plan, revised 08/08/25, showed the following:-Required staff assistance with all activities of daily living (ADLs);-Transfers, two-person assist;-Assist to gather items for bathing and assist to bath area as needed;-Two person to assist with bathing;-Assist with hair, brushing teeth/oral care, shaving, and nail care;-Assist with bathing per schedule;-Encourage to wash, rinse, and dry body parts that are within their physical ability to do. Observation and interview on 08/12/25 at1:20 P.M., with the resident showed the following:-The resident lay on his/her bed wearing a night gown with circular stains on the front of the gown;-The resident's hair appeared slightly greasy and uncombed;-The residents said he/she had an issue with the facility not assisting him/her with an adequate number of showers;-The resident said he/she would like to have at least two showers per week, but typically staff assisted the resident with one shower every couple of weeks;-He/she spoke to nursing staff about the issue and spoke to the Social Service Designee (SSD) about the issue as well. The SSD told the resident the facility was working on the shower issue. The SSD told the resident staff documented he/she refused his/her showers in the past, but the resident said that was not accurate. The resident said he/she did not refuse showers. He/she required a considerable amount of assistance to transfer in and out of the shower chair and needed assistance during the shower. During an interview on 08/13/25, at 9:56 A.M., the Shower Aide said the following:-The resident was scheduled to have a shower on the day shift, but he/she required the assistance of two staff and a mechanical lift to transfer in and out of the shower chair;-At times, he/she did not have time or assistance to complete the resident's shower as assigned;-The shower aide reviewed the records and said staff had not assisted the resident with a shower since 08/01/25 per the documentation (12 days prior).Review of the resident's electronic medication record history, dated 07/01/25 to 08/12/25, showed the following:-Showers scheduled once a day on Tuesdays and Fridays;-Staff documented completion of showers by marking as done (completed) on 07/01/25, 07/15/25, and 08/01/15.During an interview on 8/13/25, at 1:40 P.M., the resident said the following:-He/she preferred two showers per week;-If staff do not assist him/her with a shower, he/she starts feeling itchy all over and he/she would get dandruff/dry flaky skin on his/her scalp.2. Review of Resident #2's face sheet showed:-An admission date of 07/20/23;-Diagnoses included schizoaffective disorder(a combination of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may include delusions, hallucinations depressed episodes and manic periods of high energy), post-traumatic stress disorder (PTSD), anxiety, depression, and paranoid personality disorder.Review of the resident's care plan, revised 07/14/25, showed the following:-Required assistance to complete daily activities of care safely;-Allow resident to make choices, when possible;-Bath per schedule.Observation and interview on 08/12/25, at 1:22 P.M., with the resident showed the following:-The resident lay on his/her bed fully dressed and his/her hair appeared greasy;-The resident said he/she had not been assisted with a shower in approximately two weeks;-The resident said he/she was supposed to be assisted by staff with two showers per week;-The resident said he/she thought the reason for not getting a shower was due to the facility pulling the shower aide to work the floor. During an interview on 08/13/25, at 9:56 A.M., the Shower Aide said the following:-He/she thought the evening shift was responsible for assisting the resident with showers;-The SSD and the shower aide just implemented the new shower list during the past week, but prior to that, the evening staff were not competing the assigned showers;-The resident was on the shower aides list of residents that needed a shower;-The shower aide reviewed documentation and said he/she thought the resident had not had a shower in approximately 3 weeks or more.Review of the resident's electronic medical record history, dated 07/01/25 to 08/12/25, showed the following:-Showers scheduled once a day on Mondays and Thursdays;-Staff did not document completion of any showers from 07/01/25 to 07/16/25;-Staff documented resident refused on 07/17/25;-Staff did not document completion of any shower from 07/18/25-08/06/25;-Staff documented resident refused on 08/07/25;-Staff did not document completion of any shower from 08/08/25-08/10/25;-Staff documented resident refused on 08/11/25;-Staff did not document on 08/12/25.During an interview on 08/13/25, at 1:45 P.M., the resident said staff assisted him/her with a shower and changed his/her sheets today (08/13/25) and he/she felt better. If he/she did not get a shower, he/she felt itchy and more tired.3. Review of Resident #3's face sheet showed:-admission date of 12/29/12;-Diagnoses of CHF, morbid obesity, type 2 diabetes mellitus, anxiety, and major depression.Review of the resident's care plan, revised on 07/29/25, showed the following:-Required staff assistance with ADLs related to obesity and limited mobility;-One-to-two-person assistance with bathing as needed;-Encourage the resident to wash, rinse, and dry body parts that are within their physical ability to do;-Required assistance of two staff for use of bed pan for toileting.Review of the resident's electronic medical record, dated 07/01/25 to 08/12/25, showed the following:-Showers scheduled once a day on Tuesdays and Fridays;-Staff documented completion of showers by marking as done (completed) on 07/15/25, 07/23/25, and 08/01/15.Observation and interview on 8/13/25, at 1:50 P.M., with the resident showed the following:-The resident laying on his/her bed; -Resident stated he/she was bed bound, overweight, and got sweaty under his/her skin folds;-The resident's skin became raw and sore, if staff did not assist him/her with a bath;-The resident said he/she liked to have staff assist with a bed bath two times per week, but often had to wait two weeks in between bed baths;-He/she needed a bed bath to keep skin from breaking down;-He/she experienced incontinence of bladder at times and used a bed pan at times;-The resident said he/she began smelling like urine and feces when staff do not assist him/her with a bed bath twice per week;-The resident said his/her head starts itching when his/her head was dirty;-The resident said he/she talked to staff and asked for assistance with bed baths, but staff told the resident they did not have time and were too busy with other responsibilities. 4. During an interview on 08/13/25, at 9:56 A.M., the Shower Aide said the following: -He/she worked as the shower aide in the facility since January 2025;-The facility did not have another shower aide;-He/she generally worked four days per week, seven hours per day;-He/she assisted approximately 10 to 12 residents per day with showers, if no residents refused;-At times, nurses asked him/her to work the floor as an aide due to call-ins or staffing issues and when that happens, he/she was not able to complete assigned showers;-He/she was unsure how often nursing pulled him/her to work the floor as an aide;-Approximately one week ago, the Social Service Designee (SSD) suggested the shower aide change the way in which he/she gave showers;-Every resident room/bed number had two designated shower days and times per week;-In the past, he/she was focused strictly on completing the day shift showers assigned for that day;-He/she was not attempting to catch up on incomplete showers from previous days/evenings;-After working with the SSD, the shower aide was now looking at which residents were not getting showers on other days or shifts and trying to prioritize those that had gone the longest amount of time without a shower;-He/she found some residents were going two to three weeks without a shower;-The SSD had computer access to look back on past resident shower documentation for the past few weeks and found staff were either not completing or not documenting showers;-Evening shift aides were assigned residents showers, but were not completing most of the assigned showers;-Beginning last week, the SSD printed off a list last week of residents that have not had showers in two to three weeks and the shower aide was trying to prioritize showering those residents. We started doing that last week or week before last;-SSD became involved, because SSD and the shower aide noticed more residents were complaining of staff not assisting them with showers;-A majority of the residents complaining were scheduled for showers on the evening shift.-The shower aide said he/she charted the resident refused when he/she ran out of time to give the resident a shower or when nursing pulled him/her to work the floor. The shower documentation did not provide a space to document another reason for not completing the shower and the shower aide said he/she would rather not leave the documentation blank;-On average, he/she was assisting the more independent residents with one shower per week, but he/she generally did not provide showers to the residents requiring more extensive transfer/shower assistance;-In the past, he/she had reported to the charge nurse or previous Director of Nursing (DON) he/she could not complete all the showers, and they would just tell the shower aide okay;-No one was following up with a list of needed showers for the next shift;-Prior to last week no one was auditing showers to ensure staff were completing resident showers.During an interview on 08/13/25, at 1:25 P.M., Nurse Aide (NA) C said the following:-Nursing assigned each aide to work a specific hall for their shift;-For each hall and each shift, there were assigned resident showers. Aides were responsible for assisting with the assigned showers;-He/she did not have adequate time during his/her shift to complete all assigned resident showers due to other resident care responsibilities while working the floor;-He/she said he/she might complete half of the assigned resident showers for the shift on average;-He/she had not notified the nurse of not being able to complete showers.During an interview on 08/13/25, at 2:54 P.M., NA E said the following:-He/she worked the floor as an aide;-Frequently, the aides were unable to complete assigned showers due to lack of time and due to other job responsibilities.During an interview on 08/13/25, at 1:33 P.M., Certified Medication Technician (CMT) D said the following:-Staff were supposed to assist residents with two showers per week;-The aides/shower aide were not completing all the assigned resident showers;-He/she thought the issue was due to staff not encouraging residents enough to take showers;-Staff often just accepted the resident's first refusal and did not re-approach the resident later of notify the nurse of the resident refusals;-The day shift aides frequently did not complete assigned showers;-The Shower Aide frequently did not complete assigned showers. During an interview on 08/13/25, at 11:00 A.M., Licensed Practical Nurse (LPN) A said the following:-The facility had one designated shower aide and then the evening and night shifts aides were assigned showers as well;-He/she was under the impression, the day shift aides were also supposed to do showers, but some days the Shower Aide said he/she and/or the aides were not completing assigned resident showers;-When informed of an issue, he/she would pass a list of residents needing showers to the evening shift staff and ask the evening staff to complete those showers;-He/she thought the evening aides generally completed the provided list of residents needed showers, depending on staffing number and which aides were working that evening;-He/she tried to make sure the aides were documenting showers given or documenting refusals;-If the staff notified him/her of a resident refusal, the nurse would try to encourage the resident to take a shower;-The nurse knew the Shower Aide was sometimes documenting refused when he/she ran out of time or was pulled to the floor, but the shower aide should not document refused unless the resident refused the shower.During an interview on 08/13/25, at 11:20 A.M., LPN B said the following:-Staff were not completing all assigned resident showers;-He/she observed the evening shift only completing a few of the assigned showers;-He/she did not know if the night shift had assigned showers or if they were completing any showers on the night shift;-Some residents complained about not getting showers. He/she was not auditing to see which residents were assisted with showers and which residents were not getting staff assistance with showers. During an interview on 08/13/25, at 11:37 A.M, the SSD said the following:-He/she had worked at the facility for approximately 9 years and used to work as a shower aide several years prior;-Staff were supposed to provide each resident with two showers per week, unless the resident requests a different number of showers;-During resident care plan meetings, some of the residents and/or their family members mentioned concerns with not getting shower assistance or an adequate number of showers. When this occurred, he/she notified nursing of the need to shower those specific residents;-On approximately 08/07/25, he/she observed the Shower Aide did not completing all assigned resident showers. The Shower Aide appeared to be completing a portion of showers for that assigned day. It appeared no staff were assisting residents listed on the evening shift showers list with their showers. When the SSD questioned this, the Shower Aide said he/she was not able to complete all the assigned showers for each day and was not completing any resident showers assigned to the evening shift;-On 08/07/25, the SSD decided to run a report to focus on which residents had not had showers recently;-He/she ran a resident shower report for the past two weeks, 07/24/25 to 08/07/25, to determine which residents had not been assisted with showers and provided the list to the shower aide;-On 08/11/25, he/she notified the interim DON of the issue of staff not assisting residents with an adequate number of showers.During interviews on 08/12/25, at 1:54 P.M., and on 08/13/25, at 2:12 P.M., the DON said the following:-He/she worked as the interim DON of the facility since approximately 07/23/25;-He/she pulled the Shower Aide away from completing resident showers today (08/12/25) and reassigned the shower aide to work as an aide on the floor, due to terminating another aide today;-The facility had one designated shower aide for the building, but if the resident was independent with showers, the aides could also assist with showers;-Unsure how often nursing pulled the Shower Aide to work the floor in the past;-The facility scheduled residents for two showers per week;-The Shower Aide gave approximately 5 to 10 showers per day.-He/she expected staff to provide each resident with two showers per week, unless the resident refused or elected to have a different number of showers per week;-He/she was unsure if anyone was auditing the resident showers on a regular basis to ensure staff were completing the showers;-He/she thought some of the residents complained about not getting showers to the SSD, so the SSD ran a shower report;-A few days ago, the SSD came to the DON with concerns about the staff not assisting residents with showers.-The Shower Aide was not completing all assigned showers and the aides working the floor did not always have time to assist with resident showers;-All residents in the facility required at a minimum supervision for safety while in the shower;-The DON was not aware the Shower Aide documented resident refusals when he/she ran out of time to complete a shower or when pulled to work the floor;-When the Shower Aide was unable to complete assigned list, he/she should give a list of remaining showers to the charge nurse, so the nurse could assign aides to try and complete the showers or so the nurse could document the reason the shower was not given.During an interview on 08/13/25, at 3:00 P.M., the Administrator said the following:-He/she was not aware staff were not assisting residents with showers as scheduled;-All residents should be offered at least two showers per week unless the resident preferred a different number of showers.Complaint #2588293

Based on observation, interview, and record review, the facility failed to provide each resident with a nourishing, well-balanced diet that met the daily nutritional needs of the residents when the facility failed to prepare and serve meals for the residents per the facility approved menu and failed to make an nutritionally adequate substitutions to the menu. The facility census was 102. Review showed the facility did not provide a policy regarding serving sizes or nutritional values. 1. Review of the facility's February 2025 Dietary Menu showed staff were to serve the following on 02/21/25, at lunch, to the residents: -Chili, 6 ounces (oz); -Baked potato, 1 each.; -Crackers, 2 packages; -Spiced peaches, 4 oz.; -Iced tea, 8 oz.; -Water, 8 oz. Observation on 02/21/25, at 12:08 P.M., showed the following: -The surveyor requested a test tray of a resident meal; -Staff delivered two test trays to the surveyors; -Each tray contained a bowl of chili and no additional food items. Observation on 02/21/25, at 12:22 P.M., in the special care unit (SCU) showed the following: -Facility staff served lunch to the residents in the special care unit (SCU) dining room; -Staff served the residents chili in an approximate one cup sized bowl containing chili and a small dessert cup of sliced peaches for lunch; -Staff did not serve residents a baked potato or crackers, as listed on the menu. Observation and interview on 02/21/25, at 12:45 P.M., with Resident #5 said the following: -Staff did not give him/her all the food on the menu for today; -He/she was missing the baked potato, margarine, sour cream, and crackers -At times, staff only served half of the meal on the menu; -Observation showed the resident's tray contained a bowl of chili and a cup of sliced peaches. Observations and interview on 02/21/25, at 1:04 P.M., with Resident #14 said the following: -He/she did not get the full lunch meal; -Staff did not serve the baked potato with margarine and sour cream, or any crackers; -Staff did not bring him/her any iced tea; -Observation showed the resident's tray contained a bowl of chili and a cup of sliced peaches. Observation on 02/21/25, at 1:27 P.M., of the main dining room showed the following: -A table of 5 residents sat, eating lunch; -All residents had a bowl of chili and a cup of peaches; -None of the 5 residents had a baked potato, as listed on the menu. During interviews on 02/21/25, at 1:04 P.M. and at 1:45 P.M , Dietary Aide (DA) L said the following: -He/she assisted with resident lunch service; -As he/she was loading the resident food carts for the halls, he/she observed the meal ticket listed a baked potato with sour cream, but the resident meals did not include a baked potato; -He/she asked the cook about the absence of a baked potato on the resident trays and the cook said the facility did not have any potatoes to bake for the residents; -The cook told the DA, he/she was directed by the Dietary Manager (DM) to substitute Fritos for the baked potato; -The cook placed a layer of Fritos under the chili in the bowls and the sprinkled cheese on the top; -The DA said the facility frequently did not have available the menu listed foods and the cook had to make substitutions. During an interview on 02/21/25, at 1:10 P.M., [NAME] D said the following: -Earlier in the A.M., he/she checked the menu for today's lunch and the menu listed a baked potato; -The [NAME] looked in the food storage area and found no potatoes; -He/she then asked the DM what to do and the DM said to substitute Frito chili pie; -He/she did not think the Fritos were an adequate substitution for the potato; -He/she placed a handful (approximately 2 layers of Fritos) in the bottom of each bowl. He/she did not measure the amount of Fritos; -He/she then placed chili on top of the Fritos. He/she did not measure the amount of chili, but rather used the bowl as the measurement, he/she then sprinkled shredded cheese on top; -He/she used canned peaches for dessert as per the menu; -The facility did not always have the items listed on the menu, he/she had to make substitutions fairly often; -When he/she asked the DM about why the facility did not have the listed foods, the DM said he/she was not able to purchase due to facility budget restrictions or because he/she was not aware the facility was out of a certain food item; -At times, the kitchen was shorting the residents on the amount of calories in a day, due to not having the menu listed foods of not having a sufficient amount of the listed foods; -Some of the residents complain about the substitutions or the lack of food; -He/she and a couple of the other kitchen staff went to the Administrator about the issues in the kitchen. During an interview on 02/26/25, at approximately 1:35 P.M., [NAME] B said the following: -The chili meal was way too small; -He/she was unsure why they did not have potatoes to serve the residents because he/she knew the night before and let the DM know; -He/she said the DM went to the store and bought Fritos instead of potatoes; -They put the Fritos in the bowl, under the chili; -He/she was aware this actually took away from what already looked to be a small amount of chili; -He/she had gotten used to residents complaining in the evening that they are hungry. He/she makes up plenty of sandwiches and snacks for every night. During an interview on 02/25/25, at approximately 9:50 A.M., Resident #6 said the kitchen only serves out small amounts of food. He/she felt residents should already get enough in the first place, that no one should have to ask for more During an interview on 02/25/25, at approximately 10:00 A.M., Resident #11 said the following: -The amount of food given is small every time; -The chili was always a small amount like that; -He/she was unsure why the amounts are usually small. During an interview on 02/25/25, at approximately 12:30 P.M., the Restorative Nursing Aide (RNA), said the there have been a few times that residents have told him/her, following a meal, that they were still hungry. During an interview on 02/26/25, at approximately 3:15 P.M., the Dietary Manger (DM) said the following: -He/she does have a monthly budget that he/she is supposed to stay within each month; -He/she will run to the local grocery store, if the facility needs a certain food item, and it was not provided by their supplier; -He/she had to substitute potatoes because they had ran out; -He/she did go to the grocery store and purchased Fritos, due to not having time to cook baked potatoes; -He/she did not think to purchase or serve anything else; -The DM orders items, according to the menu, on a weekly basis; -None of the residents or staff have complained to him/her that there is not enough food being served. During an interview on 02/26/25, at approximately 4:10 P.M., the Registered Dietician (RD) said the following: -Staff should have served something more substantive, such as another starch or vegetable, to ensure the residents had enough to eat; -He/she would expect there to be plenty of food for all of the residents. During an interview on 02/25/25, at approximately 10:10 A.M., the Director of Nursing (DON) said he/she has not seen any problems with the amounts of food residents receive. If he/she were to have an issues with food, they would go to the dietary manager (DM), first to discuss any concerns. During an interview on 02/27/25, at 2:25 P.M., the Administrator said the following: -He/she said the DM would be expected to get an appropriate substitute; -If the DM was unsure what that would be, or what he/she should do, the administrator expected the DM to contact the RD for guidance. MO00249859 37358

Based on observation, interview, and record review, the facility staff failed to ensure food was protected from potential contamination at all times when staff failed to keep non-food contact services clean and free from debris. The facility census was 102. Review of the facility's policy titled Sanitation Principles, dated 02/01/02, showed the following information: -The purpose of the policy was to prevent the spread of bacteria that may cause food borne illnesses; -Food service areas should be maintained in a clean and sanitary manner; -The current Food Code should be utilized as guidelines for the department; -Utensils, counters, shelves, and equipment should be kept clean; -Cleaning schedule should developed and posted by the Food Service Manager (FNS) for the routine cleaning of all kitchen surfaces, equipment and utensils. Review of the Food and Drug Administration (FDA) 2022 Food Code showed non-food contact surfaces of facilities, equipment, and utensils used in the operation of the establishment must be cleaned and sanitized as frequently as necessary to prevent the creation of unsanitary conditions or the adulteration of product. 1. Observation on 02/25/25, beginning at 9:30 A.M., of the kitchen showed the following: -Ceiling vents over the serve-out/steam table, had a build-up of a grease and dust covering the surface; -White pipes running across the ceiling, were discolored and had a build-up of a grease and dust covering the surface; -The convection oven top and knobs had a build-up of a grease and dust mixture covering the surface; -The Vulcan stove knobs had a build-up of a grease and dust mixture, covering the surface; -The back of the Vulcan stove had a build-up of a grease and dust mixture, covering the entire surface and the metal pipe going up into the ceiling; -The walk-in freezer had spots of a silvery-white build-up, that was spread across the ceiling and walls. During an interview on 02/25/25, beginning at approximately 11:30 A.M., the Maintenance Director said the kitchen staff are responsible for all cleaning duties in the kitchen. He/she will do maintenance on the walk-ins as needed. During an interview on 02/26/25, at approximately 3:15 P.M., the Dietary Manager (DM) said if there was a mess, staff were expected to clean it up and he/she has not seen a cleaning policy. During an interview on 02/27/25, at 3:10 P.M., the Director of Nursing (DON) said he/she would expect kitchen staff to keep the kitchen clean. During an interview on 02/27/25, at 2:25 P.M., the Administrator said he/she would expect deep cleaning to be done at least once a week. He/she was unsure why some of the kitchen surfaces are not clean at this time. MO00249859

Based on observation, interview, and record review, the facility staff failed to ensure the baseboards, walls, and windows were clean and free of dirt. The facility census was 102. Review of the facility's policy titled Sanitation Principles, dated 02/01/02, showed the following information: -The purpose of the policy was to prevent the spread of bacteria that may cause food borne illnesses; -Food service areas should be maintained in a clean and sanitary manner; -The current Food Code should be utilized as guidelines for the department; -Utensils, counters, shelves, and equipment should be kept clean; -Cleaning schedule should developed and posted by the Food Service Manage (FNS) for the routine cleaning of all kitchen surfaces, equipment and utensils. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the non-food contact surfaces of facilities, equipment, and utensils used in the operation of the establishment must be cleaned and sanitized as frequently as necessary to prevent the creation of unsanitary conditions or the adulteration of product. 1. Observation on 02/25/25, beginning at 9:30 A.M., of the kitchen showed the following: -The 4-light switch plate, the fire extinguisher, and panel box, all together on a small wall between the stove and dishwashing area, had a build-up of a grease and dust mixture, covering the surface; -The window over the sink was dirty and it was difficult to see out. There were cobwebs, visibly moving with any air, in both of the top corners; -The corner and floorboards between the sink and convection oven were dirty with particles of food and debris. During an interview on 02/25/25, beginning at approximately 11:30 A.M., the Maintenance Director said the kitchen staff are responsible for all cleaning duties in the kitchen. He/she will do maintenance on the walk-ins as needed. During an interview on 02/26/25, at 10:15 A.M., the Regional Dietary Manager said he/she had spoken to the Dietary Manager (DM) before about the cleaning schedule and that is should probably be posted. During an interview on 02/26/25, at 10:45 A.M. and 3:15 P.M., the DM said the following: -He/she did not feel a cleaning scheduled needed to be posted; -He/she does not think staff forget to clean the kitchen, when they are unable to see the cleaning schedule; -Having a cleaning schedule would not impact how clean the kitchen was or was not; -If there is a mess, staff are expected to clean it up; -Staff know to do this and do not have to be told. During an interview on 02/27/25, at 3:10 P.M., the Director of Nursing (DON) said he/she would expect kitchen staff to keep the kitchen clean for resident's safety and to keep out rodents. During an interview on 02/27/25, at 2:25 P.M., the Administrator said the following: -He/she would expect deep cleaning to be done at least once a week; -If staff would stay on top of the cleaning, it would get better and be easier to keep it clean. -He/she was unsure why some of the kitchen surfaces are not clean at this time. MO00249859

Based on observations, interview, and record review, the facility failed to provide an ongoing program of activities to meet the interests of and support the mental and psychosocial well-being for all residents when the facility failed to have an Activity Director, a complete activity program, or activity calendars for the residents including seven residents (Resident #5, Resident #6, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #13) identified as feeling activities were important. The facility census was 102. 1. Review of Resident #8's face sheet showed: -admitted [DATE]; -Diagnoses included anoxic brain injury (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), major depressive disorder, anxiety disorder, and high blood pressure. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/02/24, showed the following: -Cognitively intact; -No behavioral symptoms; -Very important for the resident to do things with groups of people; -Very important for the resident to do his/her favorite activities; -Resident able to ambulate independently. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident remained cognitively intact; -No behavioral symptoms; -Resident able to ambulate independently. Review of the resident's care plan for psychosocial well being, updated on 01/14/25, showed the following: -Activity plan needed; -Deliver mail to resident timely; -Encourage family visits; -Encourage to attend exercise activities; -Encourage to attend religious activity; -Encourage walking outside; -Food related activities of choice; -Resident does not wish to participate in group activities at this time; -Enjoys watching action movies; -Enjoys listening to 90's rock music; -Enjoys reading car magazines; -Enjoys the Discovery channel; -Ice cream socials; -Provide activity calendar; -Required assistance with activities; -Visit with residents, staff, family, and friends. Observation and interview on 02/25/25, at 12:30 P.M., showed the following: -The resident sat on the side of his/her bed; -The resident pointed out an empty plastic sleeve hanging on his/her wall and said the facility was supposed to put an activity calendar in the sleeve each month, but no one was bringing activity calendars to the resident; -The resident said the facility had not had an activity director or a regular program of activities since approximately October 2024; -He/she did not know what activities he/she would like to attend because he/she did not have an activity calendar; -He/she might go to the activities, if the facility offered any; -He/she used enjoy watching movies with other residents. 2. Review of Resident #9's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, major depressive disorder, history of alcohol use, and high blood pressure. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -Very important for the resident to do things with groups of people; -Very important for the resident to do his/her favorite activities; -Resident able to ambulate independently. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident remained cognitively intact; -No behavioral symptoms; -Resident able to ambulate independently. Review of the resident's care plan for psychosocial well being, updated on 01/16/25, showed the following: -Activity plan needed; -Assist in reading mail and writing letters; -Deliver mail timely; -Provide computer access; -Cooking; -Encourage family visits; -Encourage to attend exercise activities; -Encourage to attend religious activity; -Encourage walking outside; -Food related activities of choice -Resident enjoys attending group activities; -Games/bingo/dominos/checkers/puzzles/crossword puzzles; -Movies; -Ice cream socials; -Provide activity calendar; -Place television on; -Provide cards and paper; -Provide reading material; -Put radio on station; -Required assistance with activities; -Visit with residents, staff, family, and friends. During an interview on 02/25/25, at 2:44 P.M., the resident said the following: -The resident did not have an activity calendar. The facility did not have an Activity Director; -One of the resident's does BINGO three times per week, but other than that the facility did not have much else going on; -He/she would like more activities; -He/she listened to music and would more music type activities. 3. Review of Resident #10's face sheet showed: -admitted [DATE]; -Diagnoses included alcohol use with alcohol induced persistent dementia, diabetes mellitus type II, schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly and a mood disorder), and traumatic brain injury. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -Very important for the resident to do his/her favorite activities; -Resident able to ambulate independently. Review of the resident's care plan for psychosocial well being, updated on 01/14/25, showed the following: -Activity plan needed; -Allow rest breaks between activities; -Assess activity preferences and help plan; -Assist resident to get to chosen activities; -Assist with activities to stay connected with friends; -Provide activities per the capacity of the resident; -Provide opportunities to be outside, when weather permits. Observation of and interview on 02/25/25, at 2:50 P.M., showed the following: -The resident sat talking at a table in the dining room with another resident; -The resident said the facility had not had an Activity Director in several months; -In the past, the AD would go to the dollar store or Wal-Mart for the residents to pick up needed items, such as deodorant and shampoo which the residents paid for. Without an Activity Director, no one went to the store for the residents; -He/she had asked some of the nurses if anyone could go to the store for him/her and they told the resident to ask the office. He/she went to the office and staff said there was no one to go to the store; -One of the facility residents calls out BINGO, but he/she would like more activities. 4. Review of Resident #6's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), alcoholic cirrhosis of liver (a chronic liver disease caused by excessive alcohol consumption over a prolonged period), and chronic kidney disease, (decreased kidney function, typically indicated by an estimated glomerular filtration rate (eGFR) between 60 and 89, and usually with no noticeable symptoms). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors; -Very important to listen to music; -Somewhat important to do his/her favorite actives; -Very important to get fresh air when the weather was good. Record review of the residents care plan, for psychosocial well-being, updated 10/14/24, showed the following: -Prevent feelings of isolation from family and friends; -Assist in visits with friends and family in a private location; -Assist to talk privately on the phone; -Assist with activities to stay connected with friends; -Encourage to talk about feelings. During an interview on 02/26/25, at approximately 10:35 A.M., the resident said the following: -He/she was the president of the resident council; -There has only been one meeting in over at least six months; -The last meeting was earlier in February 2025; -There has not been staff around to help set one up; -Residents used to get a calendar every month, so it was easy to know what was planned. Now there are no calendars given and there is no large calendar posted in any hall, for residents to see; -There is no activity director; -One resident does call out bingo, so they can do that a couple times a week; -The only normal activity that is every-other-day is group exercise; -They do have a church come in on some Sunday's, but he/she does not participate; -Some have just given up on activities unless it's doing the exercise and sometimes having popcorn; -He/she said you're out of luck if you really want to do anything. 5. Review of Resident #5's face sheet showed the following: -admitted [DATE]. -Diagnoses include hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart muscle over time, leading to an inability of the heart to pump blood effectively), chronic diastolic (congestive) heart failure (a condition where the heart's left ventricle becomes stiff and cannot relax properly, leading to a buildup of fluid in the lungs and other parts of the body due to impaired filling between heartbeats, causing symptoms of congestive heart failure while still maintaining a normal ejection of fraction (the percentage of blood pumped out with each beat)) and spinal stenosis (when the spinal canal and the space around the spinal canal become narrowed). Record review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Very important to have books, newspapers and magazines to read; -Very important to listen to the music the resident likes; -Very important to keep up with the news; - Somewhat important to do things with groups of people; -Very important to do the resident's favorite activities; -Very important to go outside to get fresh air when the weather is good; -Somewhat important to participate in religious services or practices. Review of the resident's care plan for psychosocial well-being, updated 10/14/24, showed the following: -Prevent feelings of isolation from family and friends; -Assist in visits with friends and family in a private location; -Assist to talk privately on the phone; -Assist with activities to stay connected with friends; -Encourage resident to talk about feelings. During an interview on 02/26/25, at approximately 12:25 P.M., the resident said the following: -He/she could not say when activities had last been offered, but that it has been a long time; -He/she was not sure what activities sound good, but he/she would possibly attend if they were offered; - It is a little boring; -He/she had never been given a calendar that he/she could remember; -He/she would possibly participate if something fun was offered. 6. Record review of Resident #12's face sheet showed the following: -admitted [DATE] -Diagnoses included chronic kidney disease, stage II (mild - decreased kidney function, typically indicated by an estimated glomerular filtration rate (eGFR) between 60 and 89, and usually with no noticeable symptoms); osteonecrosis (a condition where bone tissue dies due to a loss of blood supply), and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Very important to have books, newspapers, and magazines to read; -Very important to listen to the music he/she liked; -Very important to be around animals such as pets; -Very important to to keep up with the news; -Very important to do things with groups of people; -Very important to do his/her favorite activities; -Very important to go outside to get fresh air when the weather is good. Record review of the resident's care plan for psychosocial well-being, updated 10/14/24, showed the following: -Assist in visits with friends and family in a private location; -Assist to talk privately on the phone; -Assist with activities to stay connected with friends; -Encourage to talk about feelings. During an interview on 02/27/25, at approximately 11:30 A.M., the resident said the following: -Not anything much is offered for activities; -He/she said, It is boring around here. If they offer anything, you gotta grab it or you're out of luck; -There is bingo sometimes, which he/she does usually attend; -There is church sometimes, but he/she does not attend; -They have popcorn now; -His/her family purchased any items he/she may need, so does not ask any staff. 7. Review of Resident #13's face sheet showed the following: -admitted [DATE]; -Diagnoses include chronic kidney disease, stage III; chronic diastolic (congestive) heart failure, and type II diabetes mellitus (a chronic condition characterized by high blood sugar levels (hyperglycemia) due to the body's inability to use insulin effectively or produce enough insulin). Review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Somewhat important to have books, newspapers and magazines to read; -Very important to be around animals such as pets; -Very important to keep up with the news; -Very important to do his/her favorite activities; -Somewhat important to go outside to get fresh air when the weather is good; -Somewhat important to participate in religious services or practices. Review of the resident's care plan for psychosocial well-being, updated 01/14/25, showed the following: -Deliver mail timely; -Encourage family visits; -Encourage resident to attend exercise; -Encourage resident to walk/wheel outside; -Resident enjoys family visits; -Resident enjoys one on ones with manicures; -Resident enjoys participating in group activities; -Resident enjoys participating in monthly birthday parties; -Resident enjoys playing on his/her tablet and reading the paper from it; -Resident enjoys reading small novels; -Resident enjoys watching love stories; -Resident enjoys watching NCIS, crime, and true crime shows; -Ice cream socials; -Provide activity calendar; -Required assistance with activities During an interview on 02/27/25, at approximately 11:45 A.M., the resident said the following: -His/her family went to Wal-Mart to purchase most of his/her items needed; -He/she had also learned to do Wal-Mart delivery so he/she does not ask staff; -He/she did ask staff several months ago to get something and it seemed to be a big deal, so he/she no longer asks; -It has been months since the facility has had an Activity Director; -He/she did an art class once, a long time ago, and enjoyed that, but they had a Activity Director who set it up; -They no longer have anything fun or that he/she was interested in; -He/she said they would not know if anything were offered, because there is no calendar any longer. 8. During an interview 02/25/25, at 12:53 A.M., Certified Nurse Assistant (CNA) G, who worked in the Special Care Unit, said the following: -The facility did not offer much in the way of activities for the SCU residents; -The staff in the SCU did not generally have much time to provide activities for the residents; -The facility had no Activities Director for several months; -The CNA said the facility had a plastic bowling set in the SCU, but the staff had to be cautious with allowing the residents to use it because it could create a fall risk; -The facility staff did not provide any routine activities to the dementia residents; -The residents in the SCU would benefit from some activities. During an interview on 02/26/25, at 10:01 A.M., Licensed Practical Nurse (LPN) H said the following: -The facility did not currently have an Activity Director; -The facility did not offer activities to the residents residing in the special care unit, and staff did not generally have time to conduct activities with those residents; -A former resident's family member comes on Sunday afternoons and conducts a church service in the main dining room; -The alert and oriented residents complain of boredom; -The facility has a higher number of younger residents and the facility did not have much for these residents to do; -In the past, when the facility had an Activity Director, he/she would make monthly Wal-Mart and dollar store trips for the residents; -Some of the residents have complained there was no one to go to the store for them. During an interview on 02/27/25, at 1:55 P.M., LPN K said the following: -The facility had no Activity Director for approximately the past 6 months, except for one week, a few days ago; -The facility had BINGO and morning exercise three times per week, but other than that, the facility was not offering other activities to the residents; -The residents would like to have more activities; -Residents came to the nurse daily and asked what what was going on in the facility and what activities were happening; -He/she sometimes looked for coloring pages for the residents to complete; -Many of the residents were bored at the facility. During an interview on 02/26/25, at 1:43 P.M., the Financial Specialist Assistant (FSA) said the following: -The residents complained about the lack of activities; -One resident conducted BINGO for the residents and asked about collecting donations for better BINGO prizes; -The only regular activities were resident led BINGO on Monday, Wednesday, and Friday afternoons, and a restorative nursing aide (RNA) led morning exercise class on Monday, Wednesday, and Friday mornings; -The facility did not provide a current activity calendar to the residents; -The residents complained of no activities and the lack of activities led the residents to boredom and were more irritable as a result; -Several of the residents were very upset about not having anyone to go to Wal-Mart or to the dollar store. During an interview on 02/27/25 at 1:19 P.M., the SSD said the following: -The facility did not have an AD; -The only current activities were exercise three times per week and resident led BINGO three times per week; -He/she used to work as the AD at the facility several years ago; -When he/she worked as the AD, he/she would go to the store for residents two times per month, to purchase requested items for individual residents; -Residents enjoyed BINGO, but also would enjoy other activities such as music, corn hole, and trivia games; -The residents would enjoy any activities because currently there was not a lot going on for the residents; -He/she brought up the lack of activities in the morning department head meeting; -The facility administrator was trying to hire an AD. During an interview on 02/26/5, at 12:56 P.M., the facility Nurse Practitioner (NP) I said the following: -He/she was not aware the facility did not have a full-time Activity Director; -Residents would benefit from daily activities; -Activities were important for the residents; -A lack of activities could lead to boredom among the residents. During an interview on 02/26/25, at 1:36 P.M., the Medical Records Nurse (LPN J) said the facility had not had a consistent Activity Director since the end of 2023. Sometimes the residents complained to staff about a lack of activities. During an interview on 02/26/25, at approximately 2:30 P.M., Registered Nurse (RN) E said the following: -The facility was trying to hire an activity director; -Church is on Sunday mornings and some Wednesday evenings; -A resident enjoys calling bingo for everyone. During an interview on 02/25/25, at 10:05 A.M. and 11:20 A.M., and 02/27/25, at 3:10 P.M., the Director of Nursing (DON) said the following: -The facility did not currently have an Activity Director; -The Administrator hired a new AD last month, but he/she worked at the facility for approximately one week and then quit; -Currently, a RNA offered morning group exercise on Monday, Wednesday, and Friday mornings; -One of the facility's residents conducts BINGO on Monday, Wednesday, and Friday afternoons; -He/she encouraged the SSD to reach out to one of the hospice agencies to see about activities and one of the hospice agencies conducted BINGO one time last month; -He/she expects that all department heads take a role in leading some activities for the residents, until an Activity Director was hired; -The DON was unsure who runs purchases for residents, if they need anything; -The facility did not have an activity calendar. During an interview on 02/27/25, at 2:26 P.M., the Administrator said the following: -He had not assigned any current employee to be in charge of resident activities; -The facility did not have a consistent activity program for the residents; -The facility did not have an activity calendar and the residents did not have individual activity calendars; -They do not have the staff to run full-time activities; -All staff have pitched in if a resident needs something bought; -A few residents have made use of choosing deliveries for purchases; -A few residents have expressed they are not happy about the lack of activities. 37358

Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide appropriate fall follow up assessments, including neurological assessments (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for four residents (Resident #1, Resident #3, Resident #4, and Resident #7) after each resident sustained a fall with potential for head injury. The facility census was 102. Review of the facility policy titled, Incidents and Accidents, dated 11/10/24, showed the following: -The resident environment to remain as free of accident hazards as is possible, however, when an accident occurs, prompt response and reporting occurs; -Examples include falls or resident observed on the floor; -The resident should not be moved unnecessarily until condition has been assessed; -Assess the resident's injury, pain, range of motion, bruising, bleeding, and lacerations -Assess neurological signs as appropriate; -Notify the physician and obtain orders for care, including any indicated diagnostics; -Notify family of accident, status, and orders for care; -Obtain medical care as needed and transfer to emergency room , as needed. Review of the facility policy titled, Change in Medical Condition of Resident/Guest, showed the following: -Keep the physician, who is in charge of medical care, and family member/legal representatives, responsible for health care decisions and other resident/guest representatives informed of the resident/guest medical condition so they may direct the plan of care as needed; -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 condition. Change in the condition is defined as an accident involving the resident/guest which results in injury and has the potential for requiring physician intervention; -Examples of a change in condition may include a fall, new pain, and respiratory distress; -In the event of an emergency, call the physician and family member at the time the event occurs whatever time of day or night; -Document the symptoms and observations associated with the change in condition, the date and time of contact with the physician, and family member or legal representative. Notes also should include comments on the care provided by nursing personnel; -The 24-hour report serves as a reminder to report any change in condition to the upcoming shift; -Further assessment may be warranted with certain permanent changes in condition. 1. Review of Resident # 1's face sheet showed the following: -admitted [DATE]; -Diagnoses included of Alzheimer's disease. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 02/05/25, showed the following: -Severe cognitive impairment; -Resident did not reject care; -Exhibited a behavior of daily wandering; -Wandering places the resident at significant risk of getting to a potentially dangerous place; -Two or more non-injury falls since admission; -One injury (except major) fall since admission; -Independent with transfers; -Resident ambulated and did not use a wheelchair. Review of the resident's progress note dated 02/07/25, at 5:35 A.M., showed the following: -Resident was walking in the hall and staff heard a fall. Staff found the resident in the hallway. The resident re-injured a pre-existing skin tear on his/her elbow. Staff cleansed wound cleansed and a dressing and wrap applied. The resident also had a hematoma (closed wound where blood collects and fills a space inside the body) forming on the left side of his/her forehead. The resident denied pain at that time. Review of the resident's fall event report, completed on 02/07/25 at 6:12 A.M., showed a nurse documented the following: -Event date: 02/07/25 at 5:28 A.M.; -Location of fall: Hallway; -What was the resident doing just prior to fall? Walking; -Was fall witnessed? No; -Does resident exhibit or complain of pain related to the fall? No; -Location of injury: Left elbow skin tear and left head hematoma; -Note any injuries to the head, extremities, or trunk: Bump and skin tear; -Range of motion to 4 extremities without pain/limitations; -Level of consciousness: Alert wakefulness-Perceives the environment clearly and responds appropriately to stimuli; -Facial muscle movement: Strong; -Extremity movements: Strong; -Pupil size/response/shape: Both 3 millimeters/round/brisk; -Speech: Clear; -Resident responds to name; -Does not exhibit or complain of dizziness/light headedness, headache, nausea/vomiting, seizure, or other; -No changes in mental status; -Physician notified on 02/07/25 at 6:12 A.M.; -Resident representative not notified; , -Vitals signs (VS) taken. Review of the resident's medical record showed staff did not document any further progress note or fall follow up/neurological assessments on 02/07/25. Review of the resident's medical record showed staff did not document any progress note or fall follow up/neurological assessments on 02/08/25. Review of the resident's progress note, dated 02/09/25 at 9:54 A.M., showed the following: -Does resident have pain: No; -Neuro/Cognitive: Alert, confused, forgetful, oriented to person; -Change in cognitive status: No change; -VS taken. (The nurse did not include documentation of a neurological assessment due to the resident's hematoma.) Review of the resident's progress note, dated 02/09/25 at 10:39 A.M., showed the following: -It was reported to the nurse that the resident received a skin tear to his/her left forearm from a recent fall. Skin assessment completed and observed a skin tear measuring 10.0 centimeters (cm) by 5.0 cm with partial thickness tissue loss with exposed dermis. Nurse was able to approximate part of the tear. Wound bed pink and moist, wound edges rolled and indistinct, peri-wound pink with slight edema (swelling) with moderate amount of serosanguinous (contains or relates to both blood and the liquid part of blood (serum)) drainage. Nurse cleansed area and applied a treatment. Physician orders placed for treatment. (The nurse did not include documentation of neurological checks or assessment of the resident's hematoma.) Review of the resident's medical record showed staff did not document any further progress note/neurological assessment on 02/09/25. Review of a progress note, dated 02/13/25 at 6:43 A.M., showed the resident's physician documented, the following: -Resident was seen on 02/10/25, at the request of nursing staff, for evaluation of closed head injury. Nursing staff reported recent fall that resulted in hematoma to forehead. No loss of consciousness, headache, or vision changes were reported. The resident was awake and alert with baseline confusion. He/she was alert to self only on exam per baseline. The resident resides on the memory care unit and progressive weakness was reported by facility staff. -Review of objective symptoms showed alert/confusion; eyes, ears, and mouth normal; back normal; skin with resolving ecchymosis (bruise) to left side of face; extremities with normal weakness; neurological/psych: and oriented to one; -Closed head injury status post fall with no loss of consciousness reported. Resolving ecchymosis to left face. Continue follow up monitoring per protocol. Review of the resident's progress notes, dated 02/11/25 at 11:28 A.M., showed social services documented a review of the resident's plan of care with the resident's responsible party. The progress note did not mention the fall or any assessment of the resident's neurological status or assessment of the resident's hematoma. Review of the resident's medical record showed nursing staff did not document any fall follow up/neurological assessment on 02/11/25 or 2/12/25. Review of the resident's progress notes until 02/17/25 when the physician saw the resident for unrelated reasons. Observation on 02/21/25, at 12:22 P.M., showed the following: -The resident sat at a dining room table in the Special Care Unit (SCU) eating lunch; -The resident had a large, fading bruise (green in color) covering the left eye lid, the skin below his/her eye, and the left temple area. During an interview on 02/25/25, at 11:08 A.M., Certified Nursing Assistant (CNA) M said the following: -He/she arrived to work one morning approximately two weeks ago and the night shift aide said the resident fell on the night shift; -The night shift reported the resident did not hit his/her head or sustain any injuries; -CNA M went to check on the resident and found the resident had a large dark purple are on the side of his/her head and the resident had blood on his/her hand. The CNA checked the resident and found a bleeding large skin tear on the resident's left arm; -He/she went and reported to one of the day shift nurses. During interviews on 02/26/25, at 10:01 A.M. and 11:15 A.M., Licensed Practical Nurse (LPN) H said the following: -The resident #1 fell during the night and he/she came in to work the following morning; -He/she went to the unit that morning and assessed and dressed the resident's skin tear; -The nurse did not remember the exact circumstance of the resident fall, but he/she did assess the resident, complete neuro checks and place a progress note in the resident's progress notes. 2. Review of Resident #3's face sheet showed: -admitted [DATE]; -Diagnoses included hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD - a group of lung disease characterized by a narrowing of the air passageways), atrial fibrillation (an abnormal heart rhythm), and unspecified severe protein-calorie malnutrition. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -No falls since prior assessment; -Used wheelchair for mobility device; -Independent with personal hygiene, toileting hygiene, dressing, and transfers; -Dependent on supplemental oxygen; -Short of breath when lying flat; -Used oxygen therapy. Review of the resident's physician order sheet showed the following: -An order, dated 11/10/24, for staff to apply oxygen at 2 to 4 liters (L) per minute via nasal cannula to maintain the oxygen saturation above 90%. Review of the resident's progress note dated 12/24/25, at 3:28 P.M., showed the following: -The nurse noted the resident to have labored breathing, productive cough, and crackle lung sounds this shift. The nurse notified the physician and obtained orders for a chest X-Ray, Duoneb (an inhaled medication to help open the airways) four times per day for five days, and Rocephin (an antibiotic) 1 gram, intramuscular (IM) injection, give 1 dose now. Rocephin administered and other orders placed at this time. Vitals taken. Review showed staff did not document in the progress notes again until 12/25/24, at 2:01 P.M. Review of the resident's progress note, dated 12/25/24 at 2:01 P.M., showed the following: -The resident stated his/her mattress was off the frame a little on the side he/she got up and down on and he/she went to place his/her hand it, and the mattress gave out from under the resident, and he/she slid of the side of the bed and hit his/her head. The resident reported he/she fell at about 1:00 P.M., but due to current coughing fits, his/her voice was weak, so no one could hear him/her until he/she crawled closer to the door to yell for help. The resident was alert and oriented. Vital signs taken. Approximately 10 to 15 minutes later, the resident was slightly confused, and his/her speech was slurred. The nurse initially sent a text message to the physician group and after re-assessment the nurse called the emergency physician line and sent the resident to the hospital. (The nurse did not document a complete neurological assessment of the resident.) Review of the resident's fall event report, dated 12/25/24 at 2:48 P.M., showed a nurse documented the following: -The resident said his/her mattress was off the frame a little on the side he/she got up and down on and he/she went to place his/her hand, and the mattress gave out from under the resident, and he/she slid of the side of the bed and hit his/her head. The resident reported he/she fell at about 1:00 P.M., but due to current coughing fits, his/her voice was weak, so no one could hear him/her until he/she crawled closer to the door to yell for help. The resident was alert and oriented. Vitals taken. Approximately 10-15 minutes later, the resident was slightly confused, and his/her speech was slurred. The nurse initially sent a text message to the physician group and after re-assessment the nurse called the emergency physician line and sent the resident to the hospital; -No late showing injury. Care plan reviewed and appropriate; -Responsible party notified on 12/25/24 at 1:21 P.M.; -Physician notified on 12/25/24 at 1:30 P.M (The nurse did not document a complete neurological assessment of the resident.) Review of the resident's entry MDS, dated [DATE], showed the resident re-entered the facility from the hospital on 12/31/24. Review of the resident's progress notes showed staff did not document a progress note for 12/31/24, 01/01/25, or 01/02/25. Review of the resident's nurse practitioner re-admit note, dated 01/02/25 at 8:00 A.M., showed, in part, the following: -readmitted to the facility on [DATE]; -Resident seen today for a re-admission at the facility following a hospitalization after a fall with and high blood pressure. Resident was lying in bed and said he/she was feeling much better and blood pressure was stable and denied shortness of breath, chest pain, or dizziness. Resident had not fallen since return from the hospital. Resident was wearing oxygen. Resident denied pain. Admission labs ordered and medications and vital signs reviewed. Review of the resident's progress note, dated 01/03/25 at 12:39 A.M., showed a nurse documented an assessment of the resident, but did not address the resident's return from the hospital or any follow up on the hospital findings. 3. Review of Resident #4's face sheet showed: -admitted [DATE]; -Diagnoses included chronic kidney disease, dementia, type II diabetes mellitus, and adult failure to thrive. Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behavioral symptoms; -Falls prior to admission or prior assessment, but no falls during this admission; -Required substantial/maximal assistance of staff (staff does greater than half the effort) with toileting hygiene, personal hygiene, showering, and transfers; -Short of breath upon exertion (such as with walking, bathing, or transfers); -Oxygen therapy. Review of the resident's progress note dated 11/15/24, at 4:35 A.M., showed a nurse documented the following: -At 4:00 A.M., the nurse was notified by staff the resident was laying on the floor in his/her room. This nurse observed the resident was laying on the floor next to his/her bed. Resident was laying on his/her left side. The resident's bedside light was on. The nurse assessed the resident and assisted the resident to bed with no noted injuries. Call light placed in reach. Staff educated to place non-slip socks on the resident. The resident physician, responsible party, and hospice were notified. Review of the resident's fall event report dated 11/15/24, at 4:33 A.M., showed a nurse documented the following: -An unwitnessed fall with no injuries in the resident's room; -Was fall witnessed? No; -Does the resident exhibit or complain of pain related to the fall? No; -Range of motion: Without pain/limitation to all extremities; -No rotation, deformity, shortening of extremities noted; -Level of consciousness: Alert wakefulness; -Facial muscle movement: Strong; -Extremity movement: Section left blank; -Bilateral pupils size/response/shape: Section left blank; -Resident responds to name, pain, and environment; -Does the resident exhibit any of the following as a change in mental status of new onset: No changes; -Physician notified on 11/15/24 at 4:14 A.M.; -Resident representative notified on 11/15/24 at 4:14 A.M.; -Vitals taken at 11/15/24, at 4:34 A.M., at 4:41 A.M., at 5:54 A.M., at 5:55 A.M. and at 5:56 A.M. Review of the resident's progress note, dated 11/15/24, at 7:25 A.M., showed social services documented completed current MDS assessments. Social services did not document related to the fall. Review of the resident's progress note dated 11/15/24, at 12:04 P.M., showed a nurse documented the following: -This nurse was at the resident's side from 8:30 A.M. to 10:15 A.M. The resident was going through cards and pictures. Resident asked the nurse a question. Nurse re-oriented the resident to current date and situation. The resident spoke with a relative over the phone. Staff assisted the resident with fluids and protein shake. Nurse assisted the resident to the bathroom. Resident assisted the resident to bed. Resident was notified the call light was in reach. Fall precautions in place. Padding on floor next to bed. Resident's family member visited the resident and at the resident's side at 12:00 P.M. The resident's family member reported the resident ate food and appeared to feel comfortable in bed. The nurse checked on the resident at 12:50 P.M., and resident reported was feeling good at that time. Resident in bed at this time. Frequent room checks and neurological checks are being performed. (Staff did not document subsequent fall follow up/neurological assessment.) Review of the resident's progress notes dated 11/15/24, at 1:30 P.M., showed a nurse documented the following: -This nurse was called into the dining room at approximately 7:30 A.M., by staff. The resident was laying on the floor halfway under the dining room table. Resident states hit head on the edge of the table. Resident noted to have bump to the mid back of his/her head with no complaints of pain to his/her head. Resident complained of pain to his/her mid back. No noted length difference at time of assessment. Physician and hospice notified, and message left for resident's responsible party. Resident noted to be more confused than usual, attempting to collect urine specimen for test. Nurse spoke with hospice and new orders received for Haldol (anti-anxiety medication) 2 milligram dose right now and then two times per day for schizophrenic disorder/restlessness. This nurse administered the first dose. (Staff did not document subsequent neurological assessment and fall follow up.) Review of the resident's fall event report dated 11/15/24, at 1:24 P.M., showed a nurse documented the following: -An unwitnessed fall occurred in the dining room; -What was resident doing just prior to fall? Walking with wheelchair; -Was fall witnessed? No; -Does the resident exhibit or complain of pain related to the fall? Yes, mid back pain. Pain characterized as Moderate pain- Distressing/miserable; -Location of injury: Knot (Bump) to mid back part of the resident's head; -Range of motion painful/limited in lower extremity; -No rotation, deformity, shortening of extremities noted; -Level of consciousness: Alert wakefulness; -Facial muscle movement: Strong; -Extremity movement: Strong to bilateral upper and lower right extremity, weak to lower right extremity; -Bilateral pupils size/response/shape: 3 mm, round, and brisk; -Speech: Clear; -Resident responds to name, pain, and environment; -Does the resident exhibit any of the following as a change in mental status of new onset: Confusion and restlessness; -Physician notified on 11/15/24 at 8:00 A.M.; -Resident representative notified on 11/15/24 at 8:00 A.M.; -Vital signs completed. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/16/24, at 1:42 P.M., showed a nurse documented the following: -Does resident have pain? No -Neuro/cognitive: Alert, confused/forgetful, oriented to person; -Change in cognitive status: Deteriorated (consider significant change); -Respiratory status: Short of breath with exertion; -Vital signs taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/16/24, at 5:47 P.M., showed a nurse documented the following: -Does resident have pain? Yes, relieved with pain medication; -Neuro/cognitive: Alert, confused/forgetful, oriented to person; -Change in cognitive status: No change; -Respiratory status: Short of breath with exertion; -Vital signs taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/17/24, at 2:03 A.M., showed a nurse documented the following: -Does resident have pain? Yes, relieved with pain medication; -Neuro/cognitive: Alert, confused/forgetful, oriented to person, lethargic; -Change in cognitive status: Deteriorated (consider significant change); -Respiratory status: Short of breath with exertion; -Vitals taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/17/24, at 10:16 A.M., showed a nurse documented the following: -Does resident have pain? No; -Neuro/cognitive: Alert; -Change in cognitive status: No change; -Vitals taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress notes dated 11/17/24, at 10:49 A.M., showed a nurse documented the following: -Fall follow-up with no latent injuries observed. No change in activities of daily living (ADLs) or range of motion (ROM). Neuros within normal limits for resident. Vital signs taken. (Staff did not document subsequent neurological assessment.) Review of the resident's progress note dated 11/19/24, at 10:16 A.M., showed a nurse documented observed the resident this morning to have quarter-sized, yellow bruise to his/her right upper back, left lower back, and left upper arm. with no signs/symptoms of pain. (Staff did not document subsequent neurological assessment.) 4. Review of Resident #7's face sheet showed: -admitted [DATE]; -Diagnoses included dementia, collapsed cervical vertebra (neck), seizures, high blood pressure, and depression. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behavioral symptoms; -Used wheelchair for mobility device with assistance of staff to propel; -Fall prior to admission to the facility with no falls since admission. Review of the resident's progress note dated 02/07/24, at 2:33 A.M., (recorded as a late entry on 02/10/25) showed a nurse documented the following: -Resident heard calling for help. Resident stated he/she had to use the bathroom and when he/she attempted to stand, he/she misjudged the edge of the bed and rolled onto the floor. At the time, resident denied injury and/or pain. Review of the resident's fall event report dated 02/07/25, at 4:18 A.M., showed a nurse documented the following: -Unwitnessed fall in the resident's room; -What was resident doing just prior to fall? Sleeping; -Was fall witnessed? No; -Complaint of pain? No; -Location of injury? Not applicable -Range of motion: Without pain or limitation to all extremities; -Position of extremities: No rotation/deformity/shortening noted; -Level of consciousness: Alert/wakefulness; -Facial muscle movement: Strong; -Extremity movement/grasp: all four extremities strong; -Pupil size/response/shape: 3 cm/round/brisk; -Speech: Clear; -Resident responds to name; -Mental status: No changes; -Physician notified on 02/07/25 at 4:30 A.M.; -Responsible party notified on 02/10/25 at 3:00 P.M.; -Vitals taken; -Resident was found on floor adjacent to bed and latent bruising became apparent on day shift 02/07/25. Bruising across left forehead, eye, and brow resolving. Resident denied pain. Pain was resolving. Injury was resolved/healing without complications. Care plan updated. Review of the resident's medical record showed no additional progress notes on 02/07/25. Review of a progress note dated 02/08/25, at 4:33 A.M., showed a nurse documented resident continued fall follow-up without latent injures noted. Neurological checks within normal limits and denied pain or discomfort. (Staff did not document subsequent neurological assessment.) Review of the resident's medical record showed no additional progress notes on 02/08/25. Review of the resident's progress note dated 02/09/25, at 9:37 A.M., showed a nurse documented the following: -Was reported to this nurse that the resident had a fall on 02/07/25 on the overnight shift. No injuries were noted at the time of the fall. Resident remained on fall follow-up. Neurological checks were within normal limits at this time. Resident's pupils are reactive and equal bilaterally, grip strength was equal bilaterally. Bruising noted to the resident's left eye and left upper check area. No other latent injuries noted at this time. Vitals taken. Review of the resident's progress note dated 02/10/25, at 5:07 P.M., showed a nurse documented the following: -Fall follow up from 02/07/25 event. This nurse went to talk to the resident and review the environment. A fall mat was added next to the bed to promote his/her well-being, and an extra blanket was added to pad a couple of knobs that protrude from the bed frame a bit. Discoloration noted across the left side of the resident's forehead, brow, and eye, which appear to be turning yellow/green. When interviewed about the fall, the resident initially said he/she was stuck and could not get up. The resident resided in the SCU and had noted cognitive deficits. The nurse asked the resident a series of questions pertaining to safety and security. The resident stated he/she felt safe in his/her home. The resident mostly replied with word salad, about his/her youth. The resident's tone varied from a whisper to clear and loud. The resident's family member present at bedside during the interaction. Care plan updated. During an interview on 02/25/25, at 11:08 A.M., CNA M said the following: -He/she arrived to work one morning approximately two weeks ago and the night shift aide said the resident fell during the night; -The night shift reported the resident did not hit his/her head; -CNA M went to check the resident and found the resident had a purple area to his/her left eye; -The resident was crying and upset and said his/her face hurt; -He/she went and reported to one of the day shift nurses. During interviews on 02/26/25, at 10:01 A.M. and 11:15 A.M., Licensed Practical Nurse (LPN) H said the following: -He/she worked the day shift on 02/07/25; -The resident's fall occurred on the night shift; -The night nurse passed on information in report on the morning of 02/07/25 about the resident's fall; -The night nurse reported the resident fell overnight and hit his/her head; -The nurse went to the Special Care Unit (SCU) and assessed the resident, conducted neuro checks and made a progress note about the residents left forehead and eye bruise. 5. During interviews on 02/26/25, at 10:01 A.M. and 11:15 A.M., Licensed Practical Nurse (LPN) H said the following: -After a resident fall, the nurse should assess the resident for any injury, check the resident's range of motion (ROM) and assess for pain; -If a resident falls and hits his/her head or if it is an unwitnessed fall and the resident is not able to remember whether or not he/she hit his/her head, the nurse should complete neurological checks; -Neurological checks are to be completed per policy, which is every 15 minutes for the first hour then every 30 minutes for an hour the every hour for a set number of hours, LPN H was unsure exactly, but said the neuro checks were generally performed for 48 to 72 hours in total, to ensure the resident did not have a head injury; -The nurse said the facility used to have a paper form to record the neuro checks on, but several months back, the facility started using an electronic health record system, and there was no place to record the neuro checks, so he/she conducted the neuro checks, but did not record them, but rather made a progress note; -After assessment of the resident for injury, the nurse should notify the resident's physician and the resident's responsible party, the nurse should then document the assessment in the progress note. During an interview on 02/25/25, at 11:50 A.M., LPN N said the following: -After a resident fall, the nurse should complete a head to toe skin assessment on the resident and complete neuro checks, if there is a possibility of head injuries; -The nurse should notify the physician and the resident's responsible party of the fall and any injuries; -The nurse would continue neuro checks and vital signs. He/she was unsure where to record neurological checks; -He/she completed neuro checks after a resident fall, if they hit their head, but he/she was not documenting the checks; -The nurse should continue to assess the resident's pain, skin, and check ROM to the resident's extremities as part of the fall follow up every shift for three days and should document in the progress notes; -The neuro check included assessing the resident's vital signs, handgrips, and pupil reactions. During an interview on 02/26/25, at 2:05 P.M., LPN J said the following: -If a resident fell and hit his/her head or if staff were unsure if the resident hit his/her head, the staff should assess the resident's vital signs and neuro checks; -The facility had a paper to document vital signs on, but no paper to specifically record neuro checks which included hand grips and no where to document that pupils and equal and reactive to light (PEARL); -Neuro checks should be completed every 15 minutes times 4, then every 30 minutes times 4, then every hour times 4, then every 4 hours times for, then every 8 hours times four; -After each fall, the nurse should assess the resident every shift for three days following the fall and document the assessment in the progress notes. During an interview on 02/26/25, at 1:55 P.M., LPN K said the following: -If a resident falls, the nurse should chart a head to toe assessment, any injuries and the resident's vital signs in the progress notes; -If the resident hit his/her head or if it is unknown if the resident hit his/her head, the nurse should complete neuro checks; -The nurse should document the follow up assessments every shift for three days; -The nurse should complete neuro checks per protocol every shift for three days; -LPN K said the nurses documentation after falls was not the best, but the nurses were working on improving their documentation. During an interview on 02/26/25, at 2:30 P.M., Registered Nurse (RN) E said the following: -Nurses should assess the residents for injuries after each fall and document on the resident in the progress notes every shift for three days; -RN E said the nurses should do a better job documenting on residents after falls; -If the resident had a head injury or if the fall was unwitnessed, the nurse should conduct neuro checks every 15 minutes times 4, then every 30 minutes times 4, then every 1 hour times 4, then every 4 hours for the remainder of the 72 hours following the fall; -Neuro checks include assessing the resident's PEARL, reflexes, and grips; -The nurse should assess the re[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure all residents maintained acceptable parameter of nutritional status when staff failed to implement and document recommended, care planned, or ordered, weekly resident weights for three residents (Resident #1, Resident #2, and Resident #3) and failed to provide meal assistance to two residents (Resident #1 and #2). The three resident has been identified as having weight loss. The facility census was 102. Review of the facility policy titled, Weight Management, dated 10/01/10, showed the following: -Purpose was the maintenance of adequate nutrition and hydration is necessary for the resident to maintain health and prevent complications such as malnutrition and pressure sores; -Residents should be weighed monthly unless there is a problem that warrants a deviation from that routine; -Suggested weight schedule of weigh newly admitted residents weekly for four weeks, weigh residents with weight loss weekly, and all other residents monthly; -The newly recorded resident weight should be compared to the previous weight. A significant change in weight is defined, by federal regulations, as 5% change in weight in one month (30 days), 7.5% change in weight in three months (90 days), and/or 10% change in weight in six months (180 days); -Though a weight change may not occur, the resident may be identified as below ideal body weight by the Dietary Manager (DM); -The physician should be informed of a significant change in weight and may order nutritional interventions. The physician should be encouraged to document the diagnosis of clinical conditions that may be contributing to the weight loss. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. If the interdisciplinary care team desires to explore specific meal consumption information for a resident. Either the DM or the Registered Dietitian (RD) should be consulted to assist with interventions, actions are recorded in the dietary progress notes. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. The interdisciplinary plan of care communicates care instructions to staff. Review of the facility policy titled, Feeding the Impaired Resident, dated 10/01/10, showed the following: -Residents are assisted, as needed, to consume each meal so adequate nutrition is provided; -Residents should eat in the location of their preference and should be provided with a pleasant dining environment, regardless of the location; -Remove dome lid from the tray, and check to be sure everything is included on the meal tray that is required by the diet cart and the resident's preference; -Arrange dishes and silverware so the resident can reach them easily; -Open all cartons and give the napkin to the resident. Use clothing protectors as needed; -Ask the resident regarding the use of condiments such as salt, pepper, sugar, ketchup, and apply as desired; -Alternate food, readily available food, or supplements, should be offered consistent with the diet order, if the resident consumes less than half of the meal. 1. Review of Resident # 1's face sheet showed an admitted [DATE] and diagnoses included of Alzheimer's disease. Review of the resident's weight record showed the following resident weights: -On 06/28/24, weight of 172.6 pounds (lbs); -On 07/25/24, weight of 171.0 lbs (a loss of 1.6 lbs); -On 08/09/24, weight of 169.0 lbs (a loss of 2 lbs); -On 09/09/24, weight of 168.0 lbs (a loss of 1 lb); -On 09/26/24. weight of 159.0 lbs (a loss of 9 lbs). Review of the resident's October 2024 Physician Order Sheet (POS) showed the following: -An order, dated 10/07/24, for Ensure (food supplement) two times per day at 8:00 A.M. and 1:00 P.M.; -An order, dated 10/08/24, for a regular, mechanical soft diet. Review of the resident's Registered Dietitian (RD) progress note, dated 10/09/24, showed recommendation of weekly weights to monitor the resident's weight loss. Review of the resident's weight record showed the following: -On 10/15/24, weight of 157. 0 lbs (a loss of two pounds). Staff did not document additional weights for October 2024; -Staff did not document weights for November 2024 or December 2024; -On 01/10/25, weight of 156.4 lbs (a loss of .6 lbs). Staff did not document additional weights for January 2025. Review of the resident's January 2025 POS showed an order, dated 01/29/25, to admit the resident to hospice services. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/05/25, showed the following: -Severe cognitive impairment; -Diagnoses included lipodystrophy (an abnormal loss of body fat with an unknown cause); -Received mechanical altered diet; -Resident did not reject care; -Required assistance of staff with meal set up or clean up; -Resident did not have a significant weight change. -Weight 156.0 pounds (a .4 lb loss). Review of the resident's care plan, updated on 02/19/25, showed the following: -Potential for weight loss; -Ice cream with lunch and dinner, ensure two times per day; -Mechanical soft diet; -Allow sufficient time to eat; -Assess for serving smaller portions more frequently; -Maintain a list of food likes and dislikes; -Medication review to determine if medications are contributing to decreased meal consumption; -Monitor intake and output; -Offer food alternatives when appropriate for any meal; -Provide snacks between meals; -Provide a quiet dining environment; -Provide socialization opportunities during meals, provide verbal encouragement/cueing, refer to RD for evaluation of current nutritional status. Review of the resident's weight record showed the following: -On 02/21/25, weight of 151.8. lbs; -The February 2025 weight represented a significant weight loss over the last 6 months. The recorded resident weight dropped from 169 lbs in August 2024 to 151.8 lbs in February 2025, a loss of 17.2 lbs or a 10 % loss. Observation on 02/21/25, at 12:22 P.M., in the special care unit (SCU), showed the following: -The resident sat at a dining room table in the SCU; -Facility staff served lunch to the resident; -Staff served the resident a one cup sized bowl containing chili, a small dessert cup of canned sliced peaches, and a Magic Cup (a 4 ounce pudding consistency dessert cup containing 290 calories and 9 grams of protein) for lunch; -Staff did not serve residents a baked potato as listed on the menu; -Staff served a glass of water to the resident and no other beverages; -The resident appeared able to feed him/herself. Observation on 02/26/25, in the SCU, showed the following: -At 12:00 P.M., the resident sat at a dining room table and one of the nurse assistants brought the resident a lunch tray and placed the tray on the table; -Part of the meal was a side salad and a packet of ranch dressing; -The staff member walked away without assisting the resident in opening his/her packet of dressing; -The resident attempted to open the packet using his/her fingers and teeth. The resident struggled for several minutes attempting to open the dressing packet, with no success; -At approximately 12:10 P.M., the NA re-approached the resident and asked if the resident if he/she was going to eat, but the resident did not reply. The NA did not offer to assist the resident with his/her salad dressing; -At approximately 12:20 P.M., the NA brought the resident a Magic Cup (in a plastic container with a thick paper lid in place) and walked away; -The resident attempted to open the Magic Cup, but could not remove the lid; -At approximately 12:30 P.M., the NA assisted the resident in removing the Magic Cup lid. 2. Review of Resident #2's face sheet showed: -admitted [DATE]; -Diagnoses included dementia, depression, reduced mobility, and muscle weakness. Review of the resident's weight record showed the following resident weights; -On 07/25/24, weight of 160.0 lbs; -On 08/15/24, weight of 163.0 lbs; -On 09/09/24, weight of 158.0 lbs (a five pound loss); -On 10/15/24, weight of 152 0 lbs (a six pound loss). Review of the RD note, dated 10/30/24, showed the resident had a six pound weight loss in the last month. This was not significant, but lower than ideal body weight (IBW). Resident intake less than 50%. RD recommended adding weekly weights and house shakes twice per day. Review of the resident's physician orders, dated 11/07/24, showed the current diet order of regular, mechanical soft diet, high carbohydrate/calorie, assist with meals as needed, and offer puree foods to maximize caloric intake. Review of the resident's weight record showed the following resident weights; -On 11/11/24, weight of 148. 0 lbs; -Staff did not record weights for December 2024; -On 01/10/25, weight of 143.0 lbs (a five pound weight loss). Review of the resident's progress note dated 01/13/25, at 2:25 P.M., showed the following: -Resident reviewed for weight loss; -Resident had lost a significant amount of weight in the last 6 months. Staff will notify the physician and responsible party. New interventions placed in care plan or house shakes at every meal; -Will weigh weekly until stable. Review of the resident's weight record showed on 01/15/25 a weight of 144.8 lbs. Staff did not document any further weights in January 2025. Review of the resident's potential for weight loss care plan, updated 01/15/25, showed the following: -Fortified pudding with meals; -House shakes with meals; -Mechanical soft diet; -Sit at the assisted table for help as needed; -Allow sufficient time to eat; -Maintain list of food likes and dislikes; -Monitor intake and output; -Offer food alternatives when appropriate for any meal; -Provide quiet dining environment; -Provide verbal encouragement/cueing. Review of the resident's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Severe cognitive impairment; -Exhibits a behavior of daily wandering; -Weight of 145 pounds; -No weight loss or gain. Review of the resident's weight record showed staff did not document resident weight from 02/01/25 to 02/21/25. Observation on 02/21/25, at 12:22 P.M., in the SCU showed the following: -The resident sat at a dining room table in the SCU; -Facility staff served lunch to the resident; -Staff served the resident a one cup sized bowl containing chili, a small dessert cup of canned sliced peaches, and a Magic Cup for lunch; -Staff did not serve residents a baked potato as listed on the menu; -Staff served a chocolate shake and a glass of water to the resident; -The resident appeared able to feed him/herself. Review of the resident's physician orders showed an order, dated 02/24/25, for weekly weights. Observation on 02/26/25, at 12:00 P.M., in the SCU showed the following: -The resident sat at a dining room table and one of the nurse assistants brought the resident a lunch tray and placed the tray on the table; -Part of the meal was a side salad and a packet of ranch dressing; -The staff member walked away without assisting the resident in opening his/her packet of dressing; -The resident did not eat the salad or attempt to open the dressing packet. 3. Review of Resident #3's face sheet showed: -admitted [DATE]; -Diagnoses of unspecified severe protein-calorie malnutrition. Review of the resident's weight record showed on 08/09/24 the resident weighed 115 lbs. The facility did not provide any addition weights for 08/2024. Review of the resident's nurse practitioner (NP) progress note, dated 09/09/24, showed the following: -The resident was seen this day for weight loss review. The resident's current weight of 105 pounds and a previous month's weight was 115 pounds. This was a 10-pound weight loss in one month. Discussed with the resident who feels he/she was eating well. The resident was feeling well and continued to drink shakes. It is thought this could be an erroneous weight. Will have staff reweigh the resident and will then re-evaluate; -Continue protein shakes to three times per day. Review of the resident's record showed staff did not provide resident weight for 09/2024. Review of the resident's RD note, dated 10/08/24, showed the following: -Follow up to weight change; -Recommend weekly weights; -On supplement between meals; -Recommend fortified foods to meals. Review of the resident's record showed staff did not provide resident weight for 10/2024. Review of the resident's physician order sheet showed an order, dated 11/22/24, for Ensure plus 237 milliliters (mL) twice daily between meals. Review of the resident's record showed staff did not provide resident weight for 11/2024. Review of the resident's physician order sheet showed an order, dated 12/31/24, for a regular diet. Review of the resident's 5-day MDS, dated [DATE], showed the following: -Re-entered the facility on 12/31/24; -Cognitively intact; -Diagnosis of malnutrition; -Independent with eating; -Weight of 106 pounds. Review of the resident's record showed staff did not provide resident weight for 12/2024. Review of the resident's nurse practitioner progress note, dated 01/09/25, showed the following: -Resident weight listed as 105 pounds; -Severe protein-calorie malnutrition; -Protein shakes two times per day. Review of the resident's potential for weight loss care plan, updated on 01/14/25, showed the following: -Provide ensure with breakfast and supper; -Assess for serving smaller portions more frequently; -Maintain list of food likes and dislikes; -Medication review to determine if medications are contributing to decreased meal consumption; -Monitor intake and output; -Offer food alternatives when appropriate for any meal; -Provide quiet dining environment; -Provide socialization opportunities during meals; -Provide verbal encouragement /cueing; -Refer to RD for evaluation of current nutritional status. Review of the resident's record showed staff did not provide resident weight for 01/2025. Review of the resident's NP progress note, dated 02/14/25, showed the following: -Weight of 105 pounds; -Severe protein calorie malnutrition; -Protein shakes twice per day. Review of the resident's weight record, dated 02/24/24, showed a weight of 100 pounds. (This represented a significant weight loss of 15 pounds in 6 months from 115 lbs on 08/09/24 to 100 lbs on 02/24/25.) 4. During an interview on 02/26/25, at 3:45 P.M., the Restorative Nurse Aide (RNA) said the following: -He/she was responsible for weekly and monthly weights and some of the aides help with the weights at times; -The facility used to have weekly weight meetings, but had not had them for at least a couple of months; -He/she was not always able to obtain all the resident weights due to working the floor as an aide and having other responsibilities. During an interview on 02/26/25, at 2:54 P.M., the DM said the following: -Prior to 02/21/25, he/she was unsure which residents had weight loss; -On 02/21/25, the corporate nurse and the RD told the DM how to view and print and resident weight loss report; -The RD did not tell the DM which residents needed weekly weights; -The RD recommendations for weekly weights go to the nursing department; -The RNA was responsible for obtaining the weekly and monthly weights and recording the weights; -The facility did not have any weight meetings during December 2024 because the RD was filling in as a DM at another facility; -Prior to that, in November of 2024, the facility was conducting weekly weight loss meetings; -He/she asked the Director of Nursing (DON) about weekly weight meetings and the DON told the DM he/she would look into it, but the meetings did not occur; -In December 2024, he/she asked for the December weights and nursing said the RNA did not obtain the December 2024 weights due to the RNA having to work the floor as an aide. During an interview on 02/26/25, at 4:15 P.M., the RD said the following: -In the past, he/she visited the facility weekly, but he/she had not been to the facility up until 02/21/25 in approximately one month due to responsibilities at another facility; -In the past the facility had weekly weight meetings, and he/she was unaware the weekly weight meetings had stopped occurring; -In January 2025, the Quality Assurance (QA) Nurse reviewed the resident weights and informed the RD there were gaps in the resident weights and gave the RD a list of residents that the facility was adding to the weekly weight list due to weight loss; -The RD said obtaining weights as recommended and having weekly weight loss meetings were important and could help prevent significant resident weight loss; -The nursing department was responsible for obtaining resident weights; -When he/she or the QA Nurse make recommendations to nursing for interventions to help with weight loss, such as weighing a resident weekly, nursing should notify the resident's physician or nurse practitioner and obtain an order for the recommended interventions. -The RNA should be obtaining weekly weights. During interviews on 02/25/25, at 10:05 A.M., and on 02/27/25, at 3:12 P.M., the DON said the following: -The facility had a weight meeting on 02/24/25 to discuss residents with weight loss; -The DON, the Registered Nurse (RN) Unit Manager, the DM, the Regional Nurse, and the RNA attended; -Based on the meeting he/she was made aware there were residents that had been identified with weight loss, that should have been on the weekly weight loss list, but staff were not weighing these residents weekly; -He/she found out at the meeting on 02/24/25, that staff did not complete the monthly resident weights in December 2024; -The RNA was responsible for weekly and monthly weights; -The RNA said he/she had not been able to complete all the assigned weights due to being pulled from his/her position as the RNA to work as an aide on the floor; -The facility's previous weight meeting was on 01/16/25 with the corporate nurse; -He/she said the DM should review the recommendations from the RD and should notify the nursing department of any recommendations, and should notify the DON of the recommendations; -Weekly weights need to be reviewed and interventions put in place. During an interview on 02/27/25, at 2:26 P.M., the Administrator said the following: -In the past, the RD came to the facility and reviews weights one time weekly and made recommendations; -There was a gap of approximately the past month, the RD did not come to the facility, due to working at another facility; -The RD communicated directly with the DM; -Generally, all department heads review the weekly RD recommendation report; -Nursing was responsible for obtaining and recording the weekly and monthly resident weights; -The RNA generally obtained the weights, he was not notified the RNA did not have time to obtain the resident weights; -He/she expected the nursing staff to assist the residents at meal time with opening packages and assisting with eating as needed.

Based on observation, interview, and record review, facility staff failed to serve appetizing and palatable meals when kitchen staff overcooked and under seasoned foods served to residents, including two residents (Resident #6 and #5) who would not eat food/meals at times due to the poor palatability. The facility had a census of 102. Review of the facility policy, Hot and Cold Food Holding, dated 05/25/12, showed the following: -Purpose was to ensure optimal quality of foods held prior to and during meal service; -Foods should not be held on the steam table longer than 30 minutes prior to start. Review of the facility policy, Food Taste Test, dated 01/2002, showed the following: -Foods with a distinctively good taste and appearance help promote the resident/guest(s) dietary intake; -Foods should be tasted prior to meal service to test the quality of the food; -Check the food for appearance (appealing, appetizing, garnished properly, colorful); -Check for flavor, seasoning, texture and that hot foods are hot and cold foods are cold. 1. Review of Resident Council Meeting Notes, dated 2/11/25, showed residents said food was cooked too hard and was hard to eat. 2. Observation on 02/25/25, at approximately 9:30 A.M., showed the following: -A large pot of peas and carrots were boiling, on top of the stove; -A large pot of frozen, mixed vegetables, were boiling, on top of the stove. Observation on 02/25/25, at approximately 12:15 P.M., showed the following: -The rice was hard, making it difficult to chew; -The egg roll was hard and was difficult to eat. It was hard to bite into and was chewy; -The stir-fried vegetables had standing water on the plate around them and were very mushy. 3. Observation on 02/26/25, at approximately 9:40 A.M., showed the following: -The spaghetti pasta noodles, for the lunch meal, were on the stove, boiling; -Spaghetti sauce was on the steam table, warming up for serve-out, for the lunch meal. Observation on 02/26/25, at approximately 10:15 A.M., showed the spaghetti pasta noodles were on the steam table, being warmed until serve out at the lunch meal. Observation on 02/26/25, at approximately 12:35 P.M., showed the following: -The spaghetti pasta noodles were very mushy; -The spaghetti sauce was very plain, with very little or no seasoning. 4. Review of Resident #6's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), and chronic kidney disease, (decreased kidney function, typically indicated by an estimated glomerular filtration rate (eGFR) between 60 and 89, and usually with no noticeable symptoms). Review of the resident's care plan for nutritional status of potential weight loss/goal to prevent, updated 10/14/24, showed the following: -Allow sufficient time to feed/eat; -Maintain list of food likes and dislikes. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/10/25, showed the following information: -admitted [DATE]; -Cognitively intact; -No behaviors; -Independent with eating. During an interview on 02/25/25, at approximately 9:50 A.M., the resident said the following: -The food was never good. Most days it tastes really bad; -The chili that was served on 03/21/25 was plain; -The cooks don't use seasoning, so food is always plain; -Meats are usually too hard, but the pork chops are especially hard to eat; -There is an alternate, but it is just as bad; -He/she thinks they are served leftovers for the alternate. 5. Record review of Resident #5's face sheet showed the following: -admitted to the facility on [DATE]. -Diagnoses include hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart muscle over time, leading to an inability of the heart to pump blood effectively), chronic diastolic (congestive) heart failure ( a condition where the heart ' s left ventricle becomes stiff and cannot relax properly, leading to a buildup of fluid in the lungs and other parts of the body due to impaired filling between heartbeats, causing symptoms of congestive heart failure while still maintaining a normal ejection of fraction (the percentage of blood pumped out with each beat) and spinal stenosis (when the spinal canal and the space around the spinal canal become narrowed). Review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -No behaviors; -Independent with eating. Review of the resident's care plan for nutritional status of potential weight loss/goal to prevent, updated 02/24/25, showed the following: -Resident was not a breakfast eater and preferred to sleep in then asks for a drink when he/she wakes; -Allow sufficient time to feed/eat; -Assess for serving smaller portions more frequently; -Maintain list of food likes and dislikes; -Medication review to determine if medications contribute to decreased meal consumption; -Monitor intake/output. During an interview on 02/25/25, at approximately 1:45 P.M., the resident said the following: -He/she felt like there was enough to eat, but it was usually gross; -He/she was offered a ham and cheese sandwich, but by the time it was offered, he/she was so frustrated, he/she declined; -He/she had a snack of crackers instead of lunch. He/she does this a lot of the time; -Today, the rice and chicken went uneaten, because it was too hard; -All of the meat patties that are served are terrible because they are too hard to eat. 6. During an interview on 02/26/25, at approximately 1:35 P.M., [NAME] B said the following: -Some residents complain the food was just too bad to eat; -He/she makes up plenty of extra sandwiches every evening he/she works, so residents can have something else to eat in the evening; -He/she had let the Dietary Manager (DM) know his/her concerns. During an interview on 02/26/25, at approximately 2:00 P.M., [NAME] D said the following: -He/she had constant comments about how horrible the food was; -Residents ask for more seasoning, other than pepper; -He/she had let the DM know that residents complain about the taste of food. During an interview on 02/26/25, at approximately 3:15 P.M., the DM said the following: -The cooks tend to overcook items; -He/she was unsure why the cooks overcook items, because he/she has discussed this with them; -He/she has not reviewed any resident council meeting notes. During an interview on 02/26/25, at approximately 4:10 P.M., the Regional DM said the following: -Frozen vegetables should never be started too early, as they only need to be heated; -Nothing should be on the steam table for longer than 30 minutes prior to serve-out; -He/she has not reviewed any resident council meeting notes. During an interview on 02/25/25, at approximately 2:40 P.M., Registered Nurse (RN) F said the following: -Residents do often complain about the food that is served; -The biggest complaint is that it taste bad; -Some of them will say they just can't eat it; -He/she and other staff will offer the resident something else to eat; -Sometimes the resident will choose the alternate, or something else; -If they decide not to eat lunch, they may have a snack or wait until dinner; -If it's dinner, they are strongly encouraged to eat something else and are offered many choices. During an interview on 02/27/25, at approximately 1:20 P.M., the Social Services Director (SSD) said the following: -Food was hit and miss; -It can be pretty good on most days, but if it's bad, it's really bad; -The meat is often really tough. He/she will not eat the meat because it's often too tough to chew, especially pork chops. During interviewed on 02/25/25, at approximately 10:10 A.M., and on 02/27/25, at approximately 3:10 P.M., the Director of Nursing (DON) said the following: -He/she would expect an alternate to be offered, if residents are not eating the food they are given; -Residents have said, here or there, that the food does not taste good, but has not been enough to go to the team about anything; -He/she has not gone to the DM about any food issues; -He/she has never eaten the food. During an interview on 02/27/25, at approximately 2:25 P.M., the Administrator said the following: -He/she had not had any real complaints of bad food; -If someone has a complaint, he/she expected staff to address it at that very moment and get the resident something they want to eat; -He/she would expect the DM to be notified immediately of any food concerns; -He/she would expect the DM to discuss food issues with residents immediately and to make all necessary changes, right away.

Based on observation and record review, the facility failed to maintain an effective infection control program when staff failed to administer the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test for four sampled staff members (Dietary Aide B, Nurse Aide (NA) C, Licensed Practical Nurse (LPN) D and LPN E). The facility census was 108. Review of the facility's policy titled Infection Prevention and Control Manual, dated 09/01/17, showed the following: -Purpose to prevent the spread of tuberculosis in resident/guest(s) and employees; -Employees are screened for TB at the time of employment; -The Infection Preventions (IP)/designee is designated to monitor and coordinate compliance with TB screening and management per state/regional/community data/recommendations per applicable Federal and State Laws. Review of the facility's policy titled Infection Prevention and Control Manual, dated 11/14/16, showed the following: -Purpose to prevent the spread of TB through early detection of the disease in residents/guests and employees; -Method One - Apply first test and read results in seven days. If result is negative (0-9 millimeters (mm) induration not redness) apply second test the same day. Read results of second test in 72 hours and use results of second test as the baseline; -Method Two - Apply first test and read results in 72 hours. If the result is negative (0-9 mm induration) apply second test one to three weeks later. Read results of second test in 72 hours and use results of second test as the baseline; -Residents/guests or staff members with tests showing conversion should be reported to county health department. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities showed the following: -All new long term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD (a skin test) two-step tuberculin test within one month prior to starting employment in the facility; -If the initial test is zero to nine millimeters (0-9 mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. 1. Review of Dietary Aide B's personnel record showed the following information: -Hire date of 01/10/24; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 2. Review of NA C's personnel record showed the following information: -Hire date of 01/16/24; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 3. Review of LPN D's personnel record showed the following information: -Hire date of 01/23/24; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 4. Review of LPN E's personnel record showed the following information: -Hire date of 01/04/22; -Staff did not document administering the first or second step TB skin test. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said staff did not complete the first and second TB skin test. During an interview on 02/07/24, at 1:20 P.M., the Administrator said staff did not complete the employee's first and second step TB skin test. 5. During interviews on 02/07/24, at 1:10 P.M. and approximately 1:20 P.M., LPN A said the following: -He/She is the current staff development coordinator and responsible for monitoring the employee TB skin tests; -Nurses administer the first TB skin test on an employee's first day of hire; -Nurses read the new employee's first step TB skin test; -The nurse administers the second TB skin test when the employee returns within a week or two; -He/she monitors the TB skin tests multiple times per month to determine if completed; -He/she worked the floor as a charge nurse the month of January and did not discover these TB skin tests not completed. 6. During interviews on 02/07/24, at 1:20 P.M., and on 02/08/24, at 2:24 P.M., the Administrator said the following: -A charge nurse quit and LPN A worked the floor full time since 01/01/24; -The TB skin tests for the employees fell through the cracks; -The DON is interim and the nurse consultant; -The interim DON has been at the facility for a week; -The interim DON is the IP. 7. During an interview on 02/07/24, at 2:07 P.M., the Director of Nursing (DON)/IP said the following: -She is the interim DON at the facility; -She did not know for sure who is responsible for monitoring employee TB skin tests, she thinks may be the staff development coordinator; -Staff should administer first step TB skin test on employees before they work the floor and document; -She expects employee TB skin tests to be completed timely.

Based on interview, observation, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for three of four residents (Residents #15, #43, and #44) when Resident #15 was physically and verbally abused by Resident #55; when Resident #43 was physically abused by Resident #55; and when Resident #44 was verbally abused by a staff member. 1. Review of Resident #55's Facesheet, undated, showed the following: -admitted [DATE]; -Diagnoses included dementia with agitation, major depressive disorder, cognitive communication deficit, and Alzheimer's disease with late onset. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 10/04/23, showed the following: -Resident able to recall the location of his/her room, but not the season, staff names and faces, or that he/she resided in a nursing home; -Resident had severely impaired for decision making regarding tasks of daily life; -Resident did not have delusions, hallucinations, physical behaviors (hitting, pushing, etc.), verbal behaviors (cursing at others, etc.), or other behaviors (pacing, wandering, rejections of care) during the look back period. Review of the resident's care plan, dated 12/26/23, showed the following: -Goal to not injure self or others when he/she had behaviors; -Identify causes for behaviors and reduce factors that may provoke behaviors; -Send to the emergency room for evaluation. 2. Review of Resident #15's Facesheet, undated, showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease and aphasia (loss of ability to express speech) following cerebral infarction (ischemic stroke - result of disrupted blood flow to the brain). Review of the resident's significant change MDS, dated [DATE], showed the following: -Resident had long and short-term memory problems; -Resident was severely impaired for decisions making regarding daily tasks. 3. Review of the facility provided investigation, dated 12/25/23, for an incident between Resident #55 and Resident #15 showed the following: -Staff were alerted to a thud in Resident #15 and Resident #55's room; -Upon entering the room, Resident #15 was on the floor with his/her head against his/her footboard, and Resident #55 had his/her hands around Resident #15's neck; -Per the report, Resident #55 said he/she was going to kill Resident #15; -The residents were immediately separated. Resident #55 was placed on 1:1 (one on one supervision) until he/she was taken to the emergency department; -Resident #15 was noted initially to have slight redness to the neck, which had faded upon reassessment; -Resident #15 was not interviewable and did not appear to have latent effects; -Resident #55 was admitted to geri-psych services for evaluation and treatment where he/she was started on Depakote Sprinkles (an anticonvulsant) at 500 milligrams (mg) twice a day, and upon return to the facility, Resident #55 was to be on 1:1 for at least 10 days for monitoring. During an interview on 02/01/24, at 3:01 P.M., Nurse Aide (NA) 2 said Resident #55 was very friendly, but every once in a while, he/she would have outbursts and would become violent. NA 2 said he/she was present during the incident with Resident #15 and Resident #55. NA 2 said he/she heard Resident #15 yell and had difficulty opening the door because the residents were against it. NA 2 said when staff entered the room to separate the residents, Resident #55 became violent towards the staff. During an interview on 02/01/24, at 3:09 P.M., the Administrator confirmed the incident between Resident #15 and Resident #55. 3. Review of Resident #43's Facesheet,'' undated, showed the following: -admitted [DATE]; -Diagnoses included hemiplegia (paralysis to once side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (stroke) affecting left dominant side and aphasia (loss of ability to understand or express speech). Review of Resident #43's quarterly MDS, with an ARD of 11/01/23, revealed a BIMS score of 13 out of 15, indicating intact cognition. 4. Review of Resident #55's electronic medical record (EMR) Progress Notes tab showed the following: -On 1/29/23, the resident was observed at 3:40 P.M. hitting his/her roommate (Resident #43) in the head with a pedal off of wheelchair. Two staff members attempted to separate resident. Residents were separated and resident able to be redirected from room into hallway. Resident said 'I'm going to kill a [expletive], if you don't let me out of here today.' Resident then swung and hit one staff member. Another staff member got between the two of them and resident grabbed that staff member around the throat. Staff member able to loosen resident's grip. Resident continue to walk down hallway and push on the outside door. Resident with staff walking down hallway and calmed down with conversation. Resident said that he/she was upset because his/her 'felt cowboy hat' was missing. Staff notified nurse practitioner (NP) notified and orders received to send resident to emergency room (ER) for evaluation and treatment. Emergency medical service and police arrived. Resident cooperative with EMS and sat on the gurney. Review of Resident #43's EMR Progress Notes tab showed on 01/29/24, at 4:58 P.M., staff observed the resident hitting Resident #43 in the head with the pedal off of Resident #43's wheelchair. Two staff members intervened and separated the residents. Resident #43 was noted to have a bump in the middle of the head and a small indentation. Resident #43 was noted to have small skin tears on the right hand from blocking Resident #55. Staff cleaned and dressed Resident #43's wounds. Nurse practitioner assessed Resident #43 with neurological checks noted within normal limits. Resident #43 declined going to the emergency room for evaluation and treatment. During an interview on 02/01/24, at 1:10 P.M., the Staff Development Coordinator (SDC) was asked to recall the incident between Resident #43 and Resident #55. The SDC said she was in the hall with two nurse aides when they heard a noise. NA 1 entered Resident #43 and Resident #55's room and was heard telling the resident no. The SDC said she and NA 2 entered the room and saw NA 1 trying to get the wheelchair foot pedal away from Resident 355 and was hit by Resident #55. The SDC said Resident #43 had reported Resident #55 hit him/her four times with the foot pedal. The SDC said Resident #43 had red marks on his/her head and had two or three small skin tears on his/her fingers from defending him/herself. The SDC said he/she entered the hall with Resident #55 and Resident #55 was not redirectable. Resident #55 grabbed him/her around the throat. Resident #55 was then sent out to the emergency department, but returned to the facility the same night. The night of 01/29/24, Resident #55 did not return to his/her room, but was supervised by the nurse and fell asleep in a common space on a couch near the nurses' station. The SDC said Resident #55 had a previous incident with Resident #15, but was not aware of Resident #55 having behaviors at other times. During an interview on 02/01/24, at 2:42 P.M., Resident #43 indicated prior to the incident Resident #55 had taken one of Resident 43's hats off the dresser, and Resident #43 had told Resident #55, No. Resident #43 indicated he/she was sleeping when he awoke to Resident #55 hitting him/her with a spare wheelchair foot pedal from under Resident 43's bed. Resident #43 said he/she pulled Resident #55 away with his/her good hand. Resident #43 was observed to have two small bandages covering skin tears on his/her right hand. Resident #43 did not have any redness or bruising on his/her head. Resident #43 indicated staff entered the room quickly and separated Resident #55. Resident #43 said he/she was not afraid and had no previous concerns from Resident #55. During an interview on 02/01/24, at 3:01 P.M., NA 2 said he/she recalled the incident from 01/29/24. NA 2 said he/she was in the hall when he/she heard a noise and followed NA 1 entering Resident #55's room. NA 2 said Resident #43 had been asleep when attacked by Resident #55. NA 2 said Resident #55 had been moved from the secure unit about three weeks to a month ago. During an interview on 02/01/24, at 3:09 P.M., the Administrator said on 01/29/24, staff entered Resident #55's room and Resident #55 had hit his/her roommate with a wheelchair pedal. The Administrator said Resident #55 was sent out immediately and was returned to the facility around midnight. The Administrator said Resident #55 was moved to a private room and placed on one-to-one. 36917 5. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, dated 05/15/23, showed the policy strictly prohibits the abuse of any resident by any member of the facility staff. Review of Resident #44's face sheet showed the following: -admitted [DATE]; -Diagnoses included diabetes mellitus and depression. Review of Resident #44's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an observation and interview on 01/29/24, at 2:40 P.M., Resident #44 said he/she was embarrassed and humiliated by the Nursing Staff (NS) 6 and the Nursing Staff (NS) 5 because he/she could not pay for a pizza he/she ordered delivered to the facility. He/she felt like he/she was scolded and was made to feel embarrassed and ashamed that he/she could not pay for the pizza. The resident said he/she told NS 6 and NS 5 that he/she was sorry for the error and that he/she did not want to discuss it anymore. NS 6 responded to the resident and said, I am cutting all ties with you. The resident said he/she was fearful NS 6 and afraid that he/she was getting discharged . He/she was still afraid of NS 6's actions regarding the incident. Resident #44 said NS 6 told him and his/her roommate that their account was flagged at the Pizza [NAME] and they would not be allowed to order pizza delivery in the future. There were no previous issues between NS 5 and NS 6. Resident #44 was observed to be distressed and said he/she was still distraught over the incident and asked the surveyor if he/she would have any more backlash from the incident or the reported complaint. During an interview on 01/29/24, at 9:49 A.M., Resident 44's roommate said he/she was afraid his/her roommate (Resident #44) was going to have a heart attack because he was so distraught over the incident. During an interview on 01/29/24, at 4:35 P.M., the administrator said he/she was aware of the pizza delivery to Resident #44, but he/she was not aware that the resident was upset and distraught over the incident. The Administrator said that he/she would immediately remove NS 5 and NS 6 from the building and conduct an internal investigation. During an interview on 01/29/24, at 4:10 P.M., the Pizza [NAME] Manager said NS 6 and NS 5 had visited the Pizza [NAME] and offered to pay for the pizza and recommended to the manager that he/she flag the account of the two residents for non-delivery without prepayment. The manager stated that he/she did not flag the account of Resident #44 or his/her roommate and that they could order pizza anytime they wanted. During an interview on 01/29/24, at 4:57 P.M., the Administrator said she interviewed Resident #44 and he indicated to her he/she was still experiencing anxiety related to the verbal abuse. The Administrator said he/she assured Resident #44 that he/she would not be discharged from the facility and that he/she did not need to fear actions by NS 6 and NS 5 and that he/she would not be intimidated or threatened by them. The Administrator said she encouraged Resident #44 to report any future fear or concerns related to staff treatment. The Administrator said NS 6 and NS 5 had been removed from the building pending an internal investigation. During an interview on 01/30/24, at 3:50 P.M., the Administrator said the internal investigation showed verbal and mental abuse of Resident #44. MO00229656, MO00230681, MO00231045

Based on interview and record review, the facility failed to ensure bed frames and bed rails, if present, were inspected and maintained per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect 109 of 109 residents that used a bed. Review showed the facility did not provide a policy regarding maintenance of bed/bed rails. 1. Review of the form Resident Beds: Annual Maintenance - Resident Beds/Wheelchairs, showed the following; -OEM [Original Equipment Manufacturer] PM [Preventative Maintenance] Recommendations -Lubricated bed adjusting mechanisms; -Make sure wheels, castors, and locks are operable; -Check all electrical components/wiring for safety and proper operation; -Check all components for beds/wheelchairs for wear and tear; -Check all bed components for compatibility to verify that there is no risk of entrapment - per OEM recommendations; -Conduct user training with all users. Review of bed inspection reports, dated November 2023 and January 2024, showed the following; -The reports had 17 beds listed; -Four of the beds were labeled Main Building and did not have room numbers listed. Review of an audit of all beds currently in use, and provided by the Administrator, on 02/01/24, at 12:25 P.M., showed the following: -38 manual (drive) beds -36 Joerns beds; -13 Invacare beds; -15 Zenith/Basic American/Graham-Field beds; -2 [NAME] Maxi beds; -1 MC Advantage; -2 beds without manufacturer tags; -3 beds supplied by Hospice providers. Review of the MIFUs for the beds showed showed the recommended inspection / maintenance as follows: -[NAME] Maxi Rest Bariatric Bed - once per year; -Zenith II - at six months and 12 months; -[NAME] Maxi Rest Bariatric - at three months, six months, and 12 months; -[NAME] 4748 model - at two weeks then every six months; -Zenith 7000 at three months and six months; -Joerns Bed Frames Easy Care - monthly; -Drive Bed Frame - between users; -MC Advantage -- every six months. During an interview on 02/01/24, at 3:10 P.M., the Administrator said the company has the inspections in computer system. Bed inspection/maintenance records should match the MIFUs.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or resident representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident #24, #34, and #54) reviewed for bed rail use. Review of the facility policy titled, Resident Beds and Bed Safety Rails Program, effective 10/28/19, showed the policy did not address the assessment items, attempted alternatives with documented reasons for failure, and getting an informed signed consent prior to the installation of the bed rails. 1. Review of Resident #24's Face Sheet showed the following: -admitted [DATE] with readmitted [DATE]; -Diagnoses included aphasia (loss of ability to understand or express speech) following a cerebral infarction (stroke), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), adult failure to thrive, and Alzheimer's disease. Review of the resident's electronic medical record (EMR) showed staff did not have signed informed consent explaining the risks and benefits of the use of side rails or documentation to show what alternatives to side rails had been attempted prior to the use of side rails or why the alternatives had failed. Review of the resident's form titled Physical Restraint Record of Informed Consent, showed the following: -The form was signed by the resident's representative on 01/14/21; -Restraints have been found in some cases to increase falls or other accidents such as strangulation, entrapment; -Restraints can reduce independence, functional capacity and quality of life. -The form did not address the use of side rails as a potential restraint. Observation on 01/29/24, at 12:07 P.M., showed the resident was asleep in bed with bilateral upper bed rails. 2. Review of Resident #34's Face Sheet showed the following: -admitted [DATE] with readmitted [DATE]; -Diagnoses included post traumatic stress disorder (PTSD - makes one feel stressed and afraid after the danger is over), psychosis, muscle spasm, muscle weakness, panic disorder, hemiplegia (paralysis of one side of the body), history of TIA (transient ischemic attack - mini-stroke) and cerebral infarct (stroke), and restless leg (in ability to keep legs still). Review of the resident's EMR showed staff did not have signed informed consent explaining the risks and benefits of the use of side rails or documentation to show what alternatives to side rails had been attempted prior to the use of side rails or why the alternatives had failed. Review of the resident's form titled Physical Restraint Record of Informed Consent, showed the following: -The form was signed by the resident's representative on 08/06/18; -Restraints have been found in some cases to increase falls or other accidents such as strangulation, entrapment; -Restraints can reduce independence, functional capacity and quality of life; -The form did not address the use of side rails as a potential restraint. During an interview and observation on 01/30/24, at 10:33 A.M., the resident was observed to have bed rails. When asked if the facility had advised him of the risks and benefits of bed rail, the resident said he/she could not remember. 3. Review of Resident #54's Face Sheet showed the following: -admitted [DATE] with readmitted [DATE]; -Medical diagnoses included anxiety, hip pain, and insomnia. Review of the resident's EMR showed staff did not document signed informed consent explaining the risks and benefits of the use of side rails or showing what alternatives to side rails had been attempted prior to the use of side rails or why the alternatives had failed. Review of the resident's form titled Physical Restraint Record of Informed Consent, showed the following: -Form signed by the resident 04/25/23; -Restraints have been found in some cases to increase falls or other accidents such as strangulation, entrapment; -Restraints can reduce independence, functional capacity and quality of life. -The form did not address the use of side rails as a potential restraint. During an interview and observation on 01/29/24, at 5:06 P.M., the resident was noted to have bed rails. When asked if he/she had been advised of the risks and benefits of the rails, the resident responded that he/she had not. 4. During an interview on 02/01/24, at 12:46 P.M., Regional Nurse Consultant (RNC) said the physical restraint consent was signed at admission if there were rails on the bed. The bed rails were not used as restraints since they are not full side rails. 5. During an interview on 02/01/24, at 3:12 P.M., the Administrator confirmed the informed consent for restraints was being signed at admission prior to alternatives to side rails being attempted and side rails being installed.

Based on interview, record review, and observation, the facility staff failed to protect residents from possible injury when staff failed to have a process in place to ensure hot food and beverages were served at a safe temperature and failed to put sufficient interventions and oversight in place to prevent a second food burn for one resident (Resident #51). The facility census was 102. The administrator was notified on 10/20/2021, at 1:10 P.M., of an Immediate Jeopardy (IJ) which began on 10/14/2021. The IJ was removed on 10/21/2021, as confirmed by surveyor onsite verification. Record review of the facility policy titled Incidents and Accidents, dated 11/10/2014, showed the following: -The resident environment remains as free of accident hazards as is possible, however when an accident occurs, prompt response and reporting occurs. Accidents may involve residents, employees, or visitors; -An incident is an occurrence that may not be consistent with the routine operation of the facility or the routine care of a particular resident. It may involve an injury or property damage. It may involve employees, residents, or visitors; -Examples of incidents include but are not limited to falls, [CONDITION(S)], medication errors, skin tears, bruises, altercations or unusual combative behavior, attempted elopements, treatment errors, equipment malfunctioning causing injury to residents, adverse reaction to diet or medication, and smoking infractions; -If an incident occurs, the resident should not be moved unnecessarily until the condition has been assessed; -Staff should assess the resident's injury; -Staff should notify the resident's physician and obtain orders for care, including any indicated diagnostics (x-rays, laboratory orders); -Staff should obtain medical care as needed and transfer to the emergency room as needed; -Staff should document interventions in the nurses' notes and the incident should be noted on the twenty-four hour report; -An investigation should be initiated. Record review of the facility policy titled Dining Room Duties, dated 10/1/2010, showed the following: -The dining room is available to residents for social interaction during mealtime. Many residents need assistance with eating, however, still enjoy the dining room atmosphere. Nursing personnel are needed to help each resident enjoy the dining experience; -Nursing personnel assist in the dining room, as assigned by the licensed nurse; -Clothing protectors should be placed on residents who need them, prior to the meal. Record review of the Consumer Product Safety Commission Website, undated, showed the following: -Most adults will suffer third-degree [CONDITION(S)] if exposed to 150 degree water for two seconds. [CONDITION(S)] will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree [CONDITION(S)]. 1. Record review of Resident #51's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included [CONDITION(S)] disorder (a mental illness characterized by symptoms such as hallucinations or delusions, and [CONDITION(S)] and depression), dementia (a group conditions characterized by impairment of a least two brain functions, such as memory loss and judgement), and history of a cerebral infarction (stroke). Record review of the resident's current Physician Order Sheet showed the following: -An order, dated 10/16/2020, for a no added salt, pureed (a texture modified diet in which all foods have a pudding like consistency) diet. Record review of the resident's current care plan showed the following: -An intervention, dated 6/14/2021, which showed the resident was able to feed him/herself if he/she was holding his/her plate close in his/her lap. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 9/1/2021, showed the following: -Severely cognitively impaired; -Required substantial assistance with eating where the helper did more than half of the feeding effort; -He/she did not have any skin conditions. Record review of dietary temperature logs, dated 9/1/2021, showed the following: -Pasta casserole 186 degrees Fahrenheit (F); -Pureed pasta casserole 179 degrees F; -Peas 181 degrees F; -Cream of wheat 183 degrees F; -Mashed potatoes 186 degrees F; -Gravy 185 degrees F; -Cream of celery soup 188 degrees F; -Vegetable soup 188 degrees F; -Taco meat 171 degrees F; -Rice 183 degrees F. Record review of dietary temperature logs, dated 9/2/2021, showed the following: -Soup 181 degrees F; -Chicken bacon ranch casserole 173 degrees F; -Mashed potatoes 175 degrees F; -Cheese sauce 186 degrees F; -Broccoli soup 190 degrees F; -Soup 188 degrees F; -Rice 181 degrees F. Record review of dietary temperature logs, dated 9/3/2021, showed the following: -Rice 183 degrees F; -Beans and weenies 180 degrees F; -Gravy 187 degrees F. Record review of dietary temperature logs, dated 9/4/2021, showed the following: -Cream of wheat 183 degrees F. Record review of dietary logs showed facility staff did not document a food temperature log for 9/5/2021. Record review of the resident's progress notes showed the following: -On 9/5/2021, at 6:15 P.M., facility staff documented the resident spilled food onto him/herself. Redness was noted to the resident's chest. No other apparent injuries were noted at that time. Staff notified the resident's responsible party and physician. Record review of the resident's current care plan showed the following: -An intervention, dated 9/5/2021, which instructed staff to put the resident's food in bowls for the resident to be able to handle better. Record review of dietary logs showed facility staff did not document a food temperature log for 9/6/2021. Record review of the resident's progress notes dated 9/6/2021, at 11:20 A.M., showed facility staff documented the resident had redness and blisters to his/her chest. Record review of the resident's physician orders (POS) showed the following: -An order, dated 9/7/2021, to clean the resident's chest daily with normal saline, pat dry, and apply a thin layer of [MEDICATION(S)] cream (a cream used to prevent infections in patients with [CONDITION(S)]) daily until resolved. Record review of the resident's departmental notes showed the following: -On 9/7/2021, at 9:38 A.M., [MEDICATION(S)] (a pain medication used to treat moderate to severe pain) 7.5/325 was administered for signs and symptoms of pain. The resident was yelling out. Record review of dietary temperature logs, dated 9/7/2021, showed the following: -Tater tot casserole 183 degrees F; -Pureed meat 180 degrees F; -Pureed vegetables 186 degrees F; -Mashed potatoes 183 degrees F; -Cream of wheat 181 degrees F. Record review of dietary logs showed facility staff did not document a food temperature log for 9/8/2021. Record review of the resident's departmental notes dated 9/8/2021, at 6:42 P.M., showed resident noted to have redness with fluid filled blister to the chest with no noted signs or symptoms of infection at this time. Record review of dietary logs showed facility staff did not document a food temperature log for 9/9/2021, 09/10/2021, and 09/11/2021. Record review of the resident's departmental notes dated 9/11/2021, at 9:51 A.M., the resident presents with multiple areas of redness, one non-fluid filled blister, and two open blisters noted on observation. No signs or symptoms of infection are present. Record review of dietary logs showed facility staff did not document a food temperature log for 9/12/2021. Record review of dietary temperature logs, dated 9/13/2021, showed the following: -Pureed chicken 183 degrees F; -Pureed cabbage 186 degrees F; -Pureed broccoli 181 degrees F; -Cream of wheat 186 degrees F. Record review of the resident's departmental notes dated 9/14/2021, at 5:09 A.M., showed the resident continued on incident follow up with some pinkish/red discoloration to his/her chest with three to four blisters appearing to be crusting over without drainage. No signs or symptoms of pain were observed. The resident has had no grimacing, guarding, or crying. Record review of dietary temperature logs, dated 9/14/2021, showed the following: -Pureed meat 186 degrees F; -Mashed potatoes 191 degrees F; -Cream of wheat 180 degrees F; -Soup 184 degrees F. Record review of the resident's departmental notes dated 9/15/2021, at 5:31 A.M., showed the blisters to the resident's mid chest and abdomen are still present. No oozing or inflammation was seen to the area. Scabbing was seen to the mid chest, although the blisters popped to the lower abdomen and the area remained reddened. Record review of dietary temperature logs, dated 9/16/2021, showed the following: -Soups 172 degrees F and 186 degrees F; -Cream of wheat 184 degrees F; -Pureed ham 181 degrees F. Record review of dietary temperature logs, dated 9/17/2021, showed the following: -Spaghetti bake, 186 degrees F; -Pureed spaghetti bake, 181 degrees F; -Pureed vegetables, 187 degrees F; -Cream of Wheat, 188 degrees F; Record review of the resident's departmental notes dated 9/18/2021, at 3:04 P.M., showed facility staff documented the resident had redness around the burn and drainage on the dressing. Record review of dietary logs showed facility staff did not document a food temperature log for 9/18/2021. Record review of dietary logs showed facility staff did not document a food temperature log for 9/19/2021. Record review of dietary temperature logs, dated 9/20/2021, showed the following: -Chicken pot pie 191 degrees F; -Pureed meat 188 degrees F; -Cream of wheat 186 degrees F; -Mashed potatoes 183 degrees F. Record review of dietary temperature logs, dated 9/22/2021, showed the following: -Chili 190 degrees F; -Pureed chili 186 degrees F; -Pureed green beans 183 degrees F; -Cream of wheat 180 degrees F; -Vegetable soup 187 degrees F; -Cream of mushroom soup 186 degrees F; -Spanish rice 184 degrees F; -Super cereal 188 degrees F; -Oatmeal 183 degrees F. Record review of dietary temperature logs, dated 9/23/2021, showed the following: -Cream of wheat 186 degrees F; -Chili 187 degrees F; -Oatmeal 187 degrees F. Record review of dietary temperature logs, dated 9/24/2021, showed the following: -Beef tips 196 degrees F; -Noodles 180 degrees F; -Pureed meat 180 degrees F; -Pureed vegetables 186 degrees F; -Mashed potatoes 181 degrees F; -Cream of wheat 187 degrees F; -Fortified cream of wheat 187 degrees F; -Oatmeal 184 degrees F; -Pureed meat 186 degrees F. Record review of dietary temperature logs, dated 9/25/2021, showed the following: -Pureed meat 183 degrees F; -Mashed potatoes 187 degrees F; -Pureed vegetables 185 degrees F; -Cream of wheat 186 degrees F; -Fortified cream of wheat 186 degrees F; -Gravy 190 degrees F; -Oatmeal 188 degrees F. Record review of dietary temperature logs, dated 9/26/2021, showed the following: -[MEDICATION(S)] noodle casserole 177 degrees F; -Beef stew 177 degrees, F; -Pureed beef stew 174 degrees, F; -Mashed potatoes 190 degrees F; -Pureed vegetables 184 degrees F; -Cream of wheat 187 degrees F. Record review of dietary temperature logs, dated 9/27/2021, showed the following: -Cheese sauce 184 degrees F; -Broccoli cheese soup 188 degrees F; -Cream of wheat 188 degrees F; -Gravy 186 degrees F; -Cream of wheat 185 degrees F; -Pureed meat 179 degrees F. Record review of dietary temperature logs, dated 9/28/2021, showed the following: -Pureed meat 184 degrees F; -Mashed potatoes 190 degrees F; -Cream of wheat 187 degrees F; -Gravy 183 degrees F. Record review of dietary temperature logs, dated 9/29/2021, showed the following: -Ham and beans 189 degrees F; -Spinach 186 degrees F; -Pureed ham and beans 186 degrees F; -Mashed potatoes 186 degrees F; -Soups 186 and 185 degrees F; -Pureed meat 187 degrees F; -Cream of wheat 186 degrees F; -Oatmeal 186 degrees F. Record review of dietary temperature logs, dated 9/30/2021, showed the following: -Bacon ranch casserole 188 degrees F; -Pureed casserole 184 degrees F; -Cream of wheat 187 degrees F; -Ham and beans 188 degrees F; -Gravy 186 degrees F; -Pureed meat 180 degrees F; -Oatmeal 184 degrees F. Record review of dietary temperature logs, dated 10/04/2021, showed the following: -Tater tot casserole 186 degrees F; -Mashed potatoes 186 degrees F; -Cream of wheat 184 degrees F; -Macaroni and cheese 180 degrees F; -Fortified cream of wheat 187 degrees F. Record review of dietary temperature logs, dated 10/05/2021, showed the following: -Beef stroganoff 187 degrees F; -Pureed meat 181 degrees F; -Mashed potatoes 186 degrees F; -Pureed vegetables 184 degrees F; -Soup 190 degrees F; -Pureed eggs 186 degrees F; -Oatmeal 185 degrees F; -Cream of wheat, fortified and plain, 186 degrees F. Record review of dietary temperature logs, dated 10/06/2021, showed the following: -Chicken and dumplings 187 degrees F; -Pureed meat 184 degrees F; -Mixed vegetables 186 degrees F; -Mashed potatoes 187 degrees F; -Soup 192 degrees F; -Au gratin potatoes 186 degrees F; -Cream of wheat regular and fortified 187 degrees F; -Oatmeal 183 degrees F. Record review of dietary temperature logs, dated 10/07/2021, showed the following: -Chicken spaghetti 188 degrees F; -Pureed meat 180 degrees F; -Mashed potatoes 184 degrees F; -Pureed vegetables 187 degrees F; -Cream of wheat 183 degrees F; -Cheesy potatoes 186 degrees F; -Gravy 191 degrees F. Record review of dietary logs showed facility staff did not document a food temperature log for 10/8/2021, 10/9/2021, or 10/10/2021. Record review of dietary temperature logs, dated 10/11/2021, showed the following: -Pureed meat 183 degrees F; -Mashed potatoes 186 degrees F; -Soup 185 degrees F; -Chili 186 degrees F; -Cream of wheat fortified and regular 187 degrees F. Record review of dietary temperature logs, dated 10/12/2021, showed the following: -Mashed potatoes 190 degrees F; -Cream of wheat 185 degrees F; -Soup 187 degrees F; -Oatmeal 186 degrees F. Record review of dietary temperature logs, dated 10/13/2021, showed the following: -Spinach 188 degrees F; -Pureed meat 185 degrees F; -Pureed vegetables 187 degrees F; -Cream of wheat 183 degrees F; -Soup 186 degrees F; -Mashed potatoes 183 degrees F; -Baked beans 186 degrees F; -Oatmeal 186 degrees F. Record review of dietary temperature logs, dated 10/14/2021, showed the following: -Chicken pot pie 186 degrees F; -Soups 187 degrees F; -Pureed meat 183 degrees F; -Pureed vegetables 184 degrees F; -Mashed potatoes 181 degrees F; -Rice 186 degrees F; -Peas 180 degrees F; -Gravy 186 degrees F; -Cream of wheat 187 degrees F; -Oatmeal 187 degrees F. Record review of the resident's departmental notes showed the following: -On 10/14/2021, at 6:27 P.M., an aide notified the nurse the resident had spilled hot food on his/her chest. The resident was cleaned up and his/her skin was assessed. He/she had redness and was developing blisters on the sensitive skin from the previous burn. The area was cleaned with Vashe (a wound cleanser), skin prep (a protective film to help reduce friction during the removal of tapes and films) was applied, and the area was left open to air. The physician and responsible party were notified; -On 10/14/2021, at 8:44 P.M., resident was showing signs and symptoms of pain and discomfort. Pain medication was administered. Record review of the resident's current care plan showed the following: -An intervention, dated 10/14/2021, which instructed staff to supervise the resident and place a clothing protector on the resident at all meals. Record review of dietary temperature logs, dated 10/15/2021, showed the following: -Spaghetti sauce 186 degrees F; -Pureed spaghetti 173 degrees F; -Mashed potatoes 185 degrees F; -Cream of wheat 186 degrees F; -Pureed meat 180 degrees F; -Oatmeal 184 degrees F. Record review of the resident's departmental notes dated 10/18/2021, at 3:23 A.M., showed resident remains on incident follow up with no new or late appearing changes to chest. Blisters are oozing clear discharge from them. [MEDICATION(S)] (a cream used to prevent infections in patients with [CONDITION(S)]) applied to area with a loose [MEDICATION(S)] (a non-stick dressing) covering them to absorb drainage. Healing areas that were first there continue to heal. The new blisters are clear. Care is taken not to pop blisters when cleaning. No signs or symptoms of pain or discomfort was observed. Record review of the resident's Physician Orders showed the following: -An order dated 10/18/2021 to cleanse the burn to the abdominal area with Vashe, apply skin prep to the peri-wound, apply [MEDICATION(S)] cream to the wound bed, and cover with a dry dressing. Observe the area daily; -An order dated 10/ 18/2021 to cleanse the burn to the mid-chest with Vashe, apply skin prep to the peri-wound, apply [MEDICATION(S)] cream to the wound bed, and cover with a dry dressing; -An order dated 10/18/2021 to cleanse the burn to the upper chest with Vashe, apply skin prep to the peri-wound, apply [MEDICATION(S)] cream to the wound bed, and cover with a dry dressing. Record review of dietary temperature logs, dated 10/18/2021, showed the following: -Rice 206 degrees F: -Baked beans 182 degrees F; -Pureed pork 178 degrees F; -Soup 179 degrees F; -Pureed meat 185 degrees F; -Cream of wheat, fortified and plain 186 degrees F; -Oatmeal 183 degrees F. Record review of the resident's departmental notes dated 10/19/2021, at 5:19 P.M., showed burn to mid chest showed deterioration this week. The wound bed (bottom of the wound) showed slough tissue (dead tissue). No drainage was seen. The edges were distinct and intact. The peri-wound (area surrounding the wound) was pink and firm. During an interview on 10/19/21, at 3:35 P.M., Licensed Practical Nurse (LPN) A said the second time the hot food was spilled on the resident staff came to get him/her and said the resident had spilled a bowl of chili on him/herself. The resident didn't have a clothing protector on at that time and he/she is not sure if the resident was wearing one when the first burn occurred. Staff had told him/her they didn't have any available so they were trying to use a towel. The LPN told staff the resident needed someone with him/her at all times, because he/she is not able to eat independently. The resident still had some blisters from the first wound and the wound nurse said it was showing signs of infection. The second wound showed some blisters. Staff brought the resident another bowl of chili to eat to replace the one that had spilled and it was steaming hot as well. During an interview on 10/19/2021, at 3:45 P.M., Certified Medication Technician (CMT) I said the resident spilled food on him/herself twice. The first time was pureed meat and gravy and the second time was chili. The resident should be assisted, but staff let him/her eat on his/her own. Someone is supposed to be watching him/her. The facility was short staffed the night of the second incident. Both incidents took place in the evening. Someone should be sitting with the resident and if he/she needs help, staff should help. The resident should have on a clothing protector during meals. During an interview on 10/19/2021, at 5:08 P.M., the Director of Nursing (DON) said she was not the DON when the resident's first burn happened. On 9/16/2021, the Assistant Director of Nursing (ADON) told the DON the resident liked to remain independent and hold his/her plate close. After the burn on 9/5/2021, staff started giving the resident bowls for his/her meals, because he/she could hold bowls better. On 9/16/2021, the DON did an in-service with nursing staff to make sure the resident was supervised and had a clothing protector on. The DON said she did have a concern with the temperature of the food so she looked at the food temperature logs. The Dietary Manager (DM) had in-serviced dietary staff on policies on food temperatures on 9/15/2021, and found food temperature logs were not being done. Staff should look to see if a resident can handle a plate, bowl, at their cognitive status, and how close to table they are seated to determine if the resident is able to assist themselves with dining. On 10/14/2021, the resident was served chili in a bowl. No one voiced it was too hot. The DON said it was her understanding the resident was not wearing a clothing protector. A couple CNAs said clothing protectors were in laundry. Staff should have been with the resident. The resident should have been supervised. All of the interventions should be on the care plan. Staff should make sure food is appropriate temp before serving and staff should always be with him/her when eating. During an interview on 10/19/2021, at 5:27 P.M., the Administrator said after the first burn, the resident was supposed to be supervised and have on a clothing protector during meals. Food temperatures were addressed with the dietary department. On 10/14/2021, the DON approached him and let him know there was a problem with clothing protectors. The resident should have been wearing one and was not. Someone should have been supervising him/her during mealtimes. If a resident has a burn, they educate the staff on the process. During an interview on 10/19/2021, at 6:27 P.M., the MDS Coordinator said she talks to nurses and CNAs for anything new or about any changes to residents' care plans. She looks at weight, diet, code status, physical assistance level, mobility devices, or mechanical lifts. If she is aware she would care plan a resident not being able to hold their hot food or liquid. She has not care planned the residents who cannot hold their hot food or drinks, if it's necessary she can add this. If she is aware she would add spilled hot coffee on oneself to care plan. She was aware of food being spilled on the resident that burned him/her. Observations of the resident's wounds on 10/20/2021, at 10:04 A.M., showed the following: -A red area approximately the size of a quarter sized in the resident's mid abdomen; -A purple area approximately the size of a silver dollar in the resident's left mid-abdomen with open area in center approximately 1.5 centimeters x 2 centimeters; -The wound to the resident's chest approximately 4 centimeters x 5 centimeters. The upper wound is red, with yellow slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) present. Peri wound intact pink. During an interview on 10/20/2021, at 10:21 A.M., Certified Nursing Assistant (CNA) J said if an aide needs to look in a care plan, they can look at the nurses' station. It should show if a resident need a clothing protector or not and how much assistance the resident requires with dining. He/she has been putting a clothing protector on the resident for a long time. The resident was independent with eating until the first burn and then he/she started getting assist. Someone should always assist the resident with eating. During an interview on 10/20/2021, at 11:26 A.M., CNA H said before his/her first burn, staff was to keep an eye on the resident during meal times. He/she was able to feed him/herself, but needed some help with setup. After the resident spilled food on him/herself the first time, food was put in bowls so he/she could handle it easier, then it happened again. Care plans are at the nursing station. Every resident in the dining room should get a clothing protector to protect them and their clothing from accidents. Staff can tell if a resident needs assist by looking at the care plans and by knowing their residents cognitive status. During an interview on 10/26/2021, at 1:32 P.M., Registered Nurse (RN) C said if a resident needs feeding assistance and if they are unsafe for eating hot food or liquids it should be listed on the dietary slip. The resident did not have feeding assistance or that he/she was unsafe for hot food or liquids listed on his/her dietary slip before his/her [CONDITION(S)]. RN C was not aware of any other incidents. During an interview on 10/26/2021, at 12:26 P.M., CNA D said residents are monitored to see if they need assistance eating, staff finds out during report, and by the assistance level listed on the dietary slip. During an interview on 10/20/2021, at 2:02 P.M., Dietary Staff L said food should be cooked to 165 degrees F. or higher. The holding temperature is 145 degrees F. Food for residents should be served at 145 degrees F. Staff tests temperatures right out of oven then again before serving to residents. If food is over holding temp of 145 it is served out. Dietary Staff L said he/she did not know which residents are at risk for [CONDITION(S)]. The dietary staff was told today (10/20/2021) to turn the temperature down on the pureed food on the steam table. He/she had heard about a resident who got burned twice with food. He/she was not told to do anything differently with temperatures of food until today. Kitchen staff writes down food temperatures, but he/she is not sure if anyone does anything with them. During an interview on 10/20/2021, at 2:09 P.M., Dietary Staff M said food should be cooked to 165 degrees F. The holding temperature of the food on the steam table is 160 degrees F. Residents complain about cold food if less than 160. He/she is aware residents can be at risk for [CONDITION(S)] and it has happened. The resident got burned twice. The last time it happened, staff failed to put a clothing protector on him/her. They should use ones with plastic backs on them. He/she was told in a meeting today that temperatures on the pureed food should be turned down on steam table. Dietary staff L and Dietary Staff M are supposed to get 1:1 training regarding food temperatures and the steam table. Dietary Staff M said he/she checks the temperatures of food when it is pulled out of the oven and then retests the temperatures before the food is served. He/she was also told today that coffee temperatures also have to be monitored. During an interview on 10/20/2021, at 9:49 A.M., the Dietary Manager said she tries to review temperature logs at least weekly to ensure temperatures are in appropriate ranges. Lately she has tried to review more often due to incident that occurred a while back. The incident was when the resident was burned. Food has to be heated to 165 F. The facility food temps consistently range from 165 F to 185 F. Pureed foods hold temperatures better and get hotter. When food goes down hall, it cools off. Staff hold food at 135 F which is the minimal holding temp. Kitchen staff have not been checking the temperature of the coffee. The Dietary Manager said she did check the coffee temperature on 10/19/2021, and it was 175.8 degrees F. She said they can serve coffee to a maximum of 181 degrees F. She is aware of [CONDITION(S)] with the resident. Following first burn staff changed the resident from plates to bowls so he/she could hold them easier. Nursing did education on clothing protectors. No other food interventions were placed at that time because they did not want to serve him/her just cold foods. Following the second burn, gelatin was added for wound healing and staff was to make sure his/her clothing protector was on. After first burn, staff looked to see if anyone else was at risk and we did not think anyone else held bowls or plates in the same manner. The Dietary Manager thinks this resident was independent and no one wanted to take that away. After the first burn someone in nursing was supposed to assist him/her while he/she was eating. During an interview on 10/20/2021, at 12:47 P.M., the Medical Director said he is not aware of what processes the facility has in place to ensure residents are capable of eating hot foods or drinking hot liquids. He was probably made aware of the first burn. He can't imagine a facility food being that hot that it would burn a resident. Interventions that should be put in place would be policy that he tries to avoid and defers to nursing. He was sure someone let him know about the second burn. If someone needed to assist the resident with eating, staff would know and they would have been doing so. He would expect them to assist the resident and use clothing protectors after the [CONDITION(S)]. During an interview on 10/22/2021, at 2:30 P.M., the resident's primary care physician (PCP) said he had seen the resident during meal time and he/she had food all over him/her and mostly staff appear to be leaving him/her to his/her own abilities. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain the highest practicable physical, well-being, in accordance with a comprehensive assessment and plan of care for one resident (Resident #16) who was admitted on [DATE] and discharged to the hospital the next day for behaviors. On readmission on 3/7/13, the resident had several serious [DIAGNOSES REDACTED]. Staff failed to effectively communicate when the resident had increased [MEDICAL CONDITION] and decreased urinary output for more than one shift and failed to adequately assess, monitor, and timely notify the physician of this condition change. This resulted in the resident's re-admission to the hospital with [DIAGNOSES REDACTED]. Staff also failed to monitor bowel movements and failed to administer physician-ordered medication to assist in bowel elimination for one resident (Resident #5) resulting in several hours of pain and a difficult expulsion of hard bowel. The facility census was 95. 1. Record review of Resident #16's admission nursing assessment dated [DATE], showed the following information:-Entered from hospital;-Oriented to person. Long and short-term memory problems;-Behavior problems: Combative;-Skin thin and fragile;-No [MEDICAL CONDITION] Mosby's Medical, Nursing, and Allied Health Dictionary, 2002 defines [MEDICAL CONDITION] as, "The abnormal accumulation of fluid in the interstitial (between the cells) spaces of the tissues". [MEDICAL CONDITION] can be classified as non-pitting or pitting (finger pressure on the area leaves an imprint in the tissue for a period of time). Pitting [MEDICAL CONDITION] is further classified in severity by using a 1+ to 4+ scale with 4+ being the most severe. Record review of the resident's nurse's notes showed the resident had increased behavioral symptoms. On 2/16/13, staff received orders to send the resident to the hospital for evaluation and treatment. Record review of the departmental notes on 3/7/13, showed at 5:03 P.M., hospital staff reported the following to the facility: -Resident with agitation and confusion; -[DIAGNOSES REDACTED]. Symptoms include swelling and tenderness, pain in the calf or thigh, and possibly warmth); -[MEDICAL CONDITION]; - Resident continues on [MEDICATION NAME] (antibiotic) but has had regularly formed bowel movements; -Bilateral [MEDICAL CONDITION]; -appetite poor but will eat puddings, shakes and jello. Record review of the resident's re-admission nursing assessment dated [DATE], showed the following information:-Entered from hospital;-Oriented to person. Long and short-term memory problems;-Behavior problems: no;-Skin thin and fragile;-[MEDICAL CONDITION] present, 3+; bilateral legs 2+ and bilateral feet 3+. Record review of the resident's initial admission care plan showed on 3/7/13, staff noted the following information:-Resident at risk for constipation, observe for bowel movement every shift;-Potential for dehydration. Observe for changes in intake and output. Offer/encourage fluids honoring preferences;-Potential for pain. -Staff did not document any initial admission care plan problems, goals and interventions to address the resident's [DIAGNOSES REDACTED]. Record review of the physician's admission history and physical dated 3/8/13, showed in part the following information:-History of dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION] with Greenfield filter (filter usually placed in the inferior vena cava of the heart to prevent venous blood clots from reaching the [MEDICAL CONDITION] circulation from the lower extremity);-Bilateral lower extremity [MEDICAL CONDITION]. Record review of the departmental notes showed the following information:-On 3/8/13, physician here to see resident. New orders for [MEDICATION NAME] times two more weeks after previous dose stops on 3/17/13.-Between 3/8/13 to 3/12/13, staff completed 13 entries for Skilled Documentation regarding behavioral Symptoms. Staff did not document regarding the resident having [MEDICAL CONDITIONS], and bacteremia. Record review of the physician's progress note dated 3/12/13, showed the resident's general condition remained the same. Oral intake fair. Lungs clear. Record review of the departmental notes showed on 3/13/13 at 10:21 A.M., the social service director (SSD) phoned the resident's spouse and spoke with him/her about the resident moving off the secure dementia unit. Spouse gave permission to try it. Resident's spouse also asked about the resident's legs and feet being swollen. SSD documented that she would speak to resident's nurse and have the nurse follow-up with the spouse. Record review of the care plan dated 3/13/13, showed the following information:-Isolation (precautions taken to prevent the spread to other residents) related to [MEDICAL CONDITION]. Labs as ordered. Activities as appropriate. Observe for changes in condition.-Staff did not document any further care plan problems, goals and interventions to address the resident's [DIAGNOSES REDACTED]. Observation and interview on 3/14/13 between 4:08 P.M., to 4:20 P.M., showed the following:-The resident lay in bed. The resident was thin framed. His/her skin was pale and had sunken in facial features. -Second shift certified nurse assistant (CNA) BB and CNA V entered the room. Staff checked the resident for incontinence. CNA BB said the resident had a little bowel movement, the feces was light colored with a slimy, thin appearance. -As the aides provided hygiene care, CNA BB said the resident's legs were swollen and look "puffy". -The resident moaned as the staff positioned him/her from side to side during care. CNA BB asked the resident if he/she needed pain medication. -CNA V said his/her legs look a little swollen. -CNA BB said "they are swollen bad" as he/she placed socks on the resident. -CNA BB said, "He/she has not urinated today and his/her brief just now wasn't wet". -CNA V said he/she was "wet" last night on his/her shift. -CNA BB struggled to pull on the resident's pants and said, "I bet I know where all that fluid is. I hope these pants still fit, his/her legs are puffy". -The resident moaned as staff pulled up his/her pants. CNA BB said, "You gonna make it?". The resident said. "No". -Staff continued to dress the resident, and assisted him/her into the geri chair. Interviews on 3/14/13, showed the following information:-At 4:30 P.M., the SSD said she called the resident's spouse regarding the move. The spouse reported concerns about the resident's legs swelling. SSD said yesterday, she reported the spouse's concerns to registered nurse (RN) FF;-At 4:35 P.M., RN FF said he/she was not aware of any concerns with the resident's legs;-At 4:36 P.M., RN FF went to SSD office. SSD said yesterday, she told RN FF about the spouses concerns. RN FF said he/she did not remember the conversation involving the resident. They talked about several residents, but not Resident #16. RN FF said he/she even called and got orders from the physician for a doppler on another resident but nothing on Resident #16. SSD said the physician needed to be contacted. RN FF said he/she would check with charge nurse, licensed practical nurse (LPN) R. During an interview on 3/14/13 at 4:45 P.M., charge nurse LPN R said he/she had not received anything in shift report about the resident's legs. CNA BB reported the resident's legs were swollen about 10 minutes ago and he/she went and assessed the resident's legs. LPN R had not assessed the resident's legs prior to receiving the report from CNA BB. LPN R said the resident's legs were [MEDICAL CONDITION], red and cool to the touch. LPN R had not called the physician yet. Record review of the departmental notes showed the following information:-Between 3/13/13 at 10:21 A.M., to 3/14/13 at 5:03 P.M., staff did not document regarding the resident having [MEDICAL CONDITIONS], bacteremia, and decreased output;-On 3/14/13:-At 5:03 P.M., LPN noted the resident had 2+ [MEDICAL CONDITION] to bilateral lower extremities, skin was shiny and cool to the touch, positive pulses bilaterally. No signs of pain noted. Resident unable to communicate needs, does not grimace or guard as if painful. Physician notified.-At 5:12 P.M., new orders received for venous doppler (examine the structures inside the body and to evaluate blood flow at the same time.) of bilateral lower extremities, lab tests that included complete blood count, and complete metabolic (electrolyte) panel;-At 5:20 P.M., mobile x-ray notified of order for venous doppler. During an interview on 3/14/13 at 5:20 P.M., surveyor reported to charge nurse LPN R the resident's decreased urination. LPN R said he/she was not aware the resident had not urinated all day. He/she was not aware the resident had been dry on day shift and still dry on second shift. He/she had not received any reports from day or evening shift aides. LPN R said he/she would expect the aides to report a resident's decreased or no output so he/she could assess the resident and report to the physician. Observation on 3/14/13 at 5:22 P.M., the resident sat in the geri chair (reclined chair with wheels). The staff tried to help the resident eat dinner. The resident took a few bites of yogurt and drank part of the high calorie supplement. Record review of the departmental notes showed on 3/14/13 at 5:28 P.M., LPN R noted the resident with dry incontinent brief through out the day shift and remains dry on first evening shift round. Physician notified, orders received for urinary catheterization. During an interview on 3/14/13 at 5:35 P.M., CNA BB said the day aide, CNA O, told him/her in shift report the resident had not urinated and had been dry today on CNA O's shift. CNA BB said he/she had not reported the resident's decreased urination to the charge nurse LPN R. Observation and interview on 3/14/13 at 6:15 P.M., showed the resident lay on his/her back. Charge nurses LPN R and LPN DD set up the urinary catheterization supplies. LPN SS inserted the catheter into the urinary opening. No distention and no urine return at first. As LPN R massaged the resident's abdomen, dark tea colored urine presented in the collection container. LPN SS removed the catheter. LPN R measured the urine and said one collection container had 150 cc (cubic centimeter or same as ml) and the specimen cup had 125 cc (total of 275 cc of tea colored urine was collected). LPN R told LPN SS the resident was moved to the hall at shift change yesterday around 1:30 P.M. Record review of the departmental notes dated 3/14/13, showed the following information:-At 6:17 P.M., the assistant director of nursing noted the resident complained of discomfort, staff administered Tylenol. Notified physician, new order received for [MEDICATION NAME] (narcotic pain medication) one tablet every four hours as needed for pain and discomfort;-At 8:19 P.M., the Director of nursing (DON) noted the following events:-6:30 P.M., the resident ate poorly at supper and had complained of pain. Staff gave medication and assisted to bed. Catheterization with 250 ccs of dark amber fluid on return. Physician notified with new orders to change labs, doppler and urinalysis (UA) to STAT. Mobile x-ray called for stat doppler, told not available until the morning;-7:00 P.M., lab arrived. Notified physician of doppler not available until the morning, new orders to send to emergency room for evaluation and doppler study;-7:05 P.M., family arrived and did not want resident sent to hospital at this time. They wanted to wait for labs and UA;-7:15 P.M., resting quietly, no pain, 3+ [MEDICAL CONDITION] in legs and feet;-7:25 P.M., physician notified of family's request, new orders to place indwelling urinary catheter;-8:15 P.M., blood count and UA results received, awaiting additional labs;-8:35 P.M., urinary catheter draining yellow, clear urine, no pain noted, mucous membranes (oral gum tissue) pink, slight tenting (a sign of dehydration) to skin, 3+ [MEDICAL CONDITION] in legs;-8:45 P.M., received additional lab results, physician notified, orders to send to hospital;-9:00 P.M., family agreed to send resident to hospital;-9:30 P.M., hospital notified.-On 3/15/13 at 7:51 A.M., late entry for 3/14/13, resident left facility at 10:00 P.M. Record review of a handwritten statement dated 3/15/13, showed LPN S wrote the following:-On 3/12/13, the resident was up for breakfast and lunch. No acute changes in condition though his/her legs remained swollen. Resident returned to bed with feet elevated on pillow. Pedal pulses assessed with [REDACTED]. (LPN S did not document his/her assessment in the resident's medical record). During an interview on 3/15/13 at 8:35 A.M., charge nurse LPN CC said the following information:-Skilled Documentation usually had the resident's admitting diagnoses. Other [DIAGNOSES REDACTED]. If on [MEDICATION NAME] staff should document during the course of treatment and for 72 hours after the course of treatment;-He/she expected the aides to report if a resident had not urinated during their shift so he/she could assess the resident. They should not wait until the end of shift to report it. During an interview on 3/15/13 at 2:07 P.M., the DON said the following:-The facility originally admitted the resident to Skilled nursing from the hospital (2/15/13), then he/she went back to hospital for behaviors (2/16/13); -readmitted from the hospital with [MEDICAL CONDITION] (3/7/13); -She was made aware today, of the resident's spouse's concerns from 3/13/13. She did not know if the information was passed on to the appropriate people; -On 3/13/13, staff moved the resident to the front hall from the unit during shift change, not sure all staff knew about the move; -The unit nurse LPN S noticed some [MEDICAL CONDITION] but did not document it in the resident's record;-LPN S should have documented his/her assessment in the resident's record and report the assessment to the charge nurse when the resident was transferred from the unit to the front hall.-The resident was admitted with [MEDICAL CONDITION]-noted from the physician on 3/8/13 and 3/12/13, resident continued with same [MEDICAL CONDITION]. This was a new problem on admission 3/7/13. -In clinical meetings nurses look at skilled documentation. The skilled documentation should include the resident's admitting diagnoses. The charge nurse can add additional notes for areas not covered in the skilled documentation; -She expected aides to report to the charge nurse immediately if a resident had not voided and/or had a change in condition. It's listed on their name tags to report change in condition to charge nurse. During an interview on 3/20/13 at 2:00 P.M., the DON said the resident passed away at the hospital on [DATE]. Record review of the Death Certificate received from the facility on 3/21/13, showed the resident's physician noted the cause of death as [MEDICAL CONDITION]. 2. During record review of Resident #5's, 5 day MDS assessment dated [DATE], showed the following: -Dementia with behavioral disturbances; -Muscle weakness; -Lack of coordination; -Difficulty in Walking; -[MEDICAL CONDITION] (slows down many of the body's systems, including digestion, elimination, and can cause chronic constipation); -Occasionally incontinent of bowel; -Required staff assistance of one for personal hygiene; -Required staff assistance of two for transfers; -Required staff assistance of one for ambulation; -Brief Interview for Mental Status (BIMS) score of three (represents a severely impaired cognitive status). Record review of the resident's care plan dated 02/28/13, showed the facility staff assessed the resident required the following interventions: -Staff to record bowel movements; -Staff assistance of two is required to toilet, transfer, and with incontinence care when resistive; -Staff to observe for any stool abnormalities (black, blood, mucous, hard/dry/liquid, etc); -Observe for abdominal distention, increased gas, complaint of pain, nausea or vomiting; -Offer a variety of fluids; -Encourage intake; -Encourage activity as tolerated. Record review of the resident's 14 day MDS dated [DATE] showed the following: -Always incontinent of bowel; - Required staff assistance of one for transfers; -BIMS score of nine (represents a moderately impaired cognitive status). Record review of the Physician order [REDACTED]. -Milk of Magnesia (MOM -used as an antacid and laxative), 30 ml (milliliters) if no bowel movement in three days; -[MEDICATION NAME] (a stimulant laxative - acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement) 10 mg (milligram) suppository per rectum if no bowel movement within eight hours after Milk of Magnesia administration; -Fleet enema ( works by pulling water from the body into the bowel, which helps to soften the stool and cause a bowel movement), 7-19 gm/118 ml, rectally if no bowel movement within three hours after [MEDICATION NAME] administration. Record review of the facility's bowel sheet for February and March 2013 showed the following: - The resident had a large bowel movement on 02/25/13; - Staff did not document any additional bowel movement for the resident from 02/26 through 3/2/13 (five days). -The resident had an extra large bowel movement on 03/03/13. -Staff did not document any additional bowel movement for the resident until 03/08/13 (four days). -The resident had a medium bowel movement on 03/08/13. - Staff did not document any additional bowel movement for the resident from 03/09 through 03/11/13. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the Nurses' notes showed from 02/25/13 to 03/11/13, staff did not document that they administered any PRN medication to assist in bowel elimination. Staff did not document any assessment of the resident's abdomen to assess for any signs of constipation. Observation on 03/12/13 showed the following: -At 8:07 A.M., the activity director (AD) assisted the resident out of the bathroom. The AD said the resident had attempted to have a bowel movement, but was unable to expel anything. She said the feces was hard and difficult for the resident to expel. The AD assisted the resident into the wheelchair and propelled the resident to LPN P. The AD alerted LPN P of the resident's complaint of pain and difficult bowel movement elimination attempt. -At 8:20 A.M., the resident sat in his/her wheelchair next to LPN P. The resident sat with his/her head down wept and complained of rectal pain. -At 8:40 A.M., the resident continued to sit in the hall next to the LPN P. CNA Q approached the resident and the resident told the CNA that he/she did not feel well. The resident said that his/her bottom hurt. The resident told CNA Q that he/she was sore from trying to go to the bathroom. -At 8:45 A.M., LPN P and CNA Q assisted the resident to the bathroom. The CNA assisted the resident up to a standing position and LPN P assessed the resident's rectal area. The resident's skin was intact with no open areas. CNA Q assisted the resident onto the toilet. LPN P said the resident's pain related to the resident's need to expel his/her bowels. LPN P administered Milk of Magnesia to the resident (This was the fourth day the resident did not have a BM). -At 10:27 A.M., the resident sat in his/her room with head down. The resident would raise his/her head to speak and look around, but would then lower his/her head again. CNA Q said that the resident's bowel movements were regularly hard, "like rabbit pellets." -From 11:20 A.M. until 12:40 P.M., the resident remained in the bed. LPN P said he/she had refused to get up for lunch. -At 12:42 P.M., CNA Q attempted to get the resident up for lunch. The resident declined. CNA Q attempted to encourage the resident to get out of bed for a hair appointment that afternoon. The resident declined and said he/she did not feel well. -At 2:05 P.M., the resident sat up in the day room with family member. -At 3:00 P.M., the resident's family member who visited said the resident did not feel well and assisted the resident to bed. Record review of the MAR indicated [REDACTED]. Record review of the Nurses' Notes dated 03/12/13 at 10:31 A.M., showed the resident complained of rectal pain. The nurse reported, "extra large stool relieved rectal pain" . During interview on 03/14/13 at 4:50 P.M., LPN R said staff was to monitor bowel movements of their assigned residents at the end of each shift. LPN R said that the day shift was to administer Milk of magnesia if a resident has not had a bowel movement in three days, then give a [MEDICATION NAME] suppository if no results from Milk of magnesia, and then give a Fleet enema if no results from the [MEDICATION NAME] suppository. He/she said that staff would complete physician notification with no results were recorded from the in-house protocol. During interview on 03/15/13 at 10:05 A.M., LPN S said the Certified Nursing Assistants (CNAs) keep track of the resident's bowel movements. He/she said that some resident's needs required staff to administer laxatives more often than other residents are. LPN S said that he/se reviewed the bowel movement sheets daily when working. He/she said that if the resident is alert he/she ask them if they had a bowel movement, but if they are unable to communicate or remember that the protocol of Milk of magnesia, followed by a [MEDICATION NAME] suppository, followed by a Fleet enema is initiated. He/she said he/she had never notified a physician over a bowel movement. He/she said the staff just follow the protocol and get results. During interview on 03/15/13 at 2:10 P.M., the Director of Nursing (DON) said the nurses document the bowel movements. She said the nurses are to check the information the CNAs have reported. She said that the Assistant Director of Nursing (ADON) took over the daily monitoring two weeks ago. She said bowel movements are currently on her list to go over with the management nursing staff. The DON said that prior to the ADON taking over this care area it was performed according to a schedule. She said that a management nurse checked the documentation daily on day shift, and the Certified Medication Technicians (CMT) checked the documentation daily on evening shift, and the charge nurse checked the documentation daily on night shift. She said that the trigger for medication administration is three days or nine shifts without a bowel movement. She said her expectation is that staff follows the facility protocol of Milk of magnesia, [MEDICATION NAME], and Fleet enema.

Based on interview and record review the facility staff failed to obtain laboratory tests (UA with C&S- urinalysis with culture and sensitivity) per physician's orders [REDACTED].#27, and #28) out of a sample of 25 active residents plus one additional discharged resident. This failure to obtain ordered UA's with C&S in a timely manner led to the delay in treatment of [REDACTED]. The facility staff failed to obtain vital signs and temperature as ordered, failed to recognize and report a decline in the resident's condition, and failed to notify the physician of abnormal laboratory test results in a timely manner for Resident #26 which delayed treatment and resulted in the resident requiring admission to the hospital for the evaluation and treatment of [REDACTED]. The facility had a census of 106 residents. Review of Mosby's Diagnostic and Laboratory Test Reference, seventh edition, 2005, showed the following information: -A complete blood count (CBC) is a series of tests of the blood that provide information about the body's blood status and other organ systems. The CBC includes a white blood cell (WBC) count. An increased WBC count can be caused by infection, [MEDICAL CONDITION] ([MEDICAL CONDITION] of the blood), trauma, stress, tissue death, and/or inflammation; -A basic metabolic panel (BMP) is blood test that measures the body's sugar level (glucose), fluid and electrolyte (sodium (salt), potassium, and chloride) balance, calcium level, carbon [MEDICATION NAME] ([MEDICATION NAME]) level, and kidney function (blood urea nitrogen (BUN) and creatinine). Abnormal results can be due to a variety of different medical conditions, including kidney failure, breathing problems, and diabetes-related complications; -A urinalysis (UA) is a test of the urine that provides a significant amount of information about the urinary system. The components of a UA include the color, appearance, and odor of the urine, the pH, protein level, specific gravity, and glucose levels, and the presence or absence of white and/or red blood cells, white blood cell esterase, [MEDICATION NAME], and [MEDICATION NAME]. Abnormal UA results may be indicative of urinary tract disease or infection. 1. Record review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by the facility staff, dated 3/4/12, showed the following information: -The facility admitted the resident on 12/14/11; -Medical [DIAGNOSES REDACTED]. -Moderately impaired cognitive skills for daily decision-making; -Usually able to understand what others say and sometimes able to make self understood to others; -No [MEDICAL CONDITION] or behavioral issues; -Independent with bed mobility, transfers, walking in room and corridor; -Supervision required for walking on unit and off unit, and with toileting; -Supervision with setup required for dressing, personal hygiene, and eating; -Extensive assistance with bathing; -Continent of bladder and bowel. Record review of an un-timed faxed communication page dated 4/12/12, showed the following information: -Licensed practical nurse (LPN) R notified the resident's physician of the resident's complaint of dizziness, of the resident shaking, and of the resident's vital signs (blood pressure 130/70, pulse 72, respirations 16, and temperature 98.5 degrees Fahrenheit); -LPN R asked the physician if the facility could obtain labs and a UA on the resident; -The resident's physician responded with orders for the staff to obtain the resident's vital signs and temperature every six hours for 24 hours, staff to obtain a UA with C&S, and for the lab to obtain blood specimens for a CBC (complete blood count) and BMP (basic metabolic panel); -A date and time stamp at the top of the page which indicated the physician's office faxed his response to the facility on [DATE], at 2:20 P.M.; -A handwritten entry to the left middle section of the page that showed LPN S noted (acknowledged) the order six hours later on 4/12/12, at 8:54 P.M. Record review of a faxed communication page dated 4/13/12, time stamped 3:54 A.M., showed the following information: -LPN T notified the resident's physician the resident's temperature was up to 101.8 degrees Fahrenheit (F) and that staff administered Tylenol to the resident which decreased the resident's temperature to 99.5 F. LPN T also documented the application of cool wash cloths to the resident's forehead and underarms; -A hand written response from the physician for the staff to obtain a UA with C&S. Record review of the resident's April 2012, physician's orders [REDACTED]. -An order dated 4/12/12, that directed the staff to obtain a UA with C&S and have the specimen ready for the lab to pick up in the morning; -An order dated 4/12/12, for the lab to obtain blood for a CBC and BMP on 4/12/12, and for the staff to send the results of the tests to the resident's physician; -An order dated 4/13/12, for the staff to obtain a UA with C&S. Record review of the resident's nurses' notes from 4/12/12, at 8:55 P.M., through 4/19/12, at 2:19 P.M., showed the following information: - On 4/12/12, at 8:55 P.M., LPN S documented the following information: -New orders were received for the staff to obtain a UA with C&S that night and have the specimen ready for the lab to pick up in the A.M.; -Lab to draw (obtain blood for) CBC and BMP; -Staff to obtain the resident's vital signs every six hours for 24 hours; -In the next entry, dated 4/13/12, at 3:31 A.M., LPN T documented the resident's temperature was up to 101.8 degrees F and that staff administered Tylenol to the resident which decreased the resident's temperature to 99.5 F. LPN T also documented the application of cool wash cloths to the resident's forehead and underarms and that he/she notified the physician of the resident's increased temperature; -In the next entry, dated 4/13/12, at 5:17 P.M., registered nurse RN U documented he/she received an order for [REDACTED]. -In the next entry, dated 4/14/12, at 3:06 P.M., LPN V documented the resident's temperature at 98.0 F; -In the next entry, dated 4/15/12, at 1:27 A.M., LPN T documented the following information: -Resident's temperature 98.4 F; -The resident stayed in bed during the shift; -The resident was incontinent of bladder; -The resident became upset with the staff during bed checks that night; -In the last entry, dated 4/19/12, at 2:19 P.M. (four days after the resident's discharge on 4/15/12), LPN S documented notification of the resident's physician and family of the results of the resident's UA with C&S obtained on 4/16/12 (one day after the resident's discharge). Record review of a faxed communication page dated 4/15/12, at 11:30 A.M., (without the author of the communication written on the page) showed the following information: -The un-named staff member at the facility notified the resident's physician of the following: -The resident's elevated WBC count of 22.83 thousand; -The resident's elevated temperature of 99.2 axillary (usually one degree less than the actual oral temperature of the individual); -The resident was not eating, had a weak verbal response, and was not up walking around; -The staff obtained a STAT (immediate) UA with C&S that day by way of urinary catheterization; -The resident produced 60 cubic centimeters (cc) of bloody urine during the urinary catheterization; -The staff member asked the physician if he wanted the staff to send the resident to the hospital or order an antibiotic for the resident; -The staff did not document a response from the resident's physician on the page. Record review of a faxed communication page (author unknown), dated 4/15/12, at 1:30 P.M., showed the following information: -The unknown staff member notified the resident's physician that staff had notified the on-call physician of the resident's UA results with C&S to follow (when complete); -The on-call physician ordered [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) by mouth for one dose and then [MEDICATION NAME] 250 mg by mouth daily for nine days. Record review of the resident's electronic medical record (EMR) showed a discharge date of [DATE]. Record review of a nursing "Transfer Summary" dated 4/15/12, at 2:18 P.M., showed the nurse documented the following information: -The resident was usually alert and oriented to self, familiar faces, and surroundings; -The resident usually required cueing to perform activities of daily living (ADLs) and walked "ad lib" with a slow and steady gait; -The resident had a decline in condition, had been running a temperature, was not swallowing, and demonstrated poor oral intake; -The resident's family had requested the resident be sent to the emergency room (ER); -Staff notified the resident's physician and obtained an order to send the resident to the ER; -Staff had attempted to start the resident on an antibiotic but the resident was unable to swallow; -Staff notified the ambulance service and the hospital ER of the resident's transfer order. During an interview on 4/24/12, at 2:00 P.M., with the Director of Nurses (DON), the surveyor requested to review Resident #26's paper medical record including vital signs and temperature records, and lab results for 4/12/12 and 4/13/12. The DON said the staff did not obtain the UA with C&S ordered on Thursday, 4/12/12, because the staff thought the lab would not pick up the specimen over the weekend. Record review of the resident's CBC and BMP test results, provided by the DON on 4/25/12, at 3:05 P.M., showed the following information: -Lab personnel collected blood specimens from the resident on 4/13/12, at 9:20 A.M., for the performance of a CBC and a BMP; -The lab received the blood specimens on 4/13/12, at 4:04 P.M.; -The lab reported the test results to the facility on [DATE], at 11:30 P.M.; -Abnormal test results included: -WBC count: High at 22.83 thousand (normal range 4.00 to 12.00- indicative of infection, [MEDICAL CONDITION], trauma, stress, tissue death, and/or inflammation); -BUN, creatinine, sodium, and chloride levels all elevated (indicative of kidney disease, dehydration, and /or other medical conditions). Record review of the resident's UA report, provided by the DON on 4/25/12, at 3:05 P.M., showed the following information: - On 4/15/12, at 9:15 A.M. (three days after the physician ordered the test), the lab picked up a clean catch, midstream urine specimen the staff collected from the resident; -The lab received the urine specimen on 4/15/12, at 10:24 A.M.; -The lab reported the test results to the facility on [DATE], at 11:50 A.M.; -The lab performed expedited testing of the specimen; -Abnormal test results (indicative of urinary tract disease or infection) included: -Urine clarity: turbid (very cloudy); -Leukocyte (WBC) esterase: 3+ (normal is negative); -Blood: 2+ (normal is negative); -WBC: greater than 100 (normal is none to 0 - 2 seen per high power field (microscope). A comment entered by the lab underneath the WBC count entry said "Many clumps"; -Red blood cells: greater than 100 (normal is none to 0 - 2 seen per high power field); -Bacteria: 4+ (normal is negative). Record review of the resident's April 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -An order dated 1/1/12, for weekly vital signs (pulse, respirations, temperature, and blood pressure); -Entries of the resident's vital signs dated 4/5/12 and 4/12/12; -The staff failed to assess and document the resident's vital signs and temperature every six hours as ordered by the physician on 4/12/12. Record review of the resident's April 2012, "ADL Flow Sheets" showed the following information: -Staff documented the resident's daily fluid intake with meals from 4/1/12 through 4/9/12, averaged 1300 cc per day; -Staff documented the resident's daily fluid intake with meals from 4/10/12 through 4/15/12, as follows: -4/10/12: 720 cc; -4/11/12: 600 cc; -4/12/12: 720 cc; -4/13/12: no fluid intake; -4/14/12: 240 cc; -4/15/12: 240 cc; -Staff documented the resident's food intake from meals from 4/1/12 through 4/9/12, averaged 80 percent; -Staff documented the resident's daily food intake from meals from 4/10/12 through 4/15/12, as follows: -4/10/12: 25 percent; -4/11/12: 50 percent; -4/12/12: unable to determine due to illegible entries for A.M. and noon meals; -4/13/12: no food intake; -4/14/12: no food intake; -4/15/12: no food intake. Record review of the facility's policy entitled, "Change in Medical Condition of Residents", revised 11/1/01, showed the following information: -Notification of the physician, legal representative or interested family member should occur promptly ...when there is a change in the resident's condition; -Examples of changes in condition listed in the policy included the following: -Temperature elevation or fall; -Onset of confusion; new memory loss; -Overall deterioration of condition; -Decline in ADL skills; -Sudden incontinence (without history of incontinence); -Loss of appetite/unplanned weight loss/gain; -Changes in laboratory values; -Fluid intake less than 500 cc in 24 hours; -Contact the physician and family member/legal representative as follows: -In the event of death or an emergency, call at the time the event occurs whatever time of day or night; -In a non-emergency, call during normal office and daylight hours. If a non-emergency situation occurs after 5:00 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. Record review of a hospital history and physical report, dated 4/15/12, at 5:30 P.M., showed the hospital admitting physician documented the following information regarding Resident #26: -The resident's presenting complaint was confusion; -The resident's past medical history included probable stroke, dementia, high cholesterol, and high blood pressure; -The resident was somnolent (sleepy), would open his/her eyes and follow other commands minimally, but was unable to talk; -The resident exhibited decreased skin turgor; -Lab results included: -High sodium level of 165 mEq/L (normal: 136 - 145 mEq/L); -High chloride level of 128 mEq/L (normal: 98 - 106 mEq/L); -High BUN level of 62 mg/dl (normal: 10 - 20 mg/dl); -High serum osmolality 346 mmol/kg (normal: 285 - 295 mmol/kg); -Dark yellow urine with 2+ protein, trace [MEDICATION NAME], 2+ leukocyte esterase, 30 - 60 WBC's; 3+ bacteria; -Impression included: critical [MEDICAL CONDITION] (high sodium), urinary tract infection, acute (recent onset) metabolic [MEDICAL CONDITION] (brain and nervous system abnormalities caused by alterations in electrolytes and acid-base balance, and the accumulation of endogenous (made by body) toxins), acute renal (kidney) failure secondary to pre-renal azotemia (high nitrogen level in the blood due to reduced blood filtering of the kidneys), hypertensive (high blood pressure) urgency secondary to missed medications; -Plan included: resident admitted to the intensive care unit (ICU) due to the danger of his/her high sodium level and risk for [MEDICAL CONDITION] and fluid shifts in the brain, intravenous (IV- in the vein) antibiotic administration for treatment of [REDACTED]. Record review of a critical care physician's note, dated 4/17/12, at 5:41 A.M., showed the physician documented the following information: -The hospital admitted the resident with complaints of decreased oral intake and decreased level of consciousness; -The resident was found to have a urinary tract infection; -The resident was dehydrated with a severely high sodium level; -The resident experienced a [MEDICAL CONDITION] that morning, demonstrated increased difficulty with breathing, and required the insertion of a breathing tube and mechanical ventilation; -Assessment and plan included the following Diagnoses: [REDACTED]. -Sepsis with likely source being a urinary tract infection; -High sodium level; -Altered mental status with [MEDICAL CONDITION]. During an interview on 4/25/12, at 9:45 A.M., certified nurse aide (CNA) J said he/she provided care to Resident #26 on Thursday (4/12/12). CNA J said the resident was not feeling well. CNA J assisted the resident out of bed and with A.M. care. The resident was unable to feed him/herself well and required coaching to eat. CNA J said the resident lay in bed after the meal and was weak. CNA J said the next day (Friday, 4/13/12) the resident stayed in bed all day, was weak, and felt warm and clammy. CNA J said he/she turned and repositioned the resident and provided incontinent care every two hours. The resident was usually continent of bladder and bowel with rare episodes of incontinence if the staff did not toilet him/her in time. CNA J said he/she reported the resident's condition to LPN R on Thursday (4/12/12) and to LPN V on Friday (4/13/12). During an interview on 4/25/12, at 9:50 A.M., CNA F said two or three days before staff transferred Resident #26 to the ER, the resident went from walking to not walking and remained in bed more. CNA F said the resident's urine was darker in appearance. CNA F said the resident voiced no specific complaints but did not want to get out of bed. CNA F said he/she reported the resident's condition to LPN R or LPN V. During an interview on 4/24/12, at 2:10 P.M., LPN S (desk nurse) said he/she recalled the floor nurse told him/her on 4/12/12, that Resident #26 exhibited increased confusion, had an odor to his/her urine, and the resident's oral intake had decreased. LPN S thought he/she alerted the resident's physician by phone. LPN S said the physician ordered lab work for Friday 4/12/12 (4/12/12 was Thursday). LPN S said he/she had understood the lab did not pick up UA's on Saturday or Sunday. LPN S did not enter the UA order for staff to obtain the urine specimen until Sunday (4/15/12) P.M,. so the lab would pick up the fresh specimen on Monday (4/16/12) morning. LPN S just found out from lab personnel the lab did pick up UA specimens on the weekends. LPN S said he/she made a mistake when he/she entered the 4/12/12, order that directed the staff to obtain the resident's vital signs and temperature every six hours for 24 hours. Staff did obtain the resident's vital signs and temperature, but since they were unable to document the results in the EMR (because of the order entry error), staff wrote the results on pieces of paper. Staff showed the results to the resident's nurse, and then if not abnormal, the pieces of paper were tossed in the trash. During an interview on 4/24/12, at 2:25 P.M., RN U said the night shift staff obtained UA specimens. The UA specimens are then sent to the lab the next morning. RN U said staff should have obtained the urine specimen, and sent it to the lab the next day after receipt of the order. RN U said if the UA showed the resident had a bad infection, the physician may start an antibiotic before the C&S report is received. During an interview on 4/25/12, at 10:45 A.M., LPN T said on Friday 4/13/12, he/she notified the resident's physician of the resident's temperature of 101.8 F. LPN T said the physician responded with a directive to the staff to monitor the resident. LPN T said, over the weekend, the resident's temperature remained normal and the resident was more alert than he/she had been on 4/13/12. LPN T said the resident did not complain of pain but became upset with the staff for checking him/her so often for incontinence. LPN T said the resident's incontinence was not unusual for the resident. The resident did his/her normal humming and singing to him/herself during the night hours and took fluids every two hours. At times the resident would drink well, and at other times would not drink well. The staff obtained the resident's temperature once per shift since the resident was afebrile (without fever) but did not obtain the resident's other vital signs (blood pressure, pulse, and respirations). LPN T said at change of shift on 4/13/12, the out-going staff told him/her to obtain a urine specimen from Resident #26 and another resident on another hall. LPN T asked LPN S if the physician had ordered the UA, "STAT" (immediately). LPN T said LPN S told him/her the order was not STAT and the staff could obtain the urine specimen on evening of Sunday 4/15/12. LPN T said he/she did not see the resident's BMP and CBC lab results (reported to the facility by the lab on 4/13/12, at 11:30 P.M.). LPN T said lab results usually come in on the evening shift unless the lab work was ordered STAT. LPN T said he/she would have called the physician if the resident's temperature had not come down. During an interview on 4/25/12, at 12:00 P.M., LPN X said on the evening of 4/13/12, the resident was up for the P.M. meal. LPN X received in change-of-shift report information that the resident had a mild temperature that was controlled with Tylenol, would not eat well, and was on the laxative list. LPN X provided 120 cc of Med Pass (a liquid nutritional supplement) mixed with Milk of Magnesia to Resident #26 with his/her P.M. medications. The resident drank approximately 75 percent of the solution. Staff assisted the resident to bed after the P.M. meal and the resident remained able to answer yes or no to simple questions. The resident complained of pain but was unable to say where he/she hurt. LPN X said she administered Tylenol to the resident for pain relief. Toward the end of the evening on 4/13/12, LPN X received an order for [REDACTED]. LPN X noted that lab had obtained blood specimens from the resident on the morning of 4/13/12. The resident's family had called the facility and wanted to know the results of the resident's lab tests. LPN X told the family member he/she did not have the lab results at that point. LPN X called and asked the lab to fax the results of the resident's 4/13/12, A.M. lab results. LPN X passed information on to LPN T in change-of-shift report that a urine specimen was needed from the resident and for LPN T to follow up on the resident's lab results. LPN X said he/she recently learned that a UA, but not the C&S portion, can be ordered STAT with lab results returned STAT. During an interview on 4/25/12, at 12:10 P.M., LPN Z said he/she never had any difficulty with Resident #26. The resident normally slept through the night or would sing to him/herself. LPN Z did not obtain a urine specimen from the resident during his/her shift on 4/14/12. LPN Z was certain he/she did not receive that information in change-of-shift report because if he/she had, he/she would have obtained the specimen. LPN Z was unable to recall from whom he/she received change-of-shift report on 4/14/12. During an interview on 4/25/12, at 3:07 P.M., LPN R said he/she faxed the physician on afternoon of 4/12/12, and reported the resident complained of being dizzy and was shaking. LPN R asked the physician for lab orders. LPN R said when he/she worked again on Sunday 4/15/12, LPN T reported the facility had received the resident's 4/13/12, lab work and were waiting for the urine specimen to be obtained Sunday (4/15/12) evening. LPN R said LPN T told him/her the UA with C&S order was not STAT. LPN R spoke with the resident's family member on the phone on 4/15/12. The family member asked about the resident's lab results. LPN R did not find the lab results in the resident's chart but was able to find the results on the lab computer. LPN R informed the resident's family member of the results and asked what their wishes were because the resident was in bed all day, weak, and demonstrated difficulty swallowing. LPN R said the family member wanted the facility to send the resident to the ER. LPN R said he/she told the weekend supervisor (RN AA) about the resident's WBC count. RN AA told him/her the resident was septic and needed to be transferred to the ER. LPN R said RN AA took over from that point. RN AA contacted the physician and obtained an order for [REDACTED]. and inform them the facility was transferring the resident to the ER. During an interview on 4/25/12, at 11:45 A.M., LPN Y said one day during the week of 4/8/12 through 4/15/12, a staff member told him/her in change-of-shift report the resident had a fever but the fever had come down. On Thursday 4/12/12, the resident ate his/her P.M. meal in the main dining room. LPN Y thought the resident was getting better. LPN Y said he/she next worked at the facility on Sunday 4/15/12. The weekend supervisor (RN AA) met him/her at the door with the resident's 4/13/12, lab results in his/her hands and instructed him to administer [MEDICATION NAME] (an antibiotic) to the resident because the resident "was septic". LPN Y said he/she retrieved the medication from the facility's emergency kit. LPN Y crushed and tried to administer the medication to the resident; however, the resident spit out the medication. LPN Y said the resident's family was present and said they had tried all day to get the nurse on duty to send the resident to the ER. During an interview on 4/25/12, at 10:15 A.M., a representative from the lab under contract with the facility said the lab picks up urine specimens for routine UA's seven days per week with the exception of Thanksgiving Day and Christmas Day. The lab representative said the lab will pick up STAT UA urine specimens on Thanksgiving Day and Christmas Day. The lab representative said the lab processed UA's within 24 hours but the C&S report process took 48 to 72 hours because of the time it took for the culture to grow bacteria. During an interview on 4/25/12, at 2:05 P.M., the resident's physician said he was unaware facility staff had not obtained the UA with C&S ordered on [DATE], until 4/15/12. The physician said he expected the facility staff to carry out lab orders and obtain specimens when ordered. The physician was unaware the facility staff failed to obtain the resident's vital signs and temperature every six hours for 24 hours as ordered on [DATE]. The physician expected the facility staff to carry out orders, as ordered. The physician said the facility staff did not notify him over the weekend (4/14//12 to 4/15/12) of any changes in the resident's condition; however, the facility staff may have called the physician on-call. The physician expected the facility staff to report abnormal lab results to him/her as soon as the results are received. If the resident was symptomatic of a urinary tract infection, he would have ordered an antibiotic for the resident after he received notification of abnormal UA results. During interviews on 4/24/12, at 2:00 P.M. and on 4/25/12, at 1:50 P.M., the DON said she was unaware Resident #26 was ill until the weekend supervisor (RN AA) called her on Sunday (4/15/12) to report the resident's abnormal lab results and notify her of the resident's transfer to the ER. The DON said she was unsure if staff notified the resident's physician that they did not obtain a urine specimen from the resident as ordered on [DATE]. The DON said when LPN S entered the 4/12/12, orders for lab work (CBC, BMP, and the UA with C&S) he/she entered the data under the incorrect category in the computer system. This error prevented the order for the UA with C&S from being added to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The staff failed to obtain the resident's vital signs and temperature, every six hours for 24 hours, as ordered because LPN S incorrectly entered the order for every Saturday rather than for daily. The DON said this error prevented the vital sign and temperature order from being added to the MAR indicated [REDACTED]. The DON said the desk nurse (LPN S) does not obtain a change-of-shift report. The desk nurse stayed at the desk and entered orders as received. The DON said LPN S verbally communicated to the nursing staff the need to obtain a urine specimen from the resident for the UA with C&S order. The DON said LPN S incorrectly informed the nursing staff that since the lab would not pick up the urine specimen until Monday morning they did not need to obtain the urine specimen until Sunday evening. The DON said she re-educated LPN S on 4/24/12, regarding the correct procedures for lab order entry, how to correctly enter specially-ordered sets of vital signs, and of the lab's ability to pick up specimens seven day per week. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit the facility: -Assured the medical assessment of Residents #27, #28, and #29 by a licensed nurse; -Audited 30 days of lab orders and physician orders [REDACTED]. -Contacted the laboratory service for a process review to ensure the lab notified the facility staff of critical lab values; -Implemented a new form designed to track lab orders, the return of lab results, and appropriate physician notification of lab results; -Initiated daily, ongoing monitoring by the Director of Nurses and/or designee of all lab orders and results, and of physician and family notification of lab results; -Initiated in-service training of the licensed nursing staff prior to the start of their shifts regarding resident change of condition, timely notification of the physician and family of abnormal lab results, following physician's orders [REDACTED]. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "G" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 218 2. Record review of Resident #27's quarterly MDS, dated [DATE], showed the following information: -Medical [DIAGNOSES REDACTED]. -Independent with cognitive skills for daily decision-making; -Required extensive assistance with all ADLs except for eating; -Frequently incontinent of bladder. Record review of the resident's April 2012, nurses' notes showed the following information: -An entry dated 4/6/12, at 6:29 P.M., in which RN BB documented receipt of a new physician's orders [REDACTED]. -An entry dated 4/9/12, at 5:15 A.M., in which LPN Z documented he/she obtained a cloudy, yellow urine specimen from Resident #27 via intermittent urinary catheterization. Record review of the resident's April 2012, MAR indicated [REDACTED] -An order, dated 4/6/12, that directed the staff to obtain a urine specimen for a UA via intermittent catheterization; -Initials in a box under the date of 4/9/12, that indicated LPN Z completed the procedure (three days after receipt of the order). Record review of the resident's lab results, dated 4/10/12, showed the following information: -On 4/10/12, at 3:10 A.M., the lab picked up a urine specimen the staff had collected from the resident; -The lab received the urine specimen on 4/10/12, at 4/12 P.M.; -The lab reported the results of the UA to the facility on [DATE]; -The lab reported the results of the C&S to the facility on 4