Every finding on record at Big Spring Care Center for Rehab and Healthcare

Based on interview and record review, the facility failed to document notification of the responsible party or emergency contact of the resident's change in health condition, transfer to the hospital, and/or death of three residents (Resident #1, #2, and #3). The facility had a census of 42.Review of the facility provided policy, Notification of Changes, dated [DATE], showed the following:-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification;-Circumstances requiring notification include accidents resulting in injury or potential to require physician intervention; significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, or mental or psychosocial status; -Circumstances that require a need to alter treatment may include new treatment or discontinuation of current treatment; a transfer or discharge of the resident from the facility; or a change in resident rights;-For competent individuals, the facility must still contact the resident's physician and notify resident's representative. A family that wishes to be informed would designate a member to receive calls. When a resident is mentally competent, such a designated family member should be notified of significant changes in resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident;-For resident incapable of making decisions, the representative would make any decisions that have to be made; the resident should still be told what is happening to him or her; and staff to contact information of the resident's legal representative or family member must be recorded and periodically updated. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of [DATE];-Transferred to the hospital on [DATE];-An emergency contact listed with name and phone number;-Diagnoses included nontraumatic intracerebral hemorrhage (sudden, spontaneous bleed inside the brain tissue that is not caused by an injury or a head accident), atherosclerotic heart disease (condition where fatty plaque builds up inside the heart's arteries, leading to narrowed blood vessels, reduced blood flow, and serious risks like heart attacks), hypertension (high blood pressure), shortness of breath. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, updated [DATE], showed the resident's designated contact is a family member. Review of the resident's nursing progress notes showed staff the following:-On [DATE], at 7:10 P.M., the nurse was notified by staff that the resident was not his/her usual self. The nurse spoke with resident who reported: I am very confused, I don't know what time of day it is. Vitals taken blood pressure (BP) 92/59 millimeters of Mercury (mm/Hg) (normal 120/80 mm/Hg), pulse 81 beat per minute (bpm) (normal 60 to 100 bpm), temperature 97.9 degrees Fahrenheit (F) (normal 98.6 F), respirations 20 per minute (normal 12 to 20), and blood oxygen level of 83% on room air (normal above 90%). The resident denied shortness of breath or any new or increased pain. A call was placed to the physician who requested the resident be placed on 2 liters (L) oxygen (O2) via nasal cannula (NC - lightweight, flexible medical device used to deliver supplemental oxygen directly into your nostrils) and monitor. Staff should call the physician if there was a change. The resident was started on oxygen;-On [DATE], at 6:30 A.M., the Director of Nursing (DON) entered the resident's room and believed the resident to be sleeping. The DON called out the resident's name and he/she did not wake. This was not unusual. The DON tested the resident's blood sugar with the stick, and the resident did not wake. The DON continued to call the resident's name and sternum rub (involves making a closed fist and grinding the knuckles vigorously against the center of the person's chest to elicit a pain response) was performed with no response. The resident's pulse was checked with none felt. The DON called 911 and requested help from housekeeping to move the resident to the floor. Once on the floor, the resident began agonal breathing (abnormal, reflexive pattern of gasping and labored breathing that occurs when the brain is deprived of oxygen), and cardiopulmonary resuscitation (CPR - life-saving emergency procedure used when someone's breathing or heartbeat has stopped, combining chest compressions and rescue breaths to keep blood flowing to vital organs) was initiated. Housekeeping called for more help. Once additional staff arrived, the DON switched out with another staff member. The DON became the timekeeper, suctioning, and airway while keeping count of compressions and quality and had other staff rotate out for compressions. After seven rounds of compressions, emergency medical services (EMS) arrived. An airway was placed following placement of automatic external defibrillator (AED - portable medical device used to check the heart rhythm and give an electric shock if needed to restart a normal heartbeat) pads and another round of chest compressions and a pulse was found. The resident was moved to a gurney by EMS and staff and left the building at 7:15 A.M.;-On [DATE], at 12:21 P.M., a late entry, staff spoke with resident's family member. The family member had been informed by the hospital of the resident's condition.(Staff did not document notification of the resident's emergency contact or family of the resident's change of health condition or transfer to the hospital.) During an interview on [DATE], at 2:00 P.M., the Director of Nursing (DON) said the following:-The resident coded (a sudden, life-threatening crisis, meaning their heart or breathing has stopped and they need immediate resuscitation) while she was on shift;-The DON followed the ambulance to the emergency room (ER);-The DON did not call the family. The family called the facility after they were notified by the hospital. 2. Review of Resident #2's face sheet showed the following: -admission date of [DATE];-An emergency contact listed with name and phone number;-Diagnoses included Type 1 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) with hyperglycemia (high blood sugar levels), stage 4 pressure ulcer (severe injury featuring full-thickness skin and tissue loss with directly exposed bone, muscle, tendon, or cartilage) of sacral region (area at the base of the spine, just below lower back and above the tailbone), nontraumatic intracranial hemorrhage. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, updated [DATE], showed the resident's designated contact was a family member. Review of the resident's nursing progress notes showed staff documented the following: -On [DATE], at 9:22 A.M., the resident was uncooperative with care today. He/She was asking to just die. He/She refused morphine (used to relieve severe pain) unless nurse was going to give him/her enough to kill him/her. He/She was asking to go home. The resident refused treatments and medications on this shift;-On [DATE], at 4:51 P.M., the resident continued to refuse cares and treatments, and has also been refusing scheduled morphine;-On [DATE], at 4:47 P.M., resident passed away at 4:30 P.M. Hospice was contacted and confirmed death at 4:45 P.M. Hospice helped with paperwork and clean up.(Staff did not document of family or emergency contact notification of the health change and death.) During an interview on [DATE], at 2:00 P.M., the DON said the resident's emergency contact should have been notified of their death and the information should have been documented. 3. Review of Resident #3's face sheet showed the following: -admission date of [DATE];-Two emergency contacts listed with name and phone number;-Diagnoses included local infection of the skin and subcutaneous tissue (deepest layer of the skin), necrotizing fasciitis (rare but severe bacterial infection that destroys the tissue beneath the skin, including fat and the fascia (the connective tissue covering muscles)), cellulitis bilateral lower limb (common, potentially serious bacterial skin infection causing redness, swelling, and pain). Review of the resident's comprehensive MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, updated [DATE], showed the following:-Staff should encourage resident and family to express, verbalize desires or wishes, regarding personal decisions for care and/or treatment;-Notify physician and responsible party of any changes in condition. Review of the resident's nursing progress note, dated [DATE], showed staff the following:-At 7:56 A.M., the resident's wounds were assessed;-The physician was contacted due to the resident's wounds declining, as the wounds were producing thick yellow/ green drainage;-The physician ordered the resident be sent to the hospital for further evaluation with the start of antibiotics possibly through peripherally inserted central catheter line (PICC - long, thin, flexible tube put into a vein in the arm to deliver long-term medicines);-Resident notified of physician order.(Staff did not document family or emergency contact notification of change of health or transfer to the hospital.) During an interview on [DATE], at 2:00 P.M., the DON said the resident's emergency contact should have been notified of transfer to the hospital and the information should have been documented. 4. During an interview on [DATE], at 11:30 A.M., Licensed Practical Nurse (LPN) A said the following:-If a resident has a change of condition, is transferred to the hospital, or passes away at the facility, he/she would notify the resident's responsible party;-If the resident was their own self responsible party, he/she would not necessarily notify the family; -The nurse should document any notification to residents or their family. During an interview on [DATE], at 1:45 P.M., the SSD said the following:-The nurse on duty should contact the resident's family or emergency contact of changes in health condition, transfer to the hospital, and/or death at the facility;-If the resident is their own self-responsible party, sometimes the resident does not want their family to be contacted unless they go to the hospital;-All information involving contacting the family or not contacting the family should be documented. During an interview on [DATE], at 2:00 P.M., the DON said the following:-The nursing staff should notify the on-call manager if a resident has a change in health condition;-The nurse should contact the resident's family or emergency contact of changes in health condition, transfers to the hospital, or death at the facility;-If a resident is their own self-responsible party, sometimes they do not want their family contacted unless they are sent to the hospital;-All information regarding family contacts or not contacting the family, should be documented. During an interview on [DATE], at 3:15 P.M., the Administrator said the following:-Nursing staff should notify a resident's family or emergency contact for all changes of health, transfers to the hospital, or death;-Notifications should be documented in the resident's chart;-If the resident is their own person and does not want family notified that information should be documented. Complaint #3053715

Based on interview and record review, the facility failed to ensure to have process in place to ensure resident's received cardiopulmonary resuscitation (CPR - life-saving emergency procedure used when someone's breathing or heartbeat has stopped, combining chest compressions and rescue breaths to keep blood flowing to vital organs) per standard of practice when two of the four staff who performed CPR were not certified in CPR (official credential proving that you have completed a formal training course and know how to perform CPR, use an AED (automated external defibrillator), and manage choking or breathing emergencies), for one resident (Resident #1) prior to Emergency Medical Services arrival. The facility had a census of 42.Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), dated [DATE], showed the following:-If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the resident's advance directives;-CPR certified staff will be available at all times;-CPR certified staff will maintain current CPR certification for healthcare provides through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following:-admission date of [DATE];-Full code status (wished to receive CPR if heart beats or breathing stopped);-Diagnoses included nontraumatic intracerebral hemorrhage (sudden, spontaneous bleed inside the brain tissue that is not caused by an injury or a head accident), atherosclerotic heart disease (condition where fatty plaque builds up inside the heart's arteries, leading to narrowed blood vessels, reduced blood flow, and serious risks like heart attacks), hypertension (high blood pressure), and shortness of breath. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, updated [DATE], showed the following:-Full code status;-Staff should communicate code status to all care team members;-Staff should maintain readiness for emergency response. Review of the resident's nursing progress notes, dated [DATE], showed the following:-At 6:30 A.M., the Director of Nursing (DON) entered the room and the resident appeared to be sleeping;-The DON said the resident's name and he/she did not wake; -The DON checked the resident's blood sugar and he/she still did not wake;-The DON continued to say the resident's name and perform a sternum rub (involves making a closed fist and grinding the knuckles vigorously against the center of the person's chest to elicit a pain response) with no response;-The DON checked the resident's pulse, and no pulse was felt;-The DON called 911 and requested help from housekeeping to move the resident to the floor;-Once the resident was moved to the floor, he/she began agonal breathing (abnormal, reflexive pattern of gasping and labored breathing that occurs when the brain is deprived of oxygen);-The DON initiated CPR;-Housekeeping staff obtained additional staff assistance;-Another staff took over CPR;-After 7 rounds of compressions, emergency medical services (EMS) arrived;-An airway was placed following placement of automatic external defibrillator (AED - portable medical device used to check the heart rhythm and give an electric shock if needed to restart a normal heartbeat) pads and another round of chest compressions and a pulse was found;-The resident was moved to a gurney by EMS and staff and left the building at 7:15 A.M. Review of the facility's CPR certificates showed the following:-CPR certification for the DON, dated [DATE], with expiration [DATE];-CPR certification for transportation staff, dated [DATE], with expiration [DATE];-No CPR certificate provided or located for Certified Nursing Assistant (CNA) E or CNA F who provided CPR to the resident. During an interview on [DATE], at 12:10 P.M., Certified Medication Technician (CMT) B said his/her CPR certificate had lapsed and was not certified at this time. He/She would not feel comfortable providing CPR without attending recertification classes. During an interview on [DATE], at 1:30 P.M., CNA C said he/she was not currently CPR certified. He/She would feel uncomfortable performing CPR, but would perform CPR if there was no one else CPR certified. During an interview on [DATE], at 2:45 P.M., CNA F said the following: -He/She was not CPR certified;-He/She told the DON that he/she was not CPR certified prior to assisting with chest compressions on the resident;-He/She was not comfortable with the CPR process but felt he/she had no choice as he/she had to follow the DON's orders. During an interview on [DATE], at 3:30 P.M., CNA E said the following:-He/She was not CPR certified;-He/She told the DON on [DATE] that he/she was not CPR certified;-He/She was told he/she had to assist with CPR on the resident;-He/she was uncomfortable assisting with chest compressions since he/she had not been trained. During an interview on [DATE], at 2:05 P.M., the DON said the following:-The staff who assisted her with performing CPR were transportation, CNA E, and CNA F;-She initiated CPR and once additional staff arrived, she maintained the resident's airway, compression count, and monitored staff providing CPR;-She was unaware that all staff were required to be CPR certified in order to provide CPR. During an interview on [DATE], at 3:15 P.M., Administrator said that he was not aware that all staff performing CPR had to be certified.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and in manner that protects if from possible contamination when multiple staff failed to wear hair nets and facial hair nets while in the kitchen during meal preparation and meal service. The facility census was 37.Review of the facility policy, dated 06/30/25, titled Dietary Employee Personal Hygiene, showed the following:-All dietary staff must wear hair restraints to prevent hair from contacting food;-Hair restraints include hair net, hat, and/or beard restraint.Review of the most recent revision, dated 01/18/23, of the United States Food and Drug Administration (FDA) Food Code 2022, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.1. Observation 03/04/26, at 10:45 A.M., showed [NAME] A in kitchen preparing food for lunch, with hair net on and no facial net to cover facial hair of greater than 1/2 inch in length. Observation 03/04/26, at 12:00 P.M., during lunch meal serve out, showed the following:-Certified Nurse Aide (CNA) G applied a hair net to his/her head but did not apply a facial hair net with facial hair greater than 1/2 inch in length. The aide entered the kitchen to obtain milk and washed hands at sink behind the serve out line;-Nurse Aide (NA) E washed hands at sink behind the serve out line multiple times and opened kitchen entry to request additional items multiple times. The NA did not have a hair net over his/her head or facial hair net on face, with facial hair of greater than 1/2 inch in length;-Dietary Aide (DA) C in the kitchen preparing items and at the serving line and preparing resident meal plates for the lunch serve out meal. He/she had a ball cap covering his/her head, with no facial hair net on, with facial hair of greater than 1/2 inch in length;-Cook B in the kitchen with ball cap covering his/her head, with no facial hair net on face, with facial hair of greater than 1/2 inch in length, preparing food in the kitchen and cooking food at the grill and bringing grilled items out to the serving line;-Cook A in the kitchen preparing food and working with food, with hair net on his/her head and no facial hair net covering face, with facial hair of greater than 1/2 inch in length.During an interview on 03/04/26, at 1:00 P.M., the Dietary Manager (DM) said that all staff that pass the line on the floor where the tile changes color at the serve out counter, and when entering into the serving area and kitchen area, should be wearing hair nets at all times, but especially when food is being prepared. Staff should not enter the kitchen or serve out area with food in active service without a hair net on. He/she said the staff should wear facial hair nets if they have facial hair. Currently, the supply vendor did not have beard nets available. He/she was unable to get beard nets at this time.During an interview on 03/04/26, at 1:20 P.M., NA E said he/she was initially hired as a dietary aide and was transitioning to nursing staff. When starting a work day in the kitchen he/she would put on a hair net and wash his/her hands. He/she should have put on a hair net when going behind the serving line today.During an interview on 03/04/26, at 1:30 P.M., CNA F said that staff should wear hair nets when pass they kitchen door and should be worn at all times in the kitchen. Technically staff with facial hair should have on a facial hair net. During an interview and observation on 03/04/26, at 1:45 P.M., [NAME] B wore a ball cap on his/her head, with no facial hair net on face, and had facial hair of greater than 1/2 inch in the kitchen preparing for the evening meal. He/she said should be wearing a facial hair net, but the facility did not have any available.During an interview and observation on 03/04/26, at 1:55 P.M., [NAME] A was in the kitchen cleaning up after the lunch meal, with a hair net cover head but no facial hair net with facial hair of greater than 1/2 inch. He/she said that staff should always wear a hair net when in the kitchen and at the serving line. He/she said there were no facial hair nets available but they had been in use in the past.During an interview on 03/04/26, at 2:20 P.M., the Director of Nursing (DON) said that any staff that walk past the front counter, including the sink, should have hair nets and facial hair nets if needed. He/she was used to working in the kitchen and thought about putting on a hair net but then got sidetracked with resident assistance and then went behind the serve out line to wash hands and get additional items from kitchen staff.During an interview on 03/04/26, at 3:05 P.M., the Administrator said staff should wear hair nets any time they are doing meal preparation in the kitchen and at the serve out line. The staff should wear a facial hair net if the facial hair was over a certain length,1/4 to1/2 inch or greater. Complaint #2791188

Based on interview and record review, the facility failed to ensure each resident's family/responsible party was notified of changes in condition when staff did not document that the responsible party or emergency contact notifications for residents' change in health condition and/or new physician orders for three residents (Resident #1, #2, and #3). The facility had a census of 35. Review of the facility titled Medication Orders, dated May 2025, showed staff to notify the resident's sponsor or family of new medication order. Review showed staff did not provide a policy related notifications of resident change in condition to responsible party or family members. 1. Review of Resident #1's face sheet showed the following: -admission date of 04/04/25;-Two emergency contacts listed with name and phone number;-Diagnoses included encephalopathy (disease that affects the function or structure of your brain), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), cognitive communication deficit, and bipolar disorder (mental health condition characterized by significant shifts in mood, energy, and activity levels, ranging from extreme highs to lows). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 10/01/25, showed the following:-Moderate cognitive impairment;-Partial to moderate assistance required for toileting hygiene, dressing, personal hygiene;-Substantial to maximal assistance required for showering. Review of the resident's care plan, updated 07/23/25, showed the following:-Staff should be in contact with the resident and family at least quarterly and offer to review the plan of care;-Staff should notify the physician and family of significant weight changes. Review of the resident's nursing progress note dated 08/14/25, at 4:34 P.M., showed the resident had an event of being short of breath and unsuccessfully attempting to resolve episode with use of bilevel positive airway pressure (BIPAP - non-invasive therapy that uses a machine to deliver pressurized air through a mask or nasal plugs, making it easier to breathe) machine, the resident asked about difference of hospice and palliative care. Staff provided education. The resident at this time requested to have a palliative care consult. (Staff did not document responsible party notification).Review of the resident's October 2025 Physician Order Sheet (POS) showed an order, dated 10/10/25, for levofloxacin (antibiotic used to treat a variety of bacterial infections by killing the bacteria or preventing their growth) oral tablet 500 milligrams (mg), give one tablet by mouth one time a day for bacterial infection for four days.Review of the resident's nursing progress note dated 10/10/25, at 12:23 A.M., showed the resident returned from hospital on antibiotic therapy with no signs or symptoms of adverse reactions. Resident had no signs, symptoms, or complaints of pain or discomfort. Call light within reaction. Staff will continue to monitor. (Staff did not document responsible party notification.)Review of the resident's October 2025 POS showed the following:-An order, dated 10/11/25, for insulin lispro (rapid-acting insulin) injection, inject 4 units subcutaneously (below the skin) one time only related to type 2 diabetes mellitus;-An order, dated 10/13/25, insulin lispro injection, inject 4 units subcutaneously one time;-An order, dated 10/14/25, insulin lispro injection, inject 4 units subcutaneously one time only for blood sugar 411 mg/deciliter (dL). Review of the resident's nursing progress note dated 10/14/25, at 8:47 P.M., showed the resident had a blood sugar was 411 mg/dL. Staff received new orders from on call physician for a one-time order of four units of insulin lispro and recheck blood sugar level in two hours. Staff to call physician back if blood sugar level was over 400 mg/dL. Staff will continue to monitor. Review of the resident's medical record, dated 10/11/25 to 10/24/25, showed staff did not document responsible party notification of the blood sugar levels and insulin orders. Review of the resident's October 2025 POS showed an order, dated 10/25/25, for levofloxacin oral tablet 500 mg, give one tablet by mouth one time a day for COPD for 4 days.Review of the resident's medical records showed staff did not document responsible party notification of the new order.Review of the resident's nursing progress note dated 10/29/25, at 8:23 A.M., showed the resident called this staff in his/her room. The resident let this nurse know he/she was hearing children. This nurse then asked resident if he/she would like to go to the hospital. Resident then stated no and I think I need to be on hospice. This nurse asked resident if he/she felt okay enough right now. Resident stated, Yes I just need to talk to someone about hospice today. I need to be able to sleep and get on meds. The resident then asked this nurse to call his/her family member. This nurse let resident know he/she would talk to social services and the Director of Nursing (DON) first. Resident stated, I don't care what he/she says I need to be on hospice. This nurse then reassured the resident that he/she would talk to the DON and get it worked out. (Staff did not document responsible party notification.) 2. Review of Resident #2's's face sheet showed the following: -admission date of 10/15/25;-Two emergency contacts listed with name and phone number;-Diagnoses included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), COPD, and complete traumatic amputation (accidental loss of a body part, resulting from an injury) at level between knee and ankle of right lower leg. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Used wheelchair;-Substantial to maximal assistance for toileting hygiene, showering;-Partial to moderate assistance for upper body dressing;-Dependent on lower body dressing;-Partial to moderate assistance with personal hygiene. Review of the resident's care plan showed the care plan had an error and was unable to be opened in the electronic medical record. The Director of Nursing (DON) was also unable to access the care plan. Review of the resident's nursing progress notes showed staff documented the following:-On 10/21/25, at 2:47 P.M., resident yelled at a certified nurse aide (CNA) telling the aide he/she fell. When the aide asked how he/she got back in bed. The resident stated, I crawled back in bed. The resident then stated his/her shoulder hurt. The aide asked which shoulder. The resident then yelled at the aide and stated, Stop asking questions. This nurse went in to assess resident. The resident asked why. This nurse explained what the aide had told he nurse about the resident's fall. The resident stated, I didn't fall on the floor. This nurse asked what he/she meant. The resident stated, I don't want my blood pressure taken, I am fine. The resident then asked nurse to get out and close the door. (Staff did not document responsible party notification of the behaviors and reported fall/injury.)-On 10/30/25, at 5:32 P.M., the resident went to the store in his/her electric wheelchair. He/she did not have any cover on his/her foot and he/she was asked by another staff member if he/she wanted a blanket to cover his/her foot and he/she declined. The resident came back with cuts on his/her foot and said he/she hit a tree branch, this nurse asked the resident where his/her shoe was and he/she stated that he/she did not have any. Later he/she stated that he/she found the shoes. The wounds were addressed, he/she had a small abrasion on the top of the foot and big toe, the second toe has a small scratch, third toe also has a small scratch on the top of the toe, on the lateral side of the foot there was an approximate 3 inch laceration (tear or ragged cut in skin or flesh) with no depth, skin was folded back. Staff cleaned the toe and applied dressing. (Staff did not document notification of responsible party regarding the scratches and laceration.).Review of the resident's November 2025 POS showed the following:-An order, dated 11/06/25, for doxycycline hyclate (broad-spectrum prescription antibiotic used to treat a wide variety of bacterial infections) tablet 100 mg, give 1 tablet by mouth two times a day for infection for 10 days;-An order, dated 11/06/25, for ertapenem sodium (prescription antibiotic used to treat moderate to severe bacterial infections in various parts of the body) solution reconstitution 1 gram, inject 1 gram intramuscularly (deep into muscle tissue) every 24 hours for urinary tract infection (UTI - infection anywhere in the urinary system) for 10 days;-An order, dated 11/07/25, for probiotic (help with digestion and can restore the natural balance of gut microorganisms, especially after illness or antibiotic use) oral capsule, give 1 capsule by mouth one time a day for antibiotic supplementation for 13 days.Review of the resident's medical record, dated 11/06/25 and 11/07/25, showed staff did not document notification of the responsible party regarding the new orders. Review of the resident's nursing progress note dated 11/08/25, at 12:52 P.M., resident continued antibiotic therapy related to wound on left foot. Resident denied any signs or symptoms of adverse reactions at this time. Resident is afebrile (without fever). Resident was able to make needs known. (Staff did not document responsible party notification regarding the antibiotic therapy.) 3. Review of Resident #3's face sheet showed the following: -admission date of 08/22/25;-Two emergency contacts listed with name and phone number;-Diagnoses included congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), metabolic encephalopathy (brain dysfunction caused by a metabolic problem, such as a systemic illness or a chemical imbalance), and permanent atrial fibrillation (state where a normal heart rhythm cannot be restored, either because attempts to do so have failed or because the patient and clinician have mutually decided to stop trying). Review of the resident's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Use of walker and wheelchair;-No information related to functional abilities. Review of the resident's care plan showed the care plan had an error and was unable to be opened in the electronic medical record. The DON also was unable to access the care plan. Review of the resident's nursing progress notes showed staff documented the following:-On 10/27/25, at 4:45 A.M., the resident was not putting out much urine with strong smell, dark color, and sediment present. Staff to pass this on to the day nurse. (Staff did not document notification of the responsible regarding the concern/change.);-On 11/03/25, at 9:54 P.M., new orders for change catheter (hollow tube inserted in bladder to drain urine) before antibiotic therapy one time only for protocol for one day. Resident had a size 24 catheter and there were none in the building at the time. Do have size 20, and advised resident that would have to call for orders for the different size. Resident then refused stating that a 20 will leak. Staff notified DON. (Staff did not document responsible notification of the order change and resident's refusal.)Review of the resident's November 2025 POS an order, dated 11/04/25, for cefpodoxime proxetil (antibiotic used to treat a wide variety of mild to moderate bacterial infections) oral tablet 200 mg, give 1 tablet by mouth two times daily for 10 days for UTI.Review of the resident's nursing progress note dated 11/04/25, at 2:40 P.M., showed resident continued on antibiotic for UTI with no signs or symptoms of adverse reactions. Resident laying down in room. Staff will continue to be monitor for adverse reactions to medications. (Staff did not document responsible party notification of the new medication.) Review of the resident's November 2025 POS showed the following:-An order, dated 11/09/25, for probiotic oral capsule, give 1 capsule by mouth two times a day for antibiotic therapy supplement until 11/19/25;-An order, dated 11/17/25, for Seroquel (used primarily to treat various mental health conditions) oral tablet 35 mg, give 25 mg by mouth at bedtime for behavioral control.Review of the resident's medical record, dated 11/09/25 to 11/17/25, showed staff did not document notification of responsible party of the new orders. 4. During an interview on 11/19/25, at 11:15 A.M., Certified Nurse Aide (CNA) C said if a resident had change from baseline, he/she would tell the charge nurse and get the resident's vital signs. The nursing staff document and contact physician and family. During an interview on 11/19/25, at 12:00 P.M., Certified Medication Technician (CMT) B said if he/she noted a resident have change in their health condition, he/she would notify the nurse for evaluation. The nurse contacts the physician and family. During an interview on 11/19/25, at 12:30 P.M., Licensed Practical Nurse (LPN) A said nursing staff should document care as provided. If it was not charted it was not done. Staff should contact resident family or responsible party for resident change in health condition, new physician orders, falls, and anything new. During an interview on 11/19/25, at 1:00 P.M., the DON said the nursing staff should notify the on-call manager for any resident change in health condition. The nurse should contact the physician to see if any new orders. The nurse should contact the resident's family of changes in condition and new orders. If the resident is their own self responsible party, they at times do not want their family contacted unless they go to the hospital. All of this information should be documented. During an interview on 11/19/25, at 1:30 P.M., the Administrator said the nursing staff should notify a resident's family or emergency contact for all changes of health and new physician orders. This information should be documented. If the resident was their own person and did not want the family notified that should be documented. Complaint 2666127

Based on interview and record review, the facility failed to maintain all resident medical records according to professional standards of practice when the facility failed to document hospice evaluation and admission and ensure the record was complete and accurately documented for one resident (Resident #1). The facility had a census of 35.Review showed the facility did not provide a policy related to nursing documentation and medical records accuracy. 1. Review of Resident #1's face sheet showed the following information:-admission date of 04/04/25;-date of death of [DATE];-Diagnoses included encephalopathy (a disease that affects the function or structure of your brain), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), cognitive communication deficit, and bipolar disorder (mental health condition characterized by significant shifts in mood, energy, and activity levels, ranging from extreme highs to lows). Review of the resident's care plan, updated 07/18/25, showed the following:-Staff should monitor, record, and report presence of pain and/or intolerance during ambulation;-Staff should assess and document effectiveness of drug treatment;-Staff should document any abnormal behavior.(Staff did not care plan related to hospice services.) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 10/01/25, showed the following:-Moderative cognitive impairment;-Used wheelchair for mobility;-Partial to moderate assistance for toileting hygiene, dressing, personal hygiene;-Substantial to maximal assistance for showering. Review of the resident's progress note dated 10/29/25, at 8:23 A.M., showed the resident called the nurse in to the room. The resident let the nurse know he/she was hearing children. This nurse then asked resident if he/she would like to go to hospital. The resident then stated no and I think I need to be on hospice. The nurse asked resident if he/she felt okay enough right now. The resident stated, Yes I just need to talk to someone about hospice today. I need to be able to sleep and get on meds. The resident then asked this nurse to call his/her family member. The nurse let the resident know he/she would talk to social services and the Director of Nursing (DON) first. The resident stated, I don't care what he/she says I need to be on hospice. The nurse then reassured the resident that he/she would talk to the DON and get it worked out.Review of the resident's October 2025 and November 2025 Physician's Order Sheet (POS) showed an order, dated 10/31/25, for Morphine Sulfate (used to treat severe pain when other medications are not effective) oral solution 10 milligram (mg)/5 milliliter (ml), 0.25 mg every two hours as needed for pain per hospice.Review of the resident's medical record, dated 10/29/25 to 11/03/25, showed staff did not document regarding a hospice referral or assessment, or the resident being placed on hospice service. The staff did not document a physician's order related to admission of hospice services. During an interview on 11/19/25, at 12:00 P.M., Certified Medication Technician (CMT) B said staff document in the resident's medical record any care and services received. There should be orders for hospice in the chart as well. During an interview on 11/16/25, at 12:30 P.M., Licensed Practical Nurse (LPN) A said nursing staff should document any change of health condition in the resident's chart. This should include information of being evaluated and admitted to hospice services. During an interview on 11/16/25, at 1:00 P.M., Director of Nursing (DON) said she was notified that the resident wanted to go on hospice services and she advised staff to start the process and contact hospice. This information should have been documented in the resident's chart. She was not able locate any hospice records. The hospice company did not leave any records. She did not find a hospice order, or any nursing documented information on hospice services. Resident charts should show the accurate and concise information related to the resident care and if it was not documented it did not happen. Care plans should be updated as soon as possible after changes in resident care needs. During an interview on 11/16/25, at 1:30 P.M., the Administrator said there should be a physician's order for hospice evaluation and treatment. The resident's medical records should show the resident was on hospice. Staff should document resident's change in health care needs in the records. The medical record should paint a clear picture of the resident's care. Complaint 2666127

Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when facility staff failed to obtain ordered medications in a timely fashion and failed to notify the physician of the missed doses one resident (Resident #1). The facility census was 34.Review of the facility's policy Unavailable Medications, revised 05/09/25, showed the following:-This facility shall use uniform guidelines for unavailable medications;-The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications;-A STAT (immediately) supply of commonly used medications is maintained in-house for timely initiation of medications;-Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known the medication is unavailable:-Notify the Director of Nursing (DON) or on call Nursing Manager to determine if medication might be located within the facility or if it is obtainable in a timely manner from another source/satellite pharmacy;-If unable to obtain, determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication;-Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold;-If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Review of the facility's policy Medication Reordering, revised 05/09/25, showed the following:-It was the policy of the facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident;-The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals to meet the needs of each resident;-Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner;-For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container. 1. Review of Resident 1's face sheet (admission data) showed the following:-admission date of 05/08/25;-Diagnoses included chronic osteomyelitis (bone infection) of right ankle and foot, cognitive communication deficit, and other bacterial infections of unspecified site. Review of the resident's care plan, revised 05/29/25, showed the following:-The resident had an increased probability of infections related to his/her her right foot infection;-The resident was at risk for adverse reactions of his/her medications;-Administer the resident's medications as ordered. Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/08/25, showed the following:-Cognitive skills intact;-No behaviors;-Set up required with eating;-Supervision required with toileting and personal hygiene. Review of the resident's July 2025 Physician Order Sheet (POS) showed an order, dated 07/22/25, for Avycaz (antibiotic used to treat serious bacterial infections) Intravenous (IV- into or within a vein) Solution Reconstituted 2.5 gram, use 2.5 gram intravenously three times a day (TID) for osteomyelitis until 08/01/25 9:59 P.M. Dilute in 100 milliliters (ml) of normal saline and administer at 50 ml/hour. Review of the resident's progress note dated 07/23/25, at 8:04 A.M., showed Registered Nurse (RN) B noted the resident was nonresponsive and blood sugar was 53 milligrams/deciliter (mg/dL - below 70 mg/dL is considered low). RN B contacted the Director of Nursing (DON) and provider. Staff transferred the resident to the hospital by ambulance at 8:04 A.M. Review of the resident's July 2025 POS showed an order, dated 07/23/25, for linezolid intravenous solution 600 mg intravenously every 12 hours for osteomyelitis of the right foot until 08/01/25 at 11:59 P.M. Administer via PICC (long, thin flexible tube inserted into a vein to administer medications, fluids and blood products) line at 150 ml per hour. Review of the resident's progress note dated 07/29/25, at 11:05 P.M., showed a nurse documented the resident arrived at the facility by the ambulance and emergency medical transport. The resident was able to wheel down to the nurses' station to ask questions. The resident appears to be confused at times. Review of the resident's hospital discharge orders, dated 07/29/25, showed the following:-An order, dated 07/29/25, for vancomycin (an antibiotic used to treat serious bacterial infections) oral 125 milligrams (mg), four times a day. The last dose administered on 07/29/25 8:10 A.M.;-An order, undated, for linezolid (used to treat bacterial infections, including skin infections and pneumonia), 0.9% sodium chloride 600 mg intravenous every 12 hours, with time last taken unknown;-An order, undated, for Avycaz 2.5 grams intravenous every eight hours. Review of the resident's July 2025 POS showed an order, dated 07/29/25, for vancomycin HCL oral capsule 125 mg, one capsule by mouth (PO) four times a day for infection. Review of the resident's July 2025 Medication Administration Record (MAR) showed the following:-An active order for linezolid intravenous solution 600 mg/300 ml. Staff to use 600 mg intravenously every 12 hours for osteomyelitis for the right foot until 08/01/25 at 11:59 P.M. Administer via PICC line at 150 ml/hr;-An order, dated 07/29/25, for vancomycin HCL oral capsule 125 mg. Give one capsule PO four times a day for infection;-An order, no date, for Avycaz Intravenous Solution reconstituted 2.5 gm, use 2.5 grams intravenously three times a day for osteomyelitis until 08/01/25 at 09:59 P.M. Staff to dilute in 100 ml of normal saline and administer at 50 ml/hr;-On 07/29/25, at 9:00 P.M., staff documented the linezolid was not administered;-On 07/29/25 at 8:00 P.M., staff documented the vancomycin was not administered. Review of the resident's progress note dated 07/29/25, at 8:34 P.M., showed staff documented the vancomycin was on order. Staff did not document regarding the linezolid. Review of the resident's July 2025 MAR showed on 07/30/25, at 9:00 A.M., staff documented the linezolid was not administered.Review of the resident's progress notes showed on 07/30/25, at 9:23 A.M., a nurse documented the linezolid was not on-hand. Staff notified the pharmacy of the need, and they assured delivery. The medication was not received, and the pharmacy notified. (Staff did not document physician notification.)Review of the resident's July 2025 MAR showed on 07/30/25, at 9:00 P.M., staff documented the linezolid was not administered.Review of the resident's progress note dated 07/30/25, at 9:16 P.M., showed a nurse documented the linezolid not available at this time. Review of the resident's July 2025 MAR showed on 07/30/25, at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 08:00 P.M., a Certified Medication Technician (CMT) documented the vancomycin was not administered. Review of the resident's progress notes showed the following:-On 07/30/25, at 10:55 A.M., CMT E documented the vancomycin was not available;-On 07/30/25, at 11:12 A.M., CMT E documented the vancomycin was not available;-On 07/30/25 at 3:55 P.M., CMT E documented the vancomycin was not available;-On 07/30/25, at 7:23 P.M., CMT E documented the vancomycin was not available. (Staff did not document physician notification.)Review of the resident's progress notes showed on 07/30/25, at 9:21 P.M., a nurse documented the Avycaz did not arrive at this time and was not available. (Staff did not document physician notification.)Review of the resident's July 2025 MAR showed on 07/30/25, at 10:00 P.M., showed staff did not administer the Avycaz. Review of the physician's initial visit, dated 07/30/25, showed the following:-The resident had a complex medical history including right hip fracture, osteomyelitis and was evaluated today post hospital discharge;-Regarding the resident's chronic osteomyelitis of the great right toe, the resident was also evaluated by an infectious disease doctor who provided recommendations for antibiotics due to previous cultures that grew pan-resistant acinetobacter baumannii (common hospital-acquired pathogen) and methicillin-resistant staphylococcus aureus) (MRSA - type of staph that can be resistant to several antibiotics);-Medication of vancomycin HCL Oral capsule 125 mg, give one capsule PO four times a day for infection and Avycaz intravenous solution reconstituted 2.5 gm three times a day for osteomyelitis until 08/01/25;-Assessment and plan: chronic osteomyelitis of the right great toes. The resident is currently on a complex antibiotic regimen for chronic osteomyelitis of the right great toe, status post amputation. The treatment plan was recommended by the infectious physician. Continue the vancomycin, Avycaz, and linezolid. (The physician did not document regarding the missed doses.) Review of the resident's July 2025 MAR showed the following:-On 07/31/25, at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., CMT A did not administer the vancomycin;-On 07/31/25, at 9:00 A.M., showed staff did not administer the linezolid. Review of the resident's progress notes showed the following:-On 07/31/25, at 9:33 A.M., a nurse documented the linezolid was unavailable. Staff notified the DON. Staff spoke with the pharmacy, and they are to send the medication stat;-On 07/31/25, at 12:05 P.M., CMT A documented the vancomycin was on order;-On 07/31/25, at 1:32 P.M., CMT A documented the vancomycin was on order;-On 07/31/25, at 3:23 P.M. CMT A documented the vancomycin was on order;-On 07/31/25 at 07:34 P.M., CMT A documented the vancomycin was on order; -On 07/31/25, at 11:06 P.M., a nurse documented the resident continued on IV antibiotic for his/her wound. The resident picked a scab off of his/her leg this shift. (Staff did not document physician notification regarding the missed doses.) Review of the resident's August 2025 MAR showed on 08/01/25, at 12:00 P.M., 4:00 P.M. and 8:00 P.M., staff documented the vancomycin was not administered. Review of the resident's progress notes showed the following:-On 08/01/25, at 12:08 P.M., CMT E documented he/she called the pharmacy, and they stated the vancomycin would be at the facility this evening;-On 08/01/25, at 4:42 P.M., CMT E documented he/she called the pharmacy, and they stated the vancomycin would be at the facility tonight;-On 08/01/25, at 7:10 P.M., CMT E documented pharmacy stated the vancomycin would be at the facility this evening.(Staff did not document physician notification regarding the missed doses.) During interviews on 08/05/25, at 10:50 A.M. and 12:32 P.M., CMT A said the following:-The facility did not have the resident's vancomycin;-He/she reported the unavailable vancomycin to the nurse. The nurse stated the medication had been ordered;-He/she documented on 07/31/25 the four times of the vancomycin was not available;-He/she did not call the pharmacy due to the nurse stated the medication was ordered;-The facility did not have an emergency pharmacy close, so they did not deliver medications until 1:00 A.M.;-He/she documented in the progress notes of the vancomycin on order for the rest of his/her shift;-Nurses administer the IV antibiotics;-Nurses enter the physician orders in the computer; -He/she administered the oral antibiotics;-The facility has some of the medications in the medication machine;-Nurses and CMT's review the ordered medications the following morning and place them on the medication cart;-CMTS have access to the medication machine for regular medications;-He/she checks for the medication if it is unavailable;-He/she calls the pharmacy if a medication is unavailable to see if a medication was ordered;-He/she informs the nurse of an unavailable medications and documents in the progress note.During an interview on 08/05/25, at 2:35 P.M., CMT E said he/she did not administer any doses of the vancomycin on 08/01/25. He/she documented the medication was not available and he/she called the pharmacy who said the medication would be delivered that evening. He/she told the nurse and the DON on 08/01/25 who called the pharmacy on the vancomycin. During an interview on 08/05/25, at 12:12 P.M., Licensed Practical Nurse (LPN) D said the following:-He/she did not know the resident's vancomycin was not in. The resident was on an IV antibiotic. He/she saw the order for the vancomycin, but did not know it was not in the facility;-It was important for staff to start the resident's vancomycin. The resident had an infection;-He/she did not know the resident's vancomycin was not administered and unavailable;-Staff should call the pharmacy if a medication is not available;-The CMTs administer the vancomycin oral tablets and should notify the nurse if the medication is not available;-The CMT should notify the nurse and call the pharmacy if a medication is not available;-Staff should notify the physician if vancomycin is not in;-Delayed antibiotics for an infection could cause severe complications such as infections spreading and becoming septic; -Nurses enter the orders into the computer which connects to the pharmacy; -Staff should call the pharmacy if a medication is not delivered, find out the reason and notify the DON. During an interview on 08/05/25, at 12:01 P.M., Registered Nurse (RN) C said the following:-The resident's linezolid IV meds were on order, but the NP said to discontinue it;-The resident's Vancomycin should had started as soon as possible;-Nurses enter the physician orders in the computer;-Staff call the pharmacy if a medication is not available and document in the progress notes;-Staff should start vancomycin as soon as it is delivered from the pharmacy;-Nurses call the pharmacy to get an antibiotic STAT and should get it within four hours if it approved;-It could affect a resident's treatment if an antibiotic is not given, and staff should notify the physician to see if they want to change to another medication. During an interview on 08/05/25, at 12:34 P.M. and 2:13 P.M., the Director of Nursing (DON) said the following:-The nurse practitioner (NP) questioned the hospital discharge order of the resident's vancomycin due to the culture the facility had contraindicated the order. The NP sent communication and the lab to the infectious disease physician regarding the resident was resistant to vancomycin and did not see a response;-She did not know the vancomycin was not available;-The pharmacy said the linezolid needed mixed out of their facility and they were waiting for their components delivered to them (the pharmacy) to be mixed;-The linezolid was discontinued due to it was the end of the original order to give it. It was to end on 07/31/25 anyway;-She did not know if the nurse practitioner (NP) or physician was aware the resident did not receive the vancomycin and linezolid;-Vancomycin is used for an infection and microbes could grow and end up with a more severe infection if the antibiotic is not administered as ordered;-The resident was readmitted to the facility on [DATE] with an order for the vancomycin. She did not know why it was not given and it was not reported to her;-On 07/18/25, the pharmacy may have waited on approval for the Avycaz due to not administered;-She expected staff to notify the physician or NP of the Avycaz not administered on 07/18/25;-Nurses notify the provider of a resident's return to the facility from the hospital;-Nurses enter the physician order in the computer which communicates to the pharmacy;-A corporate entity which is an admission team reviews the discharge orders from the hospital;-The pharmacy delivers the medications that night if the medication is not in the emergency kit or STAT safe;-Staff should document in the progress notes if a medication is not available, notify the pharmacy and physician;-Vancomycin is used to treat infections. It could cause a more severe infection if not administered as ordered;-Nurses should document if a medication is not administered;-Nurses or CMTs should call the pharmacy if a medication is not available; -Nurses should notify the physician or NP if a medication is not available.During an interview on 08/05/25, at 12:54 P.M., the NP said the following:-She did not hear back from the infectious disease doctor on the resident's vancomycin;-She monitored the resident on the Avycaz which was the original treatment for the contagious infection;-The infectious disease physician recommended two to four weeks of the IV Avycaz;-The resident had a re-swab for the Avycaz and it showed a bacteria and vancomycin resistance;-She did not discontinue the vancomycin when the resident was readmitted to the facility on [DATE];-Facility staff did not notify her the vancomycin was not available; -She believed the hospital staff had a better understanding of the resident's condition due to diagnostic labs with immediate values and he/she would go along with the hospital's recommendations because they know best for the resident;-The resident was on linezolid while in the hospital and staff did not notify her of the linezolid not given here, it should had been at the facility for the resident;-She assumed the resident was on the vancomycin after the linezolid was discontinued and did not know the resident did not have the linezolid for 07/29/25 through 07/31/25; -She would have instructed the nurse to check the emergency kit then instruct them to call the pharmacy and pay to have it delivered STAT;-She expected staff to notify her when a resident is readmitted , she reviews the discharge orders in the computer. She does not verify accuracy but verifies safety of the interactions and if a resident is on two different antibiotics;-She expected staff to notify her if a medication is not available.During an interview on 08/05/25, at 1:42 P.M., the physician said he expected staff to notify him if an antibiotic or medication was not available. During an interview on 08/05/25, at 3:00 P.M., the Administrator said she expected staff to notify the physician if a medication/antibiotic is not available and document it in the progress notes. Complaint 2579006

1. Please refer to Event ID NXM312, exit 03/27/25. Based on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: -It was the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person; -If there was any allegation of abuse, then the facility must report immediately to the administrator and to State Survey Agency, no later than two hours; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -Sexual abuse was the non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intended to inflict injury or harm. Any touching or exposure of the anus, breast or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included depression, obesity, and panic disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/17/24, showed the resident's cognitive skills were intact and resident had no behaviors. Review of the resident's care plan, dated 06/26/24, showed the resident was at risk for mood problems as evidenced by his/her mood interview score. Staff to allow the resident to have control over situations, if possible. During an interview on 03/27/25, at 11:24 A.M., the resident said the following: -One evening, he/she played games in the main dining room and Resident #2 came into the dining room and came to him/her like he/she was going to kiss him/her; -He/she moved Resident #2 back and the resident came and gave him/her a quick kiss on the lips; -Resident #2 did hand gestures referring to his/her chest area. Resident #2 did not touch him/her; -He/she thought the kiss was gross and creepy; -He/she reported this to Licensed Practical Nurse (LPN) D. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, cognitive communication deficit, and depression. Review of the resident's care plan, dated 12/05/24, showed the following: -The resident has a serious mental illness, intellectual disabilities, and a related condition; -Staff to address emotional issues; -The resident had cognitive loss and dementia; -Staff to provide cues and supervision to resident. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitive skills severely impaired; -Rejection of care one to three days. Review of the resident's progress note dated 03/21/25, at 9:08 P.M., showed LPN D documented a resident (Resident #1) reported that Resident #2 made him/her uncomfortable. Resident #1 reported that Resident #2 came up to him/her in front of another resident and kissed him/her on the mouth. Resident #1 said he/she pushed Resident #2 and said no that is not ok. Resident #2 laughed as if it was funny. Resident #1 also reported that Resident #2 made gestures to him/her when he/she passes by. Resident #1 reports he/she felt uncomfortable and unsafe. 3. Review of DHSS records showed the facility reported the allegation of abuse to the state on 03/24/25 at 11:43 A.M. (three days after the allegation of abuse was made by Resident #1). 4. During an interview on 03/27/25, at 2:18 P.M., LPN D said the following: -On 03/21/25, Resident #1 came up to him/her and said Resident #2 came up and kissed him/her on his/her lips. Resident #1 said it made him/her feel weird; -LPN D texted the Director of Nursing (DON) on 03/21/25 of the incident; -Staff monitored Resident #2 with 15-minute checks; -The DON educated him/her the next time he/she was at the facility to report that Resident #1 said this incident made him/her feel unsafe; -LPN D considered the unwanted kiss as sexual abuse. During interviews on 03/27/25, at 1:30 P.M. and 02:30 P.M., the DON said the following: -LPN D reported to her that the resident said the kiss was unwanted and not to do it again; -LPN D texted her on Friday, 03/21/25, that Resident #1 said Resident #2 walked right up to him/her and kissed Resident #1 on his/her lips. Resident #1 said it was fast and it made him/her feel weird. Resident #1 told Resident #2 that it was not ok; -The DON said she did not know why she (the DON) did not call the allegation of abuse into the state; -LPN D reported that the resident went up and kissed Resident #1; -Resident #1 did not report Resident #2 made inappropriate gestures toward him/her. During interviews on 03/27/25, at 2:00 P.M. and 2:30 P.M., the Administrator said the following: -The allegation of abuse should have been reported to her and the state timely; -She found out about the incident on Saturday (03/22/25) and did not have all the information until Monday (03/24/25) when she talked to Resident #1; -On Sunday, 03/23/25, the DON reported that LPN D called her and said Resident #2 tried to kiss Resident #1; -After she talked to Resident #1 on Monday morning (03/24/25), it was a different story. Resident #1 said Resident #2 came up to tried to kiss him/her and he/she pushed Resident #2 away and said no, Resident #2 came back and forcibly kissed him/her on the lips and made a motion with his/her hands towards him/her; -Staff should had reported the incident immediately and reported to the state sooner. During an interview on 03/27/25, at 10:00 A.M., Certified Medication Technician (CMT) E said the following: -Examples of sexual abuse include touching inappropriate, kissing and fondling; -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:09 A.M., the Housekeeping Supervisor said the following: -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:47 A.M., Certified Nurse Aide (CNA)/CMT F said the following: -Staff should report immediately an allegation of abuse to the supervisor, charge nurse, DON or the administrator; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 1:30 P.M., the DON said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor; -Staff should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 2:00 P.M., the Administrator said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor and the supervisor reports to the administrator; -Staff should notify the state of any allegation of abuse within two hours. MO00251591

Based on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. The facility census was 44. Review showed the facility did not provide a policy regarding new employee training. 1. Review showed the facility did not provide completed training documents or skills test for the current kitchen staff. During an interview on 01/29/25, at 2:25 P.M., Dietary Aide (DA) P said the following: -DA P started in the kitchen on 01/24/25; -DA P was still in training and the Dietary Manager (DM) had not gone over any kitchen policies with him/her; -DA P did not feel that he/she had enough training to be serving lunch to residents ,but was told to do so. During an interview on 01/29/25, at 3:00 P.M., [NAME] O said the following: -Cook O started in the kitchen on 12/12/24; -The DM had not gone over facility policy with him/her; -The DM had not trained [NAME] O on facility policy and procedures; -The DM had not provided training to [NAME] O on the puree process. During an interview on 01/29/25, at 3:27 P.M., the DM said the following: -He/she started in the kitchen on 08/30/23; -None of the kitchen staff were safe serve certified including the DM; -New employees had one week of training before working on their own; -The DM had no orientation or training checklist for new kitchen staff; -The DM had no skills competency checks for kitchen staff; -The DM had no document showing staff had been trained; -The DM was not aware of any kitchen policies and procedures that the facility had; -The DM was not familiar with Centers for Medicaid and Medicare Services (CMS) dietary regulations; -DA P did not have enough training before being told to serve lunch; -DA N did not have enough training to puree food items without supervision; -Cook O had previous knowledge and experience and had adequate training; -The DM had provided sporadic in-services with kitchen staff. During an interview on 01/31/25, at 11:24 A.M., the Administrator said the following: -The kitchen staff have not had adequate training; -The DM is responsible for training the kitchen staff; -The DM should complete skills testing with all kitchen staff; -The DM should have gone over kitchen policy and procedures with new staff; -The Administrator did not review kitchen staff training, observe meal prep, or observe a meal serve out.

Based on interview and record review, the facility failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 44. Review of the facility's policy titled, Director of Food and Nutrition Services, undated, showed the following: -The Director of Food and Nutrition Services (DFNS) will be responsible for all aspects of the food and nutrition services department including, but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served; -The DFNS will be hired by corporate staff, the Administrator, or by the immediate supervisor of the position as deemed appropriate by the facility; -The DFNS will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that does not have a full time dietitian (registered dietitian nutritionist or RDN) or clinically qualified nutrition professional must designate a person to serve as DFNS. According to the Centers for Medicare and Medicaid (CMS) services State Operations Manual for nursing homes F tag 801, the DFNS hired prior to 11/28/16 must meet the following requirement no later than five years after 11/28/16, or no later than one year after 11/12/16, for those hired or designated to that position after 11/28/16: -The DFNS must be a certified dietary manager (CDM); certified food service manager; have a similar national certification for food service management and safety from a national certifying body; or have an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning; and in states that have established standards for food service managers or dietary managers, must meet state requirements for food service managers or dietary managers. During an interview on 01/31/25, at 8:59 A.M., the Dietary Manager said the following: -She started the DM position in December 2024; -She had been the DM assistant for a year; -She had two years of study and received a certificate in culinary arts from Le Cordon Bleu; -She was not a CDM and not enrolled in a training/certification course; -She was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality; -She did not have regular contact with a registered dietitian. Review of the DM's personnel file showed the facility did not provide documentation of certification, training, or experience that met the requirements for a DFNS in a long-term care setting. During an interview on 01/31/25, at 10:44 A.M the Registered Dietician (RD) said the DM should have the serv safe certification. She did not know what the corporate policy was or how soon after hiring for the DM was to have the certification. There was a correspondence course to go through to become knowledgeable which would prepare the DM to take the certified dietary manager exam. During an interview on 01/31/25, at 11:24 A.M., the Administrator said the following: -The DM is the Director of Food Services; -The DM had a degree in culinary arts; however the facility did not have a copy of it; -The DM was taking the safe serve class and test that day; -The Administrator thought the DM had the required qualifications.

Based on observation, interview, and record review, the facility failed store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to remove dented cans from use; failed to consistently label and date food; failed to ensure the dishwasher machine sanitation was at the appropriate level; failed to keep trash covered when not in use; failed to wash hands and equipment appropriately during food prep and service; and when staff failed to ensure non-food contact surfaces were clean and maintained in good repair. The facility census was 44. 1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's policy titled, Food Safety and Sanitation, not dated, showed the following: -Employees are required to have their hair styled so that it does not touch the collar; -Hair restraints are required and should cover all hair on the head; -Beard nets are required when facial hair is visible. Observations on [DATE], at 3:15 P.M., and on [DATE], at 3:03 P.M., of the kitchen staff showed [NAME] O had facial hair and did not wear a beard restraint. Observation on [DATE], at 10:21 A.M., of the kitchen staff showed [NAME] M had facial hair and was not wearing a beard restraint. Observation on [DATE], at 10:25 A.M., and on [DATE], at 11:53 A.M., showed Dietary Aide (DA) N had facial hair and was not wearing a beard restraint. During an interview on [DATE] at 2:25 P.M., DA P said the following: -All kitchen staff were responsible for putting food in the refrigerator and freezer; -Food was to be labeled with what it was and the date it was put in the refrigerator or freezer; -DA P did not know how long left over items can be stored in the refrigerator; -DA P said serving food out of dented cans could make the residents sick; -Resident food is stored in the facility walk in refrigerator and should be labeled and dated; -A hair/beard net must be worn anytime staff were in the kitchen or around food. During an interview on [DATE], at 3:00 P.M., [NAME] O said a hair and beard net should be worn at all times while in the kitchen or serving food. During an interview on [DATE], at 2:10 P.M., DA N said hair and beard nets were to be worn while preparing and serving meals. During an interview on [DATE], at 10:44 A.M., the Registered Dietician (RD) said staff should wear a beard guard if they have a beard. If staff did not have a beard guard, staff can wear a hair net over the beard. During an interview on [DATE], at 3:27 P.M., the DM said hair nets and beard nets were to be worn when in the kitchen. During an interview on [DATE], at 11:24 A.M., the Administrator said kitchen staff were required to wear hair nets and beard nets at all times while in the kitchen and serving food. 2. Review of the FDA 2022 Food Codes showed the following: -Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food; -If the integrity of the packaging has been compromised contaminants may find their way into the food. -Close inspection of cans for imperfections or damage may reveal punctures or seam defects; -Suspect cans must be returned. Review of the facility's policy titled, Food Safety and Sanitation, not dated, showed bulging or leaking cans, cans with severe dents on the seams, or broken containers of food will not be used. Observations on [DATE], at 3:15 P.M., [DATE], at 3:03 P.M., and on [DATE], at 10:20 A.M. of the of the dry food storage area showed the following: -One dented 6 pound (lb) can of diced peaches; -One dented 6 lb can of sausage gravy; -One dented 6 lb can of kidney beans; -One dented 7 lb can of pork and beans; -One dented 6 lb can of mandarin oranges. During an interview on [DATE], at 2:25 P.M., DA P said serving food out of dented cans could make the residents sick. During an interview on [DATE], at 11:24 A.M., the Administrator said dented cans should not be used and were to be returned to the distributor. 3. Review of the facility's policy titled, Food Safety and Sanitation, not dated, showed the following: -All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored; -When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food; -Leftovers are used within 72 hours (or discarded); -Perishable foods with expiration dates are used prior to the use by date on the package. Observations on [DATE], at 3:52 P.M., of the walk-in refrigerator showed the following: -One food tray containing 12 uncovered condiment containers with a red substance in them. A piece of tape on the food tray read, ,d+[DATE], Italian, Ranch, French; -One 3-quart deep clear food pan that contained lettuce, covered with aluminum foil that had a dried yellow/orange substance on it, with no date or label; -One 2-gallon plastic bag that contained approximately 25 baked potatoes with cheese that was not dated or labeled; -One ,d+[DATE] gallon of whole milk with a best by date of [DATE], labeled activities and dated [DATE]; -One large pizza box containing four slices of pizza, not dated; -Two sandwich size plastic bags containing cubed cheese, not dated or labeled; -Two clear condiment containers with a white substance in them not dated or labeled. Observation on [DATE], at 3:03 P.M., of the walk-in refrigerator showed the following: -One gallon size plastic bag containing 3 pieces of pizza with a residents name on it and no date; -Two sandwich size plastic bags containing cubed cheese not dated or labeled; -Two clear condiment containers with a white substance in them not dated or labeled. Observation on [DATE], at 10:25 A.M., of the walk-in refrigerator showed the following: -One gallon size plastic bag containing 3 pieces of pizza with a resident's name on it and no date; -One sandwich size plastic bag containing cubed cheese not dated or labeled; -Two clear condiment containers with a white substance in them not dated or labeled;. During an interview on [DATE], at 2:25 P.M., DA P said the following: -All kitchen staff were responsible for putting food in the refrigerator and freezer; -Food was to be labeled with what it was and the date it was put in the refrigerator or freezer; -DA P did not know how long left over items can be stored in the refrigerator; -Resident food is stored in the facility walk-in refrigerator and should be labeled and dated. During an interview on [DATE], at 2:10 P.M., DA N said the following: -Kitchen staff are responsible for putting food in the refrigerator, labeling it and dating it; -Leftovers can stay in the fridge for two days after being made. During an interview on [DATE], at 3:00 P.M., [NAME] O said the following: -Kitchen staff were responsible for putting food in refrigerator, including resident food; -Items were to be labeled and dated before being put in refrigerator; -Leftovers could stay in the refrigerator for up to three days; -Resident food is also stored in the walk-in refrigerator and should be dated and labeled. During an interview on [DATE], at 10:44 A.M., the Registered Dietician (RD) said staff should label and date foods with date of delivery otherwise they cannot do the first in and first out. Staff should date the date food in the cold storage and date marked for seven days out. During an interview on [DATE] at 3:27 P.M., the DM said the following: -All kitchen staff are responsible for putting food in the refrigerator; -All items should be labeled with what it is and dated with the day it goes into the refrigerator; -Resident food is kept in the facility refrigerator and should be labeled with residents name and dated; -The activities director also stored food in the refrigerator and those items need to be dated and labeled; -The DM checked the refrigerator daily for items not dated/labeled and expired items. During an interview on [DATE], at 11:24 A.M., the Administrator said all items in the refrigerator and freezer should be labeled with what it is and dated. Resident food were to be labeled and dated prior to going into the refrigerator. Staff should pull items out of the refrigerator that had passed their used by date. 4. Review of the FDA 2022 Food Code showed the presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. Review of the facility's policy titled, Resource: Sanitation of Dishes/Dish Machine, not dated, showed the final sanitization for low temperature dishwasher, spray type dish machines using chemicals to sanitize should test at 50 parts per million (ppm) hypochlorite (a strong chlorine solution used for disinfecting and sanitizing). Review of the facility's policy titled, Cleaning Dishes/Dish Machine, not dated, showed the following: -All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Observations on [DATE], at 3:16 P.M., on [DATE], at 3:04 P.M., and on [DATE], at 10:21 A.M., of the kitchen showed several 12 ounce plastic, shatterproof, stackable, drinking cups drying on a dish rack and stacked on serving cart with white powdery residue on the outside and inside. The white powdery residue could be scratched off with a butter knife. Observations [DATE], at 5:06 P.M., on [DATE], at 1:15 P.M., and on [DATE], at 1:45 P.M., showed a table in the dining room that had pitchers of flavored drinks and a pot of coffee along with three trays that held 12, 8-ounce brown coffee mugs each. The coffee mugs had a white powdery residue on the inside of them and a buildup of white powdery residue on the bottom of the cups. This residue could be scratched off using an eating utensil. Observations on [DATE] ,at 3:06 P.M., on [DATE], at 10:38 A.M., and on [DATE], at 11:04 A.M., of the kitchen showed one blue plastic basket containing adaptive eating utensils sitting on a wire rack next to the dishwasher that contained three black handle knives with debris on the blades and one gray handle knife with debris on handle. During an interview on [DATE], at 2:25 P.M., DA P said the drinking cups were ran through the dishwasher 3 or 4 times and still have a residue on them. He/she did not know what caused the white powdery residue on the drinking cups. During an interview on [DATE], at 2:10 P.M., DA N said he/she did not know what caused the white powdery residue on the drinking cups. During an interview on [DATE], at 3:27 P.M., the DM said the following: -All kitchen staff were responsible for washing dishes; -Staff should check all items that came out of dishwasher to ensure the items are clean and free of debris; -The white powdery residue on the drinking cups was from hard water and not harmful to the residents. During an interview on [DATE], at 9:22 A.M., [NAME] M and DA N said the following: -Cook M and DA N did not know how to test the sanitizer in the dishwasher; -Cook M and DA N did not know who was responsible for testing them; -Cook M used a PH test strip to test the sanitizer in the dishwasher; -The PH test strip turned yellow in color when placed in the dishwasher water; -When the test strip was compared to the reference chart on the bottle of test stripes the color yellow read 0; -Cook M and DA N did not know what the reading meant. During an interview on [DATE], at 1:52 P.M., [NAME] O said the following: -Cook O did not know how to test the sanitizer in the dishwasher; -Cook O did not know who was responsible for testing the sanitizer; -Cook O used a PH test strip to test the sanitizer in the dishwasher; -The PH test strip turned yellow in color when placed in the dishwasher water; -When the test strip was compared to the reference chart on the bottle of test stripes the color yellow read zero (0); -Cook O did not know what the reading meant. During an interview on [DATE], at 1:56 P.M., the DM said the following: -The DM checked the chemicals on the dishwasher every morning; -The DM used a chlorine test strip to test the sanitizer on the low temperature dishwasher; -The chlorine test strip of the sanitizer on the low temperature dishwasher showed 200 PPM; -The DM did not know the manufactures recommendation for the strength of the sanitizer; -The DM did not keep a log of the test; -The cooks had been trained on how to test the chemicals in the dishwasher; -The cooks should be testing the chemicals on the dishwasher when the DM is not available. During an interview on [DATE], at 10:44 A.M., the RD said the sanitization is not correct if dishes have a white film. The low temperature sanitization dish machine sanitation should be 50 to 100 ppm. Staff should contact the company who services the machine and they need to turn it down. During an interview on [DATE], at 11:24 A.M., the Administrator said the following: -The white powdery residue on the drinking cups and coffee cups was from hard water and did not believe it was harmful to the residents; -The sanitizer strength on the dishwasher should meet the manufactures recommendation. 5. Observation on [DATE], at 3:06 P.M., on [DATE], at 10:38 A.M., and on [DATE], at 11:04 A.M., of the kitchen showed the following: -One 32-gallon gray trash can containing trash uncovered; -One black two-shelf bussing cart with an attached trash bin that contained trash, sitting next to dishwasher in kitchen not covered; -One white, round trash can with step on pedal that contained trash sitting open next to stove; -The trash cans were not in use. During an interview on [DATE], at 10:44 A.M., the RD said she expected the trash cans covered when not in use. 6. Review of the FDA 2022 Food Code showed food employees shall keep their hands and exposed portions of their arms clean. Review of the facility's policy titled, Hand Washing, not dated, showed the following: -Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures; -Hands and exposed portions of arms should be washed immediately before engaging in food preparation; -Wash hands when entering the kitchen at the start of shift, after touching bare human body parts other than clean hands and clean, exposed portions of arms, during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks, when switching between working with raw food and working with ready to eat food, before donning disposable gloves for working with food and after gloves are removed, and after engaging in other activities that contaminate the hands. Review of the facility's policy titled, Employee Sanitary Practices, not dated, showed the following: -All food and nutrition services employees will practice good personal hygiene and safe food handling procedures; -Wash hands before handling food; -Gloves must be worn if raw food is handled; -Clean and sanitize equipment and work areas after use; -Use clean hands, pick flatware ad cups up by their handles, pick dishes up by their [NAME], and pick glasses up by their base. Observation on [DATE], at 10:26 A.M., of [NAME] M showed the following: -Cook M went outside to get food item out of walk-in freezer; -Cook M re-entered the kitchen and did not wash his/her hands; -Cook M used the sprayer at the dishwasher and filled a pot with water; -Cook M placed the pot of water on the stove and put a smaller empty pot in the pot of water; -Cook M with ungloved hands put his hand in the second pot touching the bottom of the pot; -Cook M used the can opener to open four cans of tomato soup; -Cook M used his/her right hand to open the trash can next to the stove and left trash can open; -Cook M donned one glove on his/her right hand and poured the four cans of tomato soup in the empty pot on the stove; -Cook M doffed the glove on his/her right hand and put in open trash can; -Cook M went outside to get a food item out of the walk-in refrigerator and re-entered the kitchen and did not wash his/her hands. Observation on [DATE], at 10:41 A.M., of the DM showed the following: -The DM went outside to get a food item out of the walk-in refrigerator, re-entered the kitchen and did not wash his/her hands or don gloves; -The DM opened a stick of butter, put the butter in a bowl to be melted and set it next to microwave; -The DM did not wash his/her hands or don gloves during this process. Observation on [DATE], at 11:34 A.M., of the puree process showed the following: -DA N gathered the blender bowl, blade, lid and serving spoon to puree food items; -DA N did not wash his/her hands; -DA N placed sweet potatoes in blender bowl, pureed potatoes then poured into metal pan; -DA N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -DA N did not wash his/her hands or don gloves; -DA N took the pan of pureed potatoes out of the kitchen to the serving area, placed on steam table, covered with lid, returned to the kitchen, cook did not wash his/her hands; -DA N went outside to get ham out of walk-in freezer, re-entered the kitchen and did not wash his/her hands; -DA N donned oven mitts to pour beans from pot to metal pan. [NAME] doffed the oven mitts and did not wash his/her hands; -DA N poured diced ham in to pan of beans; -DA N took pan of ham and beans to the serving area and placed on the steam table; -DA N re-entered the kitchen doffed his/her gloves and did not wash his/her hands; -DA N placed ham and beans in the wet blender bowl, pureed ham and beans then poured into metal pan; -DA N removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -DA N obtained a large black handled knife from the blue plastic basket containing adaptive eating utensils. The knife had food debris on the blade and was not clean; -DA N donned gloves, picked up the knife and started to make a cut in the pan of cornbread; -DA N took the knife and two other knives from the basket to the dishwasher; -DA N used his/her gloved hands to place three pieces of cornbread, into the wet blender bowl, pureed cornbread then poured into metal pan; -DA N doffed gloves and did not wash hands. Observation on [DATE], at 11:30 A.M., of the puree process showed the following: -Cook M donned gloves, sprayed a metal pan with nonstick spray, used his/her gloved hands to pick up three chicken patties, ground chicken to mechanical soft then poured in metal pan; -Cook M removed blender bowl, blade, and lid and sprayed them with hot water to remove food debris, then attached the pieces to the blender. The cook did not use soap or sanitize the equipment; -Cook M put hot water from the coffee maker in the blender bowl, used his/her gloved hands to pick up four chicken patties and place in the blender bowl; -During the puree process cook M opened the blender, used his/her gloved hands to pull out three chicken patties and tear into smaller pieces and placed back in blender, pureed chicken then poured in metal pan; -Cook M performed this task while wearing the same gloves that he/she donned at the beginning of the task. Observation on [DATE] at 12:09 P.M., of lunch preparation showed the following: -Cook M donned gloves, went out of the kitchen to the steamtable, picked up two tomatoes, held them in the air while walking back into the kitchen, placed them on a plate, unwrapped plastic used to cover sliced cheese, took out two slices of cheese placed them on a plate, then opened container of jelly and a container of peanut butter; -Cook M obtained another knife, using one knife to spread jelly on a piece of bread, then using a separate knife to spread peanut butter on a piece of bread; -Cook M then doffed his/her gloves. Observation on [DATE], at 12:22 P.M., of the lunch serve out showed the following: -DA N washed hands and donned gloves; -DA N went from serving food with serving utensils, opened a bag of hamburger buns, using his/her hands retrieved one hamburger bun, and placed it on plate, then used tongs and placed chicken patty on bun; -DA N picked up resident menu card, then sent menu card along with plate to be served to resident; -DA N did not remove his/her gloves or wash his/her hands. -DA N returned to serving food with serving utensils; -DA N using his/her hands retrieved one hamburger bun, and placed it on plate, then used tongs and placed chicken patty on bun; -DA N retrieved a package of sliced cheese from the kitchen, unwrapped the cheese, using his/her hands retrieved one slice of cheese and placed it on a chicken patty; -DA N picked up resident menu card, then sent menu card along with plate to be served to resident; -DA N did not remove his/her gloves or wash his/her hands. -DA N repeated this process four times; -Cook N did not doff his/her gloves during the lunch serve out process. During an interview on [DATE], at 2:25 P.M., with DA P said the following: -The staff were to wash hands before and after touching food, doing dishes, before and after serving food, entering the kitchen, and putting on a hair net; -DA P said gloves should be worn when food is being touched. During an interview on [DATE], at 2:10 P.M., DA N said the following: -Hands were to be washed after touching any surface; -DA N looked over items coming out of the dishwasher to ensure they were clean; -Dishes are sanitized when they are run through the dishwasher; -The blender bowl, blade and lid should be run thru the dishwasher between each item and dried before next use During an interview on [DATE], at 3:00 P.M., [NAME] O said the following: -Staff should wash hands as often as possible, after touching doorknobs, when entering the kitchen, and when handling food or trash; -When using the blender bowl to puree food items it should be ran through the dishwasher between each use and set out to air dry; -Cook O has had to dry the blender bowl with a towel during meals if the blender bowl was needed. During an interview on [DATE], at 10:44 A.M., the RD said the following: -Staff should wash hands before starting a meal service and if staff stay on the serving line only touch the scoops. Staff should wash hands when change gloves and if they leave the serving line or go to the storage room, staff should wash hands before they come back to serve a meals; -She expects dietary staff to know policies for hand hygiene and sanitation. During an interview on [DATE], at 3:27 P.M., the DM said the following: -Hand hygiene should be performed every time staff enter the kitchen, touch any food item, trash cans, doors, and tables; -All kitchen staff were responsible for washing dishes; -The blender bowl, blade, and lid should be run through the dishwasher after each use to be cleaned and sanitized; -The blender bowl, blade, and lid should be air dried between each use. During an interview on [DATE], at 11:24 A.M., the Administrator said the following: -Kitchen staff were to wash hands every time staff entered the kitchen, when hands were soiled, before food preparation, before and after glove use and after touching contaminated surfaces; -Kitchen staff were to run the blender bowl through the dishwasher to be cleaned, sanitized and air dried between each use; -Food should not be put in a wet blender bowl; -Kitchen staff were to check all items coming out of the dishwasher for cleanliness and to ensure the items are free of debris. 7. Review of the facility's Daily Cleaning Schedule,, dated 2004, showed the following: -Clean outside and inside of microwave - dietary aide; -Clean food processor after each use and under the unit - day and evening cook; -Clean trash cans - evening aide. Review of the facility's Weekly Cleaning Schedule, dated 2004, showed staff were to clean inside of walk-ins, including fans and racks. Review of the facility's Monthly Cleaning Schedule, dated 2004, showed staff were to clean overhead pipes. Review of the facility's Deep Cleaning the Kitchen, to be done every March, June, September and December, undated, showed the following: -Wipe down all ceilings; -Clean all light fixtures, vent covers, and fan covers; -Clean all appliance and containers inside and out, even the appliances not used and cover with a fresh bag; -Clean all trash cans inside and out; -Check all dishes for cracks, scratches, or blemishes and report to the administrator the findings. Observations on [DATE], at 3:16 P.M., on [DATE], at 3:04 P.M., and on [DATE], at 10:21 A.M., of the kitchen showed the following: -A 6-inch area of peeling paint on the ceiling around the round vent above the food preparation table: -A 4-inch area of peeling paint on the ceiling around the round vent above the 5-shelf rack at the end of the prep table; -A round vent on the ceiling to the left of the range hood that was partially hanging off the ceiling and the area around the vent was yellow in color; -A square, white, steel vent cover partially hanging off the ceiling above the commercial coffee and tea maker; -The microwave in the kitchen had a two-inch area on the top, a 3-inch area on the bottom around the edge where the door seals and a 2-inch area under the turn table ring where paint had peeled off. Under the peeled paint in the microwave the surface was brown and orange in color and appeared to be rust. Observations on [DATE], at 3:52 P.M., on [DATE], at 3:03 P.M., and on [DATE], at 10:25 A.M., of the walk-in refrigerator showed dust and dirt build up on the white PVC pipes and the black cables coming from the cooler fans. The PVC pipe was directly over an opened box containing individual cartons of [NAME] Ready Care chocolate shakes. During an interview on [DATE], at 2:25 P.M., DA P said he/she was not aware of any cleaning list/schedule. DA P had been cleaning what the DM told him/her to clean. During an interview on [DATE], at 2:10 P.M., DA N said he/she was not aware of a cleaning schedule. He/she cleaned what the DM tells him/her to clean. During an interview on [DATE], at 3:00 P.M., [NAME] O said the DM tells him/her what he/she is responsible for cleaning. The DA's have a cleaning schedule. He/she was not aware of any cleaning list/schedule for the cooks. During an interview on [DATE], at 3:27 P.M., the DM said the following: -Kitchen staff had daily, weekly, monthly, and quarterly cleaning schedules; -The DM assigns cleaning jobs to staff weekly. During an interview on [DATE], at 11:24 P.M., the Administrator said the following: -There should not be peeling paint on the ceiling in the kitchen; -The vents should not be hanging off the ceiling in the kitchen; -The fans and pipe in the walk-in refrigerator and freezer should be cleaned on a regular basis and be free from dust and debris; -The microwave in the kitchen was to be free of peeling paint and rust; -Peeling paint, rust, debris, and dust could contaminate food which, when served to residents could cause residents to become ill; -Kitchen staff were to be following the daily, weekly, monthly and quarterly cleaning list for the kitchen; -All repairs should be logged in the maintenance book so maintenance staff were aware of the issue and can make necessary repairs. 34871

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene after personal cares for two residents (Residents #11 and #8), during and after wound care for one resident (Resident #34), and during and after feeding tube care for one resident (Resident #149). Staff also failed to follow Enhanced Barrier Precautions (EBP) for one resident (Resident #44) who had an indwelling catheter and failed to follow their Legionella (severe form of pneumonia) Water Management Program. The facility census was 44. Review of the facility policy titled Hand Hygiene Policy and Procedure, dated 2025, showed the following: -Purpose to establish clear and standardized hand hygiene practices for all staff to prevent the spread of infections, maintain a safe environment. This policy includes specific hand hygiene practices related to peri-care to minimize the risk of urinary tract infections (UTI - bacterial infection in the urinary tract), and other infections; -This policy applies to all facility staff, including nurses, CNAs, therapists, dietary staff, housekeeping, and any personnel with direct or indirect resident contact; -All staff must perform hand hygiene correctly and consistently before, during, and after resident care activities, including peri-care, to prevent the transmission of infections; -Staff must perform hand hygiene before and after direct contact with a resident; before performing an aseptic task (e.g., wound care, catheter care); after contact with blood, body fluids, secretions, excretions, or contaminated surfaces; before and after wearing gloves; after using the restroom; before and after eating or handling food; after coughing, sneezing, or touching the face; after contact with a resident's environment (bed rails, bedside tables, medical equipment); and before and after performing peri-care; -Use alcohol-based hand rub (ABHR) with at least 60% alcohol when hands are not visibly soiled; -Use soap and water when hands are visibly soiled (e.g., dirt, blood, body fluids), after using the restroom, after caring for a resident with Clostridium difficile (C. diff - a bacteria that can cause inflammation of the colon) or Norovirus (highly contagious virus that causes gastroenteritis, or inflammation of the stomach and intestines); -Peri-care is a high-risk procedure requiring strict adherence to hand hygiene to prevent urinary tract infections (UTI's) and infections; -Before peri-care perform hand hygiene and put on gloves before providing care; -After peri-care remove gloves without touching contaminated surfaces and perform hand hygiene immediately after glove removal; -Gloves do not replace hand hygiene; -Perform hand hygiene before putting on gloves and immediately after removing them; -Change gloves when moving from a dirty to a clean task, when gloves become damaged or visibly contaminated, and when switching between different body areas (e.g., from peri-care to face washing). 1. Review of the facility policy titled Perineal Care, dated October 2010, showed the following: -The purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Assemble the equipment and supplies as needed; -Place the equipment on the bedside stand and arrange the supplies so they can be easily reached; -Wash and dry your hands thoroughly; -Put on gloves; -Wash perineal area, wiping from front to back; -Gently rinse and dry the area; -Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes; -Do not reuse the same washcloth or water; -Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth; -Gently dry perineum; -Assist the resident to turn on his/her side; -Wash the rectal area thoroughly; -Do not reuse the same washcloth or water; -Rinse thoroughly; -Dry area thoroughly; -Discard disposable items into designated containers; -Remove gloves and discard into designated container; -Wash and dry your hands thoroughly; -Reposition the bed covers; -Make the resident comfortable; -Place the call light within easy reach of the resident; -Clean the bedside stand; -Wash and dry hands thoroughly. 2. Review of Resident #11's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included quadriplegia (partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), degenerative disorders of nervous system (group of conditions that affect the nervous system, causing progressive deterioration and loss of function over time), and inclusion body myositis (a rare, chronic, and progressive muscle disease characterized by inflammation and muscle weakness). Review of the resident's significant change in condition Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/30/24, showed the following: -Cognitively intact; -Required use of motorized wheelchair; -Impairment on both sides of upper extremity and lower extremity; -Dependent on staff for oral hygiene, toileting hygiene, shower, dressing, and personal hygiene; -Dependent on staff for mobility and transfers. Review of the resident's care plan, last updated on 01/06/25, showed the following: -Resident had activities of daily living functional problems as evidenced by need for dependence on staff assistance due to diagnosis; -Resident required staff assistance for oral hygiene, toileting hygiene, shower, upper and lower body dressing, personal hygiene, chair to bed transfers, shower transfers and wheelchair mobility; -Resident had an indwelling catheter related to diagnosis; -Staff should complete catheter care appropriately; -Staff should provide catheter care per facility protocol and physician's orders; -Resident was at risk for increased probability of Infections; -Staff should clean hands before entering room, before donning gloves, between tasks as appropriate, and when leaving the room; -Staff should wear glove for high-contact care and wound care. Observations on 01/27/25, at 3:36 P.M., showed the following: -Certified Nurse Aide (CNA) H and CNA I used hand sanitizer and applied gown, gloves, and masks before entering the resident's room; -The staff entered the resident's room with the Hoyer lift (medical device that helps caregivers move patients who have limited mobility); -The resident was seated in his/her motorized wheelchair; -CNA H removed the resident's blanket and the seatbelt; -CNA H pulled the resident's upper body forward; -CNA I put the Hoyer lift pad behind residents back; -The staff hooked the lift pad to the lift and transferred the resident to the bed; -CNA H pulled the residents pants down; -CNA I went to the cabinet and picked up a clean brief; -CNA H removed the tape and opened the brief; -CNA I handed the container of wet wipes to CNA H; -CNA H used two wet wipes and cleaned peri-area and catheter (a tube that is inserted into the bladder, allowing your urine to drain freely) tubing; -Without removing gloves or using hand sanitizer, the aide rolled the resident to his/her left side; -The staff used a wet wipe and cleaned soiled buttock; -The staff pulled the soiled brief out and put in the trash; -The staff continued wiping the buttocks; - Without removing gloves or using hand sanitizer, the staff applied the clean brief; -The staff rolled the resident to his/her right side; -CNA I pulled the clean brief through and rolled resident to back side; -CNA H applied fungal powder to the private area and taped brief; -With the same gloved hands, the staff rolled the resident to left side and pull up pants, then rolled to the right side and pulled pants; -The staff rolled the resident to his/her back and attached the lift pad to the Hoyer lift and transferred the resident back to wheelchair; -Without changing gloves or cleaning hands CNA H pulled the resident's upper body forward for CNA I to remove lift pad; -CNA H re-attached the resident's seatbelt and covered the resident with the blanket; -The staff picked up trash and soil linens, removed gown and gloves and washed hands at sink and left the room. 3. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, and edema (swelling). Review of the resident's care plan, dated 10/01/24, showed the resident was at risk for increased probability of infections. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toileting hygiene, personal hygiene, dressing, shower, bed mobility. Observation on 01/28/25, at 1:35 P.M., showed the following: -CNA H and CNA I used hand sanitizer at door, applied gown, mask, and gloves and entered the resident's room; -The staff pulled the covers back from resident; -Rolled the resident to his/her left side and put the bed pan with brief under the resident; -Rolled the resident to his/her back and pulled the covers over the resident; -Pulled the residents privacy curtain and waited on the opposite of room; -While waiting CNA H pushed down soiled gowns in red bag container and noted he/she would remove the box when completed with cares; -He/she did not change gloves or use hand sanitizer; -The resident notified he/she was ready for staff to clean up; -Staff returned to resident's bed side and pulled down resident covers; -CNA H took a wet wipe and cleaned the front private area; -When putting wipe in the trash, he/she saw some bowel movement (BM) smear on his/her glove on the right hand; -He/she picked up another wet wipe with left gloved hand and wiped front area with his/her right hand; -He/she pushed the wet wipes and brief between the resident legs; -Using the interior side of his/her right glove hand touching the resident's outer thigh (with BM on opposite side of glove) and using his/her gloved left hand assisted the resident to roll to left side; -He/she then folded the soiled brief together and pulled from under resident and put into the trash bag; -He/she took the bag of soiled brief and wipes to the red bag trash on opposite side of the room;; -He/she removed soiled gloves into red bags; -CNA H returned to the resident and applied clean gloves without completing hand hygiene; -He/she picked up the bed pan and took to the resident's bathroom and put into a bag; -He/she returned to the resident's bed and assisted the resident to roll to left side, removed soiled sheet and applied a clean sheet; -CNA I assisted the resident to roll to his/her right side and pulled the clean sheet through; -CNA I assisted the resident to back side; -CNA H put pillow under the resident's right side of lower back; -CNA I put the pillow wedge under the resident's left leg; -CNA I picked up the oxygen tubing and CNA H pulled the covers over the resident; -CNA H then took the oxygen tubing and put on the resident's nose; -CNA H moved the bedside table to the resident; -CNA I ensured the resident had his/her call light and bed controls in his/her hand; -CNA H removed trash cups and papers from the resident's bedside table and picked up a pear from the resident table and the resident said he/she wanted to keep that pear; -CNA H put the pear back down on to the table; -CNA H put the trash in the red bag trash box in the room; -CNA H picked up the resident's cup from bedside table and took off the lid, poured water out of the cup into the sink and poured the contents of a new foam cup of water and ice from resident's bedside table into the resident's cup. He/she pushed the lid with straw back on the cup and put on the bedside table; -CNA I removed gown and gloves and washed hands at room and left the room to get more red bag trash boxes; -CNA H remained in room waiting for new red bag trash box to be brought to the room; -After putting boxes together and preparing soiled boxes he/she removed gown and gloves in the room and washed hands at sink and left the room. 4. Review of Resident #34's face sheet, showed the following: -admitted [DATE]; -Diagnosis included cellulitis (common and potentially serious bacterial skin infection) of buttock, chronic osteomyelitis (bone infection that occurs when bacteria invade and infect the bone tissue), pressure ulcer of sacral region stage 4 (severe pressure sore located on the sacrum (the bony area at the base of the spine) where the skin damage extends completely through all tissue layers), and urinary tract infection. Review of the resident's care plan, last updated 10/08/24, showed the following: -The resident was admitted with impaired skin integrity as evidenced by my being admitted with reoccurring chronic Stage 4 coccyx and right buttocks pressure ulcers; -Resident was dependent on staff for assistance with bed mobility; -Resident at risk for increased probability of infections; -Staff should clean hands before entering room before putting on gloves, between tasks as appropriate, and when leaving the room. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment on both sides of upper and lower body; -Dependent on staff for toileting hygiene, shower, and bed mobility; -Indwelling catheter. Observation on 01/29/25, at 9:00 A.M., showed the following: -RN B prepared wound care supplies at the treatment cart in the hallway for the resident; -He/she sprayed wound cleanser on gauze and put into a clean cup; -The nurse entered the resident room with supplies, placed supplies on a clean towel and a box of gloves on the bed; -The nurse applied a gown and gloves in room without using hand sanitizer or washing hands, the nurse said he/she had cleaned hands before preparing supplies; -The nurse moved the resident's bedside table and assisted the resident to roll to right side; -The nurse removed the soiled dressing and put it on resident's bed sheet; -The nurse wiped resident's buttock and back of upper thighs with wound cleanser on the gauze; -He/she picked up soiled gauze and dressing and took to trash can on the opposite of the bed; -He/she removed gloves and disposed in trash can; -He/she applied new gloves without using any hand sanitizer or washing hands; -Returned to the opposite side of the bed and applied a collagen pad to an area on the right buttock; -He/she then applied calcium alginate (a water-insoluble, cream-colored substance used in wound dressings) to the area on the coccyx; -He/she removed gloves and disposed to trash; -He/she put on new gloves without using any hand hygiene; -The nurse applied a protective outer dressing pad with tape and date; -He/she removed supplies from the bed, removed gloves and disposed of into the trash; -He/she applied new gloves without using hand sanitizer or washing hands; -Assisted the resident to roll to back side; -The nurse handed the resident bed controls and call light; -Then moved the bedside table to resident's bedside; -The nurse removed gloves and gown disposed to trash; -The nurse left the resident room and returned to treatment cart; -He/she had not completed hand hygiene; -He/she put on a glove and opened disinfecting wipe and briefly wiped the top of the treatment cart; -The nurse visited with a resident in the hallway and then gave the resident a fist bump; -The nurse turned to the treatment cart and used hand sanitizer and pushed cart down to nurse station. 31464 5. Review of the facility's policy entitled Feeding Tubes, undated, showed the following: -Purpose was to establish guidelines for the safe and effective management of feeding tubes in residents requiring enteral nutrition in long-term care facilities, ensuring compliance with clinical standards and regulatory requirements; -Feeding tube care will be managed to promote resident comfort, minimize complications, and ensure nutritional needs are met, in accordance with clinical guidelines and resident-specific care plans; -Inspect the tube site daily for signs of infection, leakage, or irritation and clean the site with antiseptic solution as per facility guidelines. Review of Resident #149's face sheet showed the following: -admitted [DATE]; -Diagnoses included stroke, right dominant side weakness, fluid buildup in the brain, dysphagia (swallowing disorder), feeding tube malfunction, generalized muscle weakness, and acid reflux. Review of the resident's discharge (return anticipated) MDS assessment, dated 12/21/24, showed the following: -Total dependence on others for all activities of daily living (ADLs); -Received intake via tube feeding. Review of the resident's care plan, last updated on 01/02/25, showed the following: -Feeding tube required related to dysphagia following a stroke; -Check PEG (percutaneous endoscopic gastrostomy; surgically placed feeding tube into the stomach) placement previous to flushes, medications, and feedings; -Cleanse PEG tube site and apply new drainage gauze every day shift. Review of the resident's current Physician Orders Sheet (POS) showed an order dated 12/23/24, to cleanse PEG tube site and apply new drainage gauze every day shift. Observation on 01/29/25, at 8:50 A.M., showed Registered Nurse (RN) B sanitized his/her hands, donned a surgical gown and gloves, and entered the resident's room. RN B removed the gown and gloves, exited the room, and returned to the treatment cart in the hallway. The RN retrieved spray wound cleanser from the drawer and sprayed it onto gauze he/she placed into a plastic cup, returning the cleanser to the drawer. Without performing hand hygiene, RN B donned a new gown and gloves and re-entered the resident's room. The RN spoke to the resident, raised the resident's nightgown, and cleansed the stoma site. Using the same gloves, the RN dried the site with gauze. Without performing hand hygiene, RN B changed gloves and placed and taped a clean dressing to the site. Without performing hand hygiene, the RN changed gloves, removed the protective boot from the resident's right foot to view the heel status, replaced the boot, then removed the gloves and washed his/her hands before exiting the room. 6. During an interview on 01/31/25, at 10:55 A.M., CNA H said that staff should completed hand hygiene before and after any resident care. He/she usually completed hand hygiene between glove changes. He/she said it was not appropriate to touch soiled trash or items and then touch the resident. During an interview on 01/31/25, at 9:25 A.M., Certified Medication Tech (CMT) J said staff should complete hand hygiene during every resident care, between dirty and clean, and between glove changes. Staff should clean their hands all the time. During an interview on 01/31/25, at 9:45 A.M., Licensed Practical Nurse (LPN) K said staff should complete hand washing or using hand sanitizer when doing wound care and with any resident care. Staff should clean hands before cares, when changing gloves, before putting on new gloves, and after cares. Staff should clean hands with all dirty to clean process. He/she said he/she took extra gloves and hand sanitizer into the room with wound care. During an interview on 01/29/25, at 3:00 P.M., RN B said that staff should clean hands with soap and water or hand sanitizer when entering a resident room. Staff should apply gloves, remove soiled items, and re-glove and keep re-gloving any time touch something different. He/she said sometimes he/she used hand sanitizer between glove changes. Staff should clean their hands between removing soiled peg tube dressing and applying clean gauze dressing. During an interview on 01/30/25, at 10:30 A.M., RN G said that all staff should wash hands before and after all resident cares, including wound care, catheter care, and peg tube care. Hands should be cleaned after removing soiled gauze and before putting on clean gauze. Staff should clean hands between glove changes and between any dirty and clean process. Staff should not touch dirty trash, laundry, or anything possibly soiled and then touch the resident for cares without cleaning hands and changing gloves. During an interview on 01/30/25, at 11:45 A.M., RN A said staff should wash hands or use hand sanitizer before and after every resident care. Staff should clean hands with every glove change. Staff should not touch any soiled items with gloved hands and then touch the resident without cleaning hands and changing gloves. Staff should clean hands between dirty and clean process of wound care, catheter care, and peg tube care. During an interview on 01/30/25, at 3:00 P.M., the Director of Nursing (DON) said staff should complete hand hygiene between every task, upon entering the resident room, when leaving the resident room, between meal tray pass, after personal breaks, and any time touch anything soiled. Staff should clean hands during catheter care or toileting care. Staff should change gloves and clean hands between dirty to clean process. The same with wound care, clean hands and change gloves dirty to clean process. During an interview on 01/30/25, at 3:25 P.M., the Administrator said that all staff are trained and in-serviced on appropriate hand hygiene. Staff should clean hands all the time, after any resident cares, any touch of any contaminated items, and between dirty and clean process. Staff should not have gloves on and push down the red bag trash or any other trash and then touch the resident without changing gloves or cleaning hands. 7. Review of the facility's policy entitled Enhanced Barrier Precautions (last reviewed 3/2024) showed the following: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities; -All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions; -All staff receive training on high-risk activities and common organisms that require EBP; -The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; -An order for EBP will be obtained for residents with wounds and/or indwelling medical devices such as urinary catheters and feeding tubes, even if the resident is not know to be infected or colonized with a MDRO; -PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's 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 providing hygiene, changing briefs or assisting with toileting, device care or use related to urinary catheters, and feeding tubes; -EBP 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; -For a resident who has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO, use EBP. Review of Resident #44's face sheet (shows basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included sepsis (infection in the bloodstream), gangrene (skin tissue death caused by an infection or lack of blood flow), below-the-knee amputation, chronic kidney disease stage 3, and neuromuscular dysfunction of the bladder. Review of the resident's significant change MDS, dated [DATE], showed the following information: -Cognition intact; -Bilateral lower limb impairment; -Indwelling catheter. Review of the resident's current POS, dated 01/31/25, showed orders for catheter care and monitoring. The POS did not include orders for EBP. Review of the resident's care plan, last updated 12/17/24, showed resident at risk for increased probability of infections. Place on EBP related to an indwelling Foley catheter and multiple wounds until resolved. Observation on 01/29/25, at 10:25 A.M., showed CNA C was in the resident's room, preparing to clean the resident's catheter. Upon the surveyor's entrance to the room, CNA C already wore gloves, but did not don a surgical gown. CNA C performed the catheter and peri area cleaning using pre-moistened wipes, bagged the trash, removed his/her gloves, and washed his/her hands at the resident's sink before exiting the room. During an interview on 01/29/25, at 10:35 A.M., the resident responded that the CNA did wash his/her hands prior to donning gloves. The resident said staff always wash their hands and don gloves before doing catheter and peri area cleaning, but he/she had not seen CNA C or other staff wear a surgical gown during that procedure. During an interview on 01/29/25, at 11:15 A.M., CNA C said he/she usually wore a gown and gloves to do catheter care and when assisting a nurse with wound care. The CNA said wearing the gown and gloves was based on the facility's EBP policy to protect the residents. During an interview on 01/29/25, at 4:25 P.M., CNA E said per facility policy staff should wash their hands and don a gown and gloves to assist residents on isolation, for catheter care, and any wound care. During an interview on 01/29/25, at 3:00 P.M., RN B said staff should use EBP including gown and gloves, for residents with open wounds, peg tubes, catheters. There should be a sign on that resident's door to remind staff when needed. During an interview on 01/30/25, at 10:30 A.M., RN G said staff should wear gown and gloves for EBP for residents with a catheter, wounds, or any indwelling medical device. During an interview on 01/30/25, at 11:45 A.M., RN A said staff should wear gown & gloves for residents with wounds, catheters, or tube feedings when completing personal cares. During an interview on 01/30/25, at 3:00 P.M., the DON said should use EBP for any resident that has a sign on their door, anyone with catheter cares, wound cares, open wounds, multi-drug resistant organisms, or peg tubes. 8. Review of a facility policy entitled Legionella Water Management Program, revised July 2017, showed the following information: -As part of the infection prevention and control program, the facility has a water management program, overseen by the water management team; -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaire's disease; -The water management program used by the facility is based on the Centers for Disease Control and Prevention (CDC) and ASHRAE (American Society of Heating, Refrigeration, and Air-Conditioning Engineers) recommendations for developing a Legionella water management program; -The water management program includes an interdisciplinary water management team; a detailed description and diagram of the water system in the facility, including: receiving, cold water distribution, heating, hot water distribution, and waste; the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP (continuous positive airway pressure; keeps the breathing airways open during sleep) machines, hydrotherapy equipment, etc.; -the identification of situations that can lead to Legionella growth, such as: construction, water main breaks, changes in municipal water quality, and the presence of biofilm, scale or sediment, water temperature fluctuations, water pressure changes, water stagnation, and inadequate disinfection; specific measures used to control the introduction and/or spread of Legionella; the control limits or parameters that are acceptable and that are monitored; a diagram of where control measures are applied; a system to monitor control limits and the effectiveness of control measures; -a plan for when control limits are not met and/or control measures are not effective; and documentation of the program; -The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: control limits not consistently met, major maintenance or water service change, any disease cases associated with the water system, or changes in laws, regulations, standards or guidelines. Review of facility's records showed the facility did not provide documentation related to water testing pertaining to the facility's Legionella program. During an interview on 01/30/25, at 1:43 P.M., the Maintenance Director said the following: -The facility used to complete Legionella testing with testing strips, but he could not recall when the last time this was completed.; -There were issues in the past with getting testing strips, but did not know if it were a current issue; -He did not know if the facility had any Legionella testing materials onsite. During an interview on 01/30/25, at 1:52 P.M., the Administrator said the following: -The facility does not complete Legionella testing; -The facility staff conduct regular running of water to prevent growth of Legionella; -She checks the water quality reports every six months and as any issues are identified; -If any water quality issues are identified related to Legionella the facility immediately stops usage of facility water and enacts the water management plan; -The facility would complete Legionella testing if any concerns related to Legionella testing were identified in the water quality report; -The facility does not maintain any Legionella testing materials onsite. 48534 34871

Based on observation, interview, and record review, the facility failed to ensure the home was administered in an effective and efficient manner to ensure the highest practical well-being of all residents when the facility failed pay their bills in a timely manner. The facility census was 44. 1. Review of the facility's laboratory service invoices showed the following: -An invoice, dated 07/08/24, showed an amount owed of $2664.31. The invoice showed a note of terms of net 30 days; -An invoice, dated 08/08/24, showed an amount owed of $241.41. The invoice showed a note of terms of net 30 days; -An invoice, dated 09/05/24, showed an amount owed of $3466.70. The invoice showed a note of terms of net 30 days; -An invoice, dated 10/28/24, showed an amount owed of $2880.47. The invoice showed a note of terms of net 30 days. Review of the laboratory's accounts receivable (A/R) aging detail spreadsheet which listed the invoices showed the following: -An invoice, dated 07/08/24 with a due date of 08/07/24. The invoice total and open balance due were $2664.31; -An invoice, dated 08/08/24 with a due date of 10/07/24. The invoice total and open balance due were $241.41; -An invoice, dated 09/05/24 with a due date of 10/05/24. The invoice total and open balance due were $3466.70. Review of the facility check dated 11/25/24, paid to the laboratory showed an amount of $10,918.42. Review of the laboratory's accounts receivable (A/R) aging detail spreadsheet which listed the invoices showed an invoice, dated 10/28/24 with a due date of 11/27/24. The invoice total and open balance due were $2880.47. During an interview on 01/29/25 at 2:58 P.M., the Business Office Manager (BOM) said he/she had received invoices from the company that had not been paid. The company provides laundry soap and kitchen and housekeeping chemicals. He/she and corporate staff received invoices from the providers usually through email. He/she reviewed the invoices to make sure they were correct and emailed them to the billing system which are approved by the regional manager to be paid. He/she did not know the process from there. During an interview on 01/30/25, at 2:03 P.M., the Director of Fiscal Services said the facility paid the bill on 11/25/24. She did not know why it was late. The company provided chemicals for the dishwasher and laundry. During an interview on 01/31/25, at 10:09 A.M., the Laboratory Company Representative said his/her company provided the dishwashing detergent and sanitizers for the kitchen dishwasher and laundry and housekeeping chemicals to the facility. The facility did not show the bill paid up and had not paid the bill since July 2024. During an interview on 01/30/25, at 1:32 P.M., and 01/31/25, at 1:33 P.M., the Administrator said she did not know of the laboratory bill being late. The BOM is responsible to submit the bills to the corporate staff. She expected the facility bills to be paid. MO00246960

Based on observation, interview, and record review, the facility failed to act as a fiduciary and properly manage residents' funds when the facility failed to maintain access to a petty cash fund that ensured all resident could receive cash requests of less than $100.00 (or less then $50.00 if the resident received Medicaid) the same day for three residents (Resident #1, #26, and #44) out of a total sample of 17 residents. The facility census was 44. Review of the facility policy titled, Personal Needs Allowance (PNA), revised February 2019, showed the following: -All patients that the facility receives the original income checks in full are to be credited with $50.00 to their PNA account; -Petty cash in the amount of $750.00 is to be kept for small requests and should be replenished on a as needed basis; -All patients must sign their request and receipts acknowledging receipt of funds. (The policy did not address how quickly residents should be able to obtain their funds.) 1. Review of the resident council minutes, dated 12/30/24, showed the facility's banking hours were 10:30 A.M. to 3:00 P.M. 2. Review of Resident #1's face sheet (admission data) showed the resident admitted to the facility on [DATE] and readmitted on [DATE]. Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/24/24, showed the resident had intact cognitive skills. Review of the resident's authorization for patient account, dated 11/14/24, showed the resident signed to delegate the nursing facility to handle his/her financial transactions on his/her behalf. Review of the facility's maintained resident fund account showed as of 01/29/25 the resident with an ending balance of $38.76. During an interview on 01/28/25, at 10:15 A.M., during the group interview, the resident said he/she would like to have access to his/her funds available on the weekend. He/she had family visit this past weekend and wanted more money. 3. Review of Resident #26's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the resident had intact cognitive skills. Review of the resident's authorization for patient account, undated, showed the resident signed to delegate the nursing facility to handle his/her financial transactions on his/her behalf. Review of the facility's maintained resident fund account showed as of 01/29/25, the resident had a balance of $422.01. During an interview on 01/28/25, at 10:15 A.M., during the group interview, the resident said if he/she forgets to ask for his/her money during the week, he/she would like his/her personal funds on the weekends. 4. Review of Resident #44's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the resident's cognitive skills were moderately impaired. Review of the resident's authorization for patient account, undated, showed the resident signed to delegate the nursing facility to handle his/her financial transactions on his/her behalf. Review of the facility's maintained resident fund account showed as of 01/29/25, the resident had a balance of $637.00. During an interview on 01/28/25, at 12:50 P.M., the resident said he/she keeps in mind the time limits to access his/her money, but he/she plans ahead so it had not been an issue for him/her. There was a time when he/she wanted to buy a snack, but he/she did not have money to do so because it was outside the timeframe to obtain his/her money from the facility. He/she would like to have more access to his/her money. 5. Observations throughout the survey, 01/26/25 through 01/31/25, showed a laminated sign posted at the front office located near the facility entrance door which stated Resident trust banking Monday through Friday 10:30 A.M. until 3:00 P.M. 6. During an interview on 01/28/25, at 10:54 A.M., the Activity Director said the following: -The front office is open Monday through Friday from 10:30 A.M. to 3:00 P.M. if a resident wants cash; -The Business Office Manager (BOM) informs the resident how much money is available; -Residents sign a receipt book and the BOM writes it down on the log; -All the residents are pretty good about getting their money from 10:30 A.M. to 3:00 P.M. Monday through Friday; -Some residents occasionally say they want money after 3:00 P.M.; -He/she had heard residents say they have to wait till tomorrow to get money; -Residents did not have access to cash on the weekends. During an interview on 01/29/25, at 2:58 P.M., the BOM said the following: -He/she is responsible for the resident fund accounts; -Residents ask him/her for cash; -He/she writes the requested cash on a list and the resident signs a receipt; -Residents can access cash Monday through Friday from 8:00 A.M. to 4:30 P.M. The facility tries to have the banking hours from 10:30 A.M. to 3:00 P.M., but if a resident needs cash before then, staff can get the cash for them; -Residents come to the office to access cash and have it for the weekend; -Residents cannot get cash after hours or on the weekends. During an interview on 01/29/25 at 10:34 A.M., Registered Nurse (RN) A said residents cannot get money on the weekends because there is no one in the front office. During an interview on 01/29/25, at 11:29 A.M., the Director of Nursing (DON) said the following: -Residents go to the front office and ask the BOM for cash Monday through Friday during banking hours; -The resident are not able to get money on the weekends; -The residents know the office is closed on Saturday and Sundays. During an interview on 01/30/25, at 1:32 P.M., the Administrator said the following: -Residents access funds Monday through Friday from 10:00 A.M. to 3:00 P.M.; -Residents use the soda machine or the local store so staff get enough money for them to have until Monday.

Based on observation and interview, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment when a handrail in a common area remained in an unsafe condition, chair cushions in a common area were in disrepair, and two walls of one resident's (Resident #16) room were damaged. A sample of 17 residents was reviewed; the facility census was 44. Review of a facility policy entitled Maintenance Service, revised December 2009, showed the following: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include maintaining the building in good repair and free from hazards; -The Maintenance Director is responsible for maintaining work order requests. Review of the facility policy entitled Quality of Life - Homelike Environment, revised May 2017, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment; -Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment, inviting colors and decor, and personalize furniture and room arrangements. 1. Observation on 01/29/25, at 8:15 A.M., and on 01/30/25, at 8:20 A.M., of the 100 hall TV lounge area showed the following: -One rocking chair with a 4 to 6 inch tear in the right side of the cushion cover, exposing the foam interior and plastic piping with two rough/sharp ends, and a 3 to 4 inch tear on the left side exposing the plastic piping; -A second rocking chair with two 2 to 3 inch tears to the top of the cushion, revealing the inner foam. During an interview on 01/31/25, at 9:08 A.M., Certified Nurse Aide (CNA) L said he/she had not noticed the torn rocking chair cushions in the 100 hall TV lounge area. Several residents do like to sit there to watch TV. During an interview on 01/31/25, at 9:11 A.M., Certified Medication Tech (CMT) J said he/she was unaware of the torn rocking chair cushions. During an interview on 01/31/25, at 11:48 A.M., the Director of Nursing (DON) said he/she not aware of lounge rocking chair cushions that were torn with inner foam and piping exposed. Staff should have reported that to housekeeping. During an interview on 01/31/25, at 1:32 P.M., the Administrator said he/she was not aware of the torn rocking chair cushions. Staff should have told housekeeping or maintenance and those cushions should be thrown away and replaced. 2. Observations on 01/26/25, at 4:17 P.M., on 01/29/25, at 12:05 P.M., and on 01/30/25, at 12:05 P.M., of the hallway outside the dining room showed the handrail end cap was off and resting on top of the railing. The uncapped handrail end had two sharp connector edges, approximately 6 inches from the doorway into the dining room. The handrail was located directly under a hand sanitizer gel dispenser and adjacent sign board listing the meal service times. Review of the Maintenance Request Log located at the nurses' desk showed staff did not document repair needed to the hand rail outside the dining room. During an interview on 01/30/25, at 1:34 P.M., the Maintenance Director said nobody had told him/her about the broken hand rail. During an interview on 01/31/25, at 11:48 A.M., the DON said he/she was not aware of an issue regarding a hand rail that was in need of repair. 48534 3. Review of Resident #16's face sheet (gives basic profile information) showed an admitted facility on 06/13/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/27/24, showed the following information: -Severely impaired cognition; -Able to self propel wheelchair; -Required partial assistance for dressing, bathing, transfers, and toileting. Observations on 01/27/25, at 2:10 P.M., on 1/29/25 at 8:05 A.M., and on 1/31/25, at 9:25 A.M., of the resident's room showed the wall along bed had damage to an area at least 4 feet wide by 3 feet high. The area had multiple gouges of varying lengths, widths, and depths that penetrated through the paint, drywall paper, and drywall. Areas of orange coloring were visible in numerous spots where the paint and drywall paper was peeled/curled back. Observation and interview on 01/31/25, at 1:16 P.M., in the resident's room showed the resident in his/her room, sitting in a wheelchair. The 4 to 6 inch wall to the left of the sink area was visibly damaged, with egg-sized pieces of the drywall and part of the vinyl baseboard missing. During the observation, the resident said the walls looked messy. He/she said it looked like they had been hit quite a few times with wheelchairs or something, and he/she would like it to be fixed. Review of the Maintenance Request Log located at the nurses' desk showed staff did not document repair needed to the resident's walls. During an interview on 01/31/25, at 9:14 A.M., the Maintenance Supervisor said he/she was not aware of the condition of the resident's walls and it was not on the list of rooms needing repairs. The condition of the resident's walls was unacceptable. During an interview on 01/31/25, at 11:24 P.M., the Administrator said he/she was not aware of the condition of the resident's walls. The resident's room was not on the list of rooms that needed repairs. The condition of the resident's walls was unacceptable. 4. During an interview on 01/31/25, at 9:08 A.M., CNA L said staff should report maintenance needs and repair requests to the Maintenance Director or put it on the Maintenance Log at the nurses' desk. During an interview on 01/31/25, at 9:11 A.M., CMT J said staff should log in maintenance requests/repairs needed on the book at the nurses' desk. The Maintenance Director checked the log daily. During an interview on 01/31/25, at 10:40 A.M., Registered Nurse (RN) A said staff should put maintenance requests on the log at the nurses' desk. During an interview on 01/31/25, at 9:14 A.M., the Maintenance Supervisor said staff were to log any request for repairs in the maintenance log book. He/she had a list of rooms that needed repairs. During an interview on 01/31/25, at 11:48 A.M., the DON said staff should report all maintenance issues to the Maintenance Director by putting it on the log at the nurses' desk. The Maintenance Director checked the log every morning. During interviews on 01/31/25, at 11:24 P.M. and 1:32 P.M., the Administrator said the staff should log all maintenance request in the maintenance log book or telling the Maintenance Supervisor directly if the repair is more urgent.

Based on observation, interview, and record review, the facility failed to have a system or records that showed provided an accurate reconciliation of controlled medications when facility's licensed staff failed to ensure the Emergency Kit (E-Kit) and the form titled BNDD (Bureau of Narcotics and Dangerous Drugs) Kit Administration Record matched the current narcotic count, when a random count of the narcotics in the E-Kit with the nurse did not match. The facility census was 44. Review of the facility provided policy titled BNDD Kit Policy, dated March 2019, showed the following: -The BNDD kit is owned, managed, and controlled by the long-term care facility; -The BNDD kit will be used when extenuating circumstances exist; -When accessing/opening the BNDD kit the nurse will contact the physician to obtain an order to access the BNDD kit and an order to administer the medication; -The nurse opening the BNDD kit will fill out the form titled Missouri Emergency Kit Order/Audit Form with a witness nurse; -A physical count will be performed on each medication each time the BNDD kit is opened. The quantity on hand shall be documented for each medication listed on the Order/Audit Form; -If a medication is removed from the BNDD kit for administration to a resident that quantity shall be documented in the column QTY ORDERED. This is the quantity that the nurse is requesting that the pharmacy replenish; -If a medication is added to the BNDD kit that quantity shall be documented in the QTY REFILLED. This is the quantity the pharmacy sent as a replacement for what needs to be replaced; -Two nurses shall initial the counts on the Order/Audit form each time the BNDD kit is opened; -The tag numbers shall be documented on the bottom of the Order/Audit form; -The Order/Audit form shall be faxed to the pharmacy upon completion so that the pharmacy knows to replenish the desired medication; -When removing a dose from the BNDD kit the nurse shall document the utilization on the BNDD kit administration record; -A daily shift audit will be performed on the tag numbers and documented on the Tag Log Audit Form; -The DON and/or consultant pharmacist will perform a periodic audit of BNDD kit utilization and records; -An annual physical inventory will be taken on the BNDD kit; -A list of the contents of the BNDD kit shall be displayed on the outside of the container; -A soonest to expire date shall be displayed on the outside of the container. 1. During observation, record review, and interview on 01/29/25, at 2:12 P.M., Registered Nurse (RN) A said the following: -The E-Kit was currently located in the locked black medication cart near the medication room. The cart had a key for the outside of cart and a key for the locked narcotic box on the inside. They did not use lock/tag numbers. The charge nurse was the only one that had the keys to the cart. The nursing staff did not count this cart at shift change. The medications were only counted when the nurse entered to sign out a medication. There was not a two person count of this cart. When signing out a medication, the staff person counted the pills and then sign out the needed medication on the log. The count should match the previous logged out dose. The current count of the Hydrocodone (controlled medication used to treat pain) 5/325 milligrams (mg) showed 6 tablets in cart and 5 tablets on the log. The nurse stated that it should be 6 tablets on the log and he/she would make the correction in the log. He/she said someone just documented incorrectly; -Review of the record, titled BNDD Kit Administration Record, showed the following: -The three-ring binder showed seven pages for the month of January; -On 01/10/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 10 on hand, 1 used, and 9 remaining; -On 01/11/25, staff signed out one dose of un-named medication, dosage 5/325 mg and showed 8 on hand, 1 used, and 7 remaining; -On 01/12/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 7 on hand, 1 used, and 8 crossed out to show 6 on hand; -On 01/13/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 6 on hand, 1 used, and 5 remaining; -On 01/13/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 6 on hand, 1 used, with 5 remaining; -On 01/23/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 9 on hand, 1 used and 8 remaining; -On 01/23/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 8 on hand, 1 used and 7 remaining; -On 01/24/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 7 on hand, 1 used and 6 remaining; -On 01/25/25, staff signed out one dose of Hydrocodone 5/325 mg and showed 6 on hand, 1 used and 5 remaining; -On 01/29/25, observation showed Hydrocodone 5/325 mg with 6 tablets in the cart and 5 tablets on the log. During an interview on 01/30/25, at 10:30 A.M., RN G said the nurses were not counting the E-Kit each shift. The nurse counted the medication at the time of need. When pulling a medication, the nurse had to look back on the log and find the last time someone used the specific medication they were checking out and then add this to the log on the next open line. During an interview on 01/30/25, at 11:45 A.M., RN A said that the Director of Nursing (DON) stocks the E-Kit cart when the medications arrived from the pharmacy. The pharmacy does not enter the E-Kit or write on the log. When the nurse opened the cart he/she wrote the amount of the specific medication he/she was checking out. There was not a full count done with two nurses at each shift or when checking out medications. The log and amount available should match. He/she fixed the log from the inaccuracy on 01/29/25. During an interview on 01/30/25, at 12:00 P.M., the DON said that the current E-Kit was temporary, and they had used this set up for less than two months. The E-Kit was the black and red medication cart located near the medication room. The narcotics were double locked in the cart. The pharmacy delivered the medications and the nurses put all the non-narcotics in the E-Kit and the DON stocked the narcotics. She did not make any note that medications were added into the log. The pharmacy told the DON to put the medications into the cart and then circle on the packing sheet if anything was missing and return the packing sheet to the pharmacy. The nursing staff did not count the E-Kit narcotics every shift, they only count the specific medication needed by themselves when checking out a narcotic. The DON reviewed the log and noted areas where the staff only wrote the strength and did not write the medication name. She said that she had asked the nurses to write the name and strength of the medication in the QTY Ordered line. She audited the E-Kit on Mondays. During an interview on 01/30/25, at 12:15 P.M., the Administrator said she was not aware of the E-Kit process but was aware that it was rocky at the time. She said the facility was in the process of transitioning. She thought they had been using the current system since December.

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #34) Foley catheter (sterile tube inserted into the bladder to drain urine) bag (bag that collects urine drained from a catheter inserted into the bladder) and when staff yelled in the dining room, and when the facility smoking scheduled was at the same time as lunch causing smoking residents to choose between smoke break and a hot meal. The facility census was 44. Review of facility policy titled Procedure for Ensuring Resident Rights, dated 2025, showed the following: -Residents are encouraged to participate in the Resident Council; -The facility will support and facilitate resident-led discussions on improving care; -No staff member may interfere with or retaliate against residents for voicing concerns. 1. Review showed facility did not provide a policy related to catheter. Review of Resident #34's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder), urinary retention, and urinary incontinence. Review of the resident's care plan, dated last updated 10/08/24, showed the following: -The resident required an indwelling urinary catheter due to diagnosis of neurogenic bladder; -The resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma; -Staff should provide catheter care per facility protocol or doctor's orders; -Store collection bag inside a protective dignity pouch. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/28/24, showed the following: -Cognitively intact; -Had an indwelling catheter (thin, hollow tube that's inserted into the bladder to drain urine). Review of the resident's physician's order sheet (POS), current as of 01/31/25, showed the following: -An order, dated 05/07/24, to check placement of Foley catheter securement device (anchor) and dignity bag (bag used to cover and hold the catheter collection bag so it is not visible) every shift; -An order, dated 10/01/24, to change Foley catheter bag monthly and as needed; -An order, dated 10/08/24, for Foley catheter care every shift and as needed; -An order, dated 10/18/24, to change Foley catheter monthly and as needed. Observation of the resident showed the following: -On 01/26/25, at 5:01 P.M., the resident was in bed with his/her eyes closed. A catheter bag was visible on left side of bed facing the open door with about 100 cubic centimeter (cc - a unit of volume used to measure liquids and medications) yellow urine visible. The catheter bag was not covered with a dignity cover; -On 01/27/25, at 3:29 P.M., the resident was in bed with eyes closed. The catheter bag was facing the door with yellow urine visible from hallway; -On 01/28/25, at 9:42 A.M., the resident was in bed with housekeeping in the room and nursing staff providing medications. The catheter bag was facing the door with about 200 cc yellow urine visible; -On 01/28/25, at 12:37 P.M., the resident was resting in bed with eyes closed. The catheter bag was facing the door with no dignity cover and had about 300 cc yellow urine visible from the hallway; -On 01/28/25, at 2:00 P.M., the resident was in bed on the telephone. The catheter bag was visible with over 300 cc urine visible from the hall. During an interview on 01/29/25, at 1:10 P.M., Certified Nurse Aide (CNA) C said that catheter bags should be in a dignity bag when resident is in a wheelchair or in the common areas. The catheter bag did not necessarily need to be in privacy bag when the resident was in their room unless the resident wanted that. He/she said that if the care plan had dignity bag us on it, then it should be done. During an interview on 01/29/25, at 1:25 P.M., CNA D said catheter bags should be in a dignity bag at all times so it was not visible to others. During an interview on 01/29/25, at 2:15 P.M., CNA E said residents should have catheter bags in dignity bag when out in public, but not necessarily in a dignity bag when in their room unless they want it. If it in their care plan to use one, then staff should follow care plan. During an interview on 01/29/25, at 2:24 P.M., Certified Medication Tech (CMT) F said catheter bags should be kept in dignity bags. During an interview on 01/29/25, at 3:00 P.M., Registered Nurse (RN) B said catheters should be covered if the resident wants it covered. Some residents do not care whether it is covered in their room or out of their room and just want to get to the activity. During an interview on 01/30/25, at 10:30 A.M., RN G said that catheter bags should be in a dignity bag at all times. Even in resident rooms the catheter bag should be in a cover because the resident might have a visitor. During an interview on 01/30/25, at 11:45 A.M., RN A said catheter bags should always be in a dignity bag, even in the resident room. During an interview on 01/30/25, at 3:00 P.M., the Director of Nursing (DON) said catheter bags should be in dignity covers. They should not be visible in common areas or in resident rooms. The bag should not be visible in resident rooms from the hallway. If a resident's care plan states a dignity bag should be used, there really should be a dignity bag. During an interview on 01/30/25, at 3:25 P.M., Administrator said staff should ensure that resident catheter bags were in dignity covers at all times. 2. Observation on 01/26/25, at 5:30 P.M., showed the Dietary Manager (DM) yelling does everyone have their food. Raise your hand if you do not. Observation on 01/29/25, at 1:09 P.M., showed the DM yelling, from behind the serving area to residents, who were sitting at their tables throughout the dining room, asking the residents if they wanted seconds. CNA C responded there is no need to yell. Observation on 01/31/25, at 12:42 P.M., showed Dietary Aide (DA) R behind the serving area yell through the dining room to Resident #19, do you want cheese. During an interview 01/31/25, at 8:50 A.M., Resident #41 said that staff often yell at meals, but they have to check who does not have food, they probably could be quieter. During an interview on 01/30/25, at 12:50 P.M., Resident #29 said mealtime in the dining room was very loud because of the staff yelling and some residents playing music. During an interview on 01/31/25, at 12:42 P.M., the DM said the he/she ensured that all residents had received their meals by checking all meal tickets and by screaming through the dining room asking the residents if they had received their food. During an interview on 01/31/25, at 10:57 A.M., the DON said a lot of yelling goes on during mealtime that is not necessary. The DON had spoken with the DM about the yelling during meal time. Facility staff members have complained about the DM yelling during meal time. Staff should be using their inside voice when in the building. The staff who are serving meals could ensure that all residents have received their meals so the DM would not have to yell. During an interview on 01/31/25, at 11:24 A.M., the Administrator said there was sufficient staff in the dining room to ensure that all residents received their meals. The kitchen staff should not be yelling through the dining room to the residents. 48534 3. Observation on 01/29/25, at 12:40 P.M., showed the following: -Resident #33 eating lunch when CNA D asked the resident if he/she was going to eat or go out and smoke. The resident stayed at the table and finished his/her food; -Resident #14 was eating lunch when CNA D asked the resident, do you want to smoke or eat. We'll put a cover over your food and you can eat when you come back. The resident took a bite of his/her ham and beans and left the dining room to smoke. CNA C put a food cover over the resident's food that was left on the table. Observation on 01/30/25, at 12:45 P.M., of the lunch serve out showed the following: -DA N prepared Resident #14's plate and sent to be served to the resident. Resident #14 was outside smoking. The plate was put to the side and left uncovered; -DA N prepared Resident #33's plate and sent to be served to the resident. Resident #33 was outside smoking. The plate was put to the side and left uncovered. During an interview on 01/30/25, at 12:50 P.M., Resident #29, who was in the smoking area, said the he/she was often made to choose between smoking or eating. Meals being served by kitchen staff are often not on time. He/she had to leave his/her food on the table, and go smoke during smoking time. He/she would return to the dining room to finish the meal, which was often cold by this time. During an observation on 01/30/25, at 12:50 P.M., of Resident #33, who was in the smoking area said, It's time to go eat my cold sandwich. During an interview 01/31/25, at 8:50 A.M., Resident #41 said sometimes he/she had to choose between the schedule cigarette break and having a hot lunch because the staff would not take the residents to smoke until the next scheduled smoke break at 3:30 P.M. During an interview on 01/30/25, at 12:51 P.M., Housekeeper (HK) Q, who was supervising residents smoking, said the following he/she was told residents had to smoke at designated smoking times or they would not be allowed to smoke until the next designated smoking time. There were no exceptions or altering of the designated smoking times. Lunch is often served late and residents often had to choose between smoking and eating a warm meal. During an interview on 01/31/25, at 10:57 A.M., the DON said meals were not always served on time. When meals were served late residents should be given the option to smoke when they are done eating. Residents should not be made to choose between eating a hot meal or smoking.

Based on observation, interview, and record review, the facility failed to assess the use of a seat belt, failed to obtain written consent for use of the seat belt, failed to document what less restrictive options were attempted, failed to document risk versus benefit review related to the seat belt use, failed to obtain a physician's order for use of the seat belt, and failed to care plan the use of the seat belt for one resident (Resident #11) who was unable to effectively and consistently remove the seat belt without staff assistance. The facility census was 44. Review of the facility provided policy titled Use of Restraints, dated December 2007, showed the following: -Restraints should only be used for the safety and well-being of the resident and only after alternatives have been tried unsuccessfully; -Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls; -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body; -The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint; -Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to treat the medical symptom, to protect the resident's safety, and to help the resident attain the highest level of his/her physical or psychological well-being; -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms; - Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor); -The order shall include the specific reason for the restraint (as it relates to the resident's medical symptom), how the restraint will be used to benefit the resident's medical symptom, and the type of restraint, and period of time for the use of the restraint.; -Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment; -Reorders are issued only after a review of the resident's condition by his or her physician; -Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident; -Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency; -Restraints with locking devices shall not be used; -A resident placed in a restraint will be observed at least every thirty minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record; -The opportunity for motion and exercise is provided for a period of not less than ten minutes during each two hours in which restraints are employed; -Restrained residents must be repositioned at least every two hours on all shifts; -Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use; -Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination; -Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms; -Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. 1. Review of Resident #11's face sheet (brief information sheet about the resident), showed the following: -admitted [DATE]; -Diagnoses included quadriplegia (partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), degenerative disorders of nervous system (group of conditions that affect the nervous system, causing progressive deterioration and loss of function over time), inclusion body myositis (a rare, chronic, and progressive muscle disease characterized by inflammation and muscle weakness), post traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying even). Observation and interview on 01/27/25, at 3:36 P.M., showed the following: -Certified Nurse Aide (CNA) H and CNA I entered the resident room with the Hoyer lift (mechanical lift used for non-weight bearing transfers); -Resident was seated in the electric wheelchair, covered with a blanket; -Staff removed the resident's blanket, the resident had a seatbelt across his/her lab; -CNA H unbuckled and removed the seatbelt; -The staff transferred the resident to the bed; -The staff completed resident personal cares; -The staff transferred the resident back to the wheelchair with the Hoyer lift; -The resident requested CNA H re-applied the seatbelt. CNA buckled the belt across the resident's lap area. Review of the resident's significant change in condition Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/30/24, showed the following: -Cognitively intact; -Restraints not used in chair or bed; -Required use of motorized wheelchair. Review of the resident's care plan, last updated on 01/06/25, showed the following: -Resident was admitted with specialized high back wheelchair with arms that hold his/her phone and tablet for ease of use; -Staff should Instruct his/her in the use of the wheelchair as needed; -Resident's wheelchair was his/her main mode of transportation; -Staff should assist the resident with mobility as necessary; -Resident was at risk for falling related to inability to ambulate; -Staff should encourage resident to use environmental devices such as hand grips or handrails. (Staff did not care plan related to resident's use of the seat belt.) Review of the resident's Physician's Order Sheet (POS), current as of 01/30/25, showed no orders for use of a seatbelt or restraint. During an interview on 01/27/25, at 4:27 P.M., the resident said he/she had a seatbelt on wheelchair. He/she was not able to take it off. He/she was aware the seatbelt was considered a restraint, but he/she had enough motion in his/her upper torso that he/she would adjust too much or have a muscle spasm was afraid of falling out of the wheelchair. The resident said he/she was of sound mind and wanted to have the seatbelt and he/she had signed consent. During an interview on 01/30/25, at 10:30 AM., Registered Nurse (RN) G said the resident had a seatbelt in his/her wheelchair and thought that most staff knew that. He/she said would think it was on the care plan, but did not know. He/she was aware of the seatbelt just from working with resident and in report. During an interview on 01/30/25, at 11:45 A.M., RN A said he/she was not sure if the resident had a seatbelt for his/her wheelchair, but if he/she did then he/she should be able to unbuckle him/herself, or it would be considered a restraint. He/she did not know the facility policy about restraints. He/she said there should be a physician's order, it should be in the care plan, and it would require close monitoring if used. During an interview on 01/29/25, at 2:15 P.M., CNA E said the resident had a seatbelt on his/her wheelchair that he/she requested. It should be in the care plan. The resident was repositioned in the wheelchair throughout the day and staff lay him/her down throughout the day for personal cares and to give him/her a break from the wheelchair. During an interview on 01/29/25, at 2:30 P.M., the Director of Nursing (DON) said the resident had a seatbelt in his/her wheelchair and that should be in the care plan. He/she did not know if there was signed consent for the seatbelt or a physician's order, but that should have been completed prior to using the seatbelt. During an interview on 01/29/25, at 2:45 P.M., the Administrator said she was not aware that the aides were putting the seatbelt on for the resident. The resident was not supposed to have a seatbelt. She had discussed with the resident in the past that it was a restraint, and the facility did not allow restraints. The resident had a fear of falling due to past trauma. His/her wheelchair was able to incline and decline. There was not any paperwork completed for consent or risks because the facility did not allow restraints.

Based on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: -It was the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person; -If there was any allegation of abuse, then the facility must report immediately to the administrator and to State Survey Agency, no later than two hours; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -Sexual abuse was the non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intended to inflict injury or harm. Any touching or exposure of the anus, breast or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included depression, obesity, and panic disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/17/24, showed the resident's cognitive skills were intact and resident had no behaviors. Review of the resident's care plan, dated 06/26/24, showed the resident was at risk for mood problems as evidenced by his/her mood interview score. Staff to allow the resident to have control over situations, if possible. During an interview on 03/27/25, at 11:24 A.M., the resident said the following: -One evening, he/she played games in the main dining room and Resident #2 came into the dining room and came to him/her like he/she was going to kiss him/her; -He/she moved Resident #2 back and the resident came and gave him/her a quick kiss on the lips; -Resident #2 did hand gestures referring to his/her chest area. Resident #2 did not touch him/her; -He/she thought the kiss was gross and creepy; -He/she reported this to Licensed Practical Nurse (LPN) D. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, cognitive communication deficit, and depression. Review of the resident's care plan, dated 12/05/24, showed the following: -The resident has a serious mental illness, intellectual disabilities, and a related condition; -Staff to address emotional issues; -The resident had cognitive loss and dementia; -Staff to provide cues and supervision to resident. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitive skills severely impaired; -Rejection of care one to three days. Review of the resident's progress note dated 03/21/25, at 9:08 P.M., showed LPN D documented a resident (Resident #1) reported that Resident #2 made him/her uncomfortable. Resident #1 reported that Resident #2 came up to him/her in front of another resident and kissed him/her on the mouth. Resident #1 said he/she pushed Resident #2 and said no that is not ok. Resident #2 laughed as if it was funny. Resident #1 also reported that Resident #2 made gestures to him/her when he/she passes by. Resident #1 reports he/she felt uncomfortable and unsafe. 3. Review of DHSS records showed the facility reported the allegation of abuse to the state on 03/24/25 at 11:43 A.M. (three days after the allegation of abuse was made by Resident #1). 4. During an interview on 03/27/25, at 2:18 P.M., LPN D said the following: -On 03/21/25, Resident #1 came up to him/her and said Resident #2 came up and kissed him/her on his/her lips. Resident #1 said it made him/her feel weird; -LPN D texted the Director of Nursing (DON) on 03/21/25 of the incident; -Staff monitored Resident #2 with 15-minute checks; -The DON educated him/her the next time he/she was at the facility to report that Resident #1 said this incident made him/her feel unsafe; -LPN D considered the unwanted kiss as sexual abuse. During interviews on 03/27/25, at 1:30 P.M. and 02:30 P.M., the DON said the following: -LPN D reported to her that the resident said the kiss was unwanted and not to do it again; -LPN D texted her on Friday, 03/21/25, that Resident #1 said Resident #2 walked right up to him/her and kissed Resident #1 on his/her lips. Resident #1 said it was fast and it made him/her feel weird. Resident #1 told Resident #2 that it was not ok; -The DON said she did not know why she (the DON) did not call the allegation of abuse into the state; -LPN D reported that the resident went up and kissed Resident #1; -Resident #1 did not report Resident #2 made inappropriate gestures toward him/her. During interviews on 03/27/25, at 2:00 P.M. and 2:30 P.M., the Administrator said the following: -The allegation of abuse should have been reported to her and the state timely; -She found out about the incident on Saturday (03/22/25) and did not have all the information until Monday (03/24/25) when she talked to Resident #1; -On Sunday, 03/23/25, the DON reported that LPN D called her and said Resident #2 tried to kiss Resident #1; -After she talked to Resident #1 on Monday morning (03/24/25), it was a different story. Resident #1 said Resident #2 came up to tried to kiss him/her and he/she pushed Resident #2 away and said no, Resident #2 came back and forcibly kissed him/her on the lips and made a motion with his/her hands towards him/her; -Staff should had reported the incident immediately and reported to the state sooner. During an interview on 03/27/25, at 10:00 A.M., Certified Medication Technician (CMT) E said the following: -Examples of sexual abuse include touching inappropriate, kissing and fondling; -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:09 A.M., the Housekeeping Supervisor said the following: -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:47 A.M., Certified Nurse Aide (CNA)/CMT F said the following: -Staff should report immediately an allegation of abuse to the supervisor, charge nurse, DON or the administrator; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 1:30 P.M., the DON said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor; -Staff should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 2:00 P.M., the Administrator said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor and the supervisor reports to the administrator; -Staff should notify the state of any allegation of abuse within two hours. MO00251591

Based on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: -It was the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person; -If there was any allegation of abuse, then the facility must report immediately to the administrator and to State Survey Agency, no later than two hours; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -Sexual abuse was the non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intended to inflict injury or harm. Any touching or exposure of the anus, breast or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 12/26/24; -Diagnoses included depression, obesity, and panic disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/17/24, showed the resident's cognitive skills were intact and resident had no behaviors. Review of the resident's care plan, dated 06/26/24, showed the resident was at risk for mood problems as evidenced by his/her mood interview score. Staff to allow the resident to have control over situations, if possible. During an interview on 03/27/25, at 11:24 A.M., the resident said the following: -One evening, he/she played games in the main dining room and Resident #2 came into the dining room and came to him/her like he/she was going to kiss him/her; -He/she moved Resident #2 back and the resident came and gave him/her a quick kiss on the lips; -Resident #2 did hand gestures referring to his/her chest area. Resident #2 did not touch him/her; -He/she thought the kiss was gross and creepy; -He/she reported this to Licensed Practical Nurse (LPN) D. 2. Review of Resident #2's face sheet showed the following: -admission date of 09/23/24; -Diagnoses included Alzheimer's disease, cognitive communication deficit, and depression. Review of the resident's care plan, dated 12/05/24, showed the following: -The resident has a serious mental illness, intellectual disabilities, and a related condition; -Staff to address emotional issues; -The resident had cognitive loss and dementia; -Staff to provide cues and supervision to resident. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitive skills severely impaired; -Rejection of care one to three days. Review of the resident's progress note dated 03/21/25, at 9:08 P.M., showed LPN D documented a resident (Resident #1) reported that Resident #2 made him/her uncomfortable. Resident #1 reported that Resident #2 came up to him/her in front of another resident and kissed him/her on the mouth. Resident #1 said he/she pushed Resident #2 and said no that is not ok. Resident #2 laughed as if it was funny. Resident #1 also reported that Resident #2 made gestures to him/her when he/she passes by. Resident #1 reports he/she felt uncomfortable and unsafe. 3. Review of DHSS records showed the facility reported the allegation of abuse to the state on 03/24/25 at 11:43 A.M. (three days after the allegation of abuse was made by Resident #1). 4. During an interview on 03/27/25, at 2:18 P.M., LPN D said the following: -On 03/21/25, Resident #1 came up to him/her and said Resident #2 came up and kissed him/her on his/her lips. Resident #1 said it made him/her feel weird; -LPN D texted the Director of Nursing (DON) on 03/21/25 of the incident; -Staff monitored Resident #2 with 15-minute checks; -The DON educated him/her the next time he/she was at the facility to report that Resident #1 said this incident made him/her feel unsafe; -LPN D considered the unwanted kiss as sexual abuse. During interviews on 03/27/25, at 1:30 P.M. and 02:30 P.M., the DON said the following: -LPN D reported to her that the resident said the kiss was unwanted and not to do it again; -LPN D texted her on Friday, 03/21/25, that Resident #1 said Resident #2 walked right up to him/her and kissed Resident #1 on his/her lips. Resident #1 said it was fast and it made him/her feel weird. Resident #1 told Resident #2 that it was not ok; -The DON said she did not know why she (the DON) did not call the allegation of abuse into the state; -LPN D reported that the resident went up and kissed Resident #1; -Resident #1 did not report Resident #2 made inappropriate gestures toward him/her. During interviews on 03/27/25, at 2:00 P.M. and 2:30 P.M., the Administrator said the following: -The allegation of abuse should have been reported to her and the state timely; -She found out about the incident on Saturday (03/22/25) and did not have all the information until Monday (03/24/25) when she talked to Resident #1; -On Sunday, 03/23/25, the DON reported that LPN D called her and said Resident #2 tried to kiss Resident #1; -After she talked to Resident #1 on Monday morning (03/24/25), it was a different story. Resident #1 said Resident #2 came up to tried to kiss him/her and he/she pushed Resident #2 away and said no, Resident #2 came back and forcibly kissed him/her on the lips and made a motion with his/her hands towards him/her; -Staff should had reported the incident immediately and reported to the state sooner. During an interview on 03/27/25, at 10:00 A.M., Certified Medication Technician (CMT) E said the following: -Examples of sexual abuse include touching inappropriate, kissing and fondling; -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:09 A.M., the Housekeeping Supervisor said the following: -Staff should report immediately an allegation of abuse to the supervisor; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 10:47 A.M., Certified Nurse Aide (CNA)/CMT F said the following: -Staff should report immediately an allegation of abuse to the supervisor, charge nurse, DON or the administrator; -The facility should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 1:30 P.M., the DON said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor; -Staff should notify the state of any allegation of abuse within two hours. During an interview on 03/27/25, at 2:00 P.M., the Administrator said the following: -She considers an unwanted kiss as sexual abuse; -Staff should report immediately an allegation of abuse to the supervisor and the supervisor reports to the administrator; -Staff should notify the state of any allegation of abuse within two hours. MO00251591

Based on interview and record review, the facility failed to ensure all residents received care per professional standards of practice when staff failed to obtain ordered blood tests in a timely fashion for one resident (Resident #8) out of a total sample of 17 residents. The facility census was 44. Review of the facility's policy titled, Laboratory Services For Nursing Staff, dated 2025, showed the following: -The facility shall provide or arrange for laboratory services to meet residents' medical needs; -The nursing staff is responsible for coordinating, collecting, and documenting laboratory specimens in accordance with state and federal regulations; -All laboratory results must be reviewed, documented, and communicated to the provider in a timely manner. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, and edema (swelling). Review of the resident's care plan, updated 10/01/24, showed the following: -The resident has urinary incontinence problems as evidenced by need for dependent on staff for assistance to use the bedpan for toileting; -The resident is at risk for increased probability of infections. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/03/24, showed the resident was cognitively intact. Review of the resident's progress note dated 11/29/24, at 1:02 A.M., showed a licensed practical nurse (LPN) documented the aides reported the resident had bleeding vaginally the past few days. The nurse reported that is why the Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely.) was discontinued. The aides reported the bleeding is heavier tonight. The nurse notified the physician of the resident's condition and orders received to get complete blood count (CBC) in the morning and he will follow up after the CBC results. Review of the resident's Physician Order Sheet showed an order, dated 11/29/24, for CBC sent to the lab company one time only related to urinary tract infection. Review of the resident's progress note dated 12/01/24, at 12:51 A.M., showed a nurse documented the resident stated he/she is still bleeding vaginally. The CBC has yet to be drawn. The nurse added the resident to the physician's list for him/her to assess the resident and follow up on order for the CBC. Review of the resident's medical record, on 01/29/25, showed staff had not obtained the CBC ordered 11/29/24. During an interview on 01/29/25 at 10:34 A.M., Registered Nurse (RN) A said the following: -When a nurse receives an order from physician, he/she gives the lab order to the Director of Nursing (DON) who enters the order into the computer; -Staff order lab orders for a change in condition, need for urinalysis, or edema issues; -Staff text or call the physician for needed labwork; -The DON is the only one who has access to enter lab requests; -The DON prints the lab results and gives it to staff; -Staff notify the physician and update him on the lab results; -The physician reviews the lab results and gives new orders based on the results; -He/she did not see the resident's CBC results ordered 11/29/24. During interviews on 01/29/25, at 11:29 A.M., and on 01/30/25, at 8:50 A.M., the DON said the following: -Nurses get a lab order and she enters the lab orders in the new lab company computer which started 01/01/25; -She checks the lab portal every day for lab results; -Nurses have a lab binder that has a log to enter information of the lab; -She prints lab results and puts them in the physician folder for him to review; -Staff call the physician with critical lab results; -The physician comes to the facility on Monday and Wednesdays and reviews the lab results and he/she writes orders if needed and the nurse documents it in the computer system; -Staff order labs for a change in condition, all new admissions, or a follow up lab; -With the old lab company, the nurse called the physician or texted to request a lab; -Staff wrote on the lab order requisition form and then staff progressed to enter the lab order in the computer and print out the requisition order, place it in the lab book at the desk under the date it needed drawn; -The old lab came Tuesday and Thursdays and emailed the facility the lab results, prior to emails the lab company faxed the results; -Staff checked the fax machine throughout the day for lab results; -She checked the computer daily until the facility received a result and would email the lab if no results;. -Staff wanted a CBC for the resident due to vaginally bleeding, but did not know for sure the reason; -The resident has improved with the bleeding; -She did not find the CBC results for the resident. During an interview on 01/30/25, at 01:32 P.M., the Administrator said if a resident had an order for labs to be drawn, they should be drawn as ordered.

Based on observation, interview and record review the facility failed to provide prompt and adequate assessment, intervention, documentation and physician notification for one resident (Resident #1) who complained about a toothache and had swelling in the left jaw. The resident later complained of frequent and severe pain but was not able to tell staff where he/she was hurting. The dentist saw the resident 18 days later and identified two abscessed teeth (pus enclosed in the tissues of the jaw bone at the tip of an infected tooth) and two decaying teeth. During this period of time the resident experienced a severe weight loss of 5.1% in one month's time. The resident's weight stabilized after starting antibiotics for the abscessed teeth. Eleven residents were sampled out of a census of 43. Record review of the online source Mayo Clinic regarding Tooth Abscesses, showed the following information: -Signs and symptoms of a tooth abscess include: ~Severe, persistent, throbbing toothache; ~Sensitivity to hot and cold temperatures; ~Sensitivity to the pressure of chewing or biting; ~Fever; ~Swelling in face or cheek; ~Tender, swollen lymph nodes under jaw or in neck; ~Sudden rush of foul-smelling and foul-tasting fluid in mouth and cessation of pain if the abscess ruptures; -When to see a doctor: See your dentist promptly if you have any signs or symptoms of a tooth abscess. If you have a fever and swelling in your face and you can't access your dentist, go to an emergency room . Fever and swelling may indicate that the infection has spread deeper into your jaw and surrounding tissue or even to other areas of your body. Causes: ~A tooth abscess occurs when bacteria invades the dental pulp (the soft, innermost part of the tooth that contains blood vessels, nerves and connective tissue).~Bacteria enter through either a dental cavity or a chip or crack in the tooth and spread all the way down to the root. The bacterial infection causes swelling and inflammation. The tight space within which the inflammation occurs forces pus into a pocket (abscess) at the tip of the root. Record review of the Long-Term Care Facility Resident Assessment Instrument user's manual Version 3.0 dated May 2010, showed the following information: -Poor oral health had a negative impact on: ~Quality of life ~Overall health ~Nutritional Status -Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions such as aspiration, [MEDICAL CONDITION], endocarditis (infection in the lining of the heart) and poor control of diabetes -Conduct an exam of the resident's lips and oral cavity. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth, floor and check lining. Check for abnormal mouth tissue, abnormal teeth or inflamed or bleeding gums. The assessor should use his or her gloved finger to adequately feel for massed or loose teeth. Record review of the care plan dated developed on 1/12/10, showed staff did not develop problems, goals and interventions to address the resident's dental health and need for staff assistance to provide oral care. Record review of Resident #1's Minimum Data Set (MDS) a federally mandated assessment to be completed by facility staff dated 11/30/10, showed under section L-Oral/Dental Status for check all that apply. Staff did not check the area for Mouth or facial pain, discomfort or difficulty with chewing. Record review of the nurse's notes dated 2/6/11 from 6:00 A.M., to 6:00 P.M., showed -Registered Nurse (RN) A noted Resident #1 ate very little lunch. Ate about 50% of supper. Spoke with resident after supper, states he/she has a toothache, left lower side. Left lower jaw with slight swelling. Medication nurse will give the resident Tylenol for pain. Will monitor. Left note for Social Service Director (SSD) regarding resident's tooth. Resident's spouse called to inform of resident not eating secondary to toothache. (RN A did not document he/she contacted the resident's physician. No documentation of an oral assessments of the resident's mouth). Record review of the February 2011, physician's orders [REDACTED]. Record review of the Medication Record on 2/6/11, showed the following information: -At 6:30 P.M., staff initialed they administered Extra Strength Tylenol two tablets to the resident for complaint of toothache; -Staff to complete a pain assessment every shift: ~Day shift staff wrote "NA"; ~Evening shift staff wrote "NA"; During an telephone interview on 3/10/11 at 8:51 A.M., the Assistant Director of Nursing (ADON) said the medication record did not have a zero to indicate no pain present. The "NA" meant not applicable or no pain present. (Staff administered Tylenol on 2/6/11, for the resident's complaint of pain but wrote "NA".) Record review of a facility form used by the charges nurses for shift report to the oncoming charge nurse showed the following: -On 2/6/11: ~Day shift, RN A noted "not eating well due to toothache" to oncoming nurse LPN B; No documentation RN A notified the resident's physician. ~Evening shift, LPN B noted a check mark. No documentation regarding the resident's tooth to oncoming nurse LPN C. No documentation LPN B notified the resident's physician. ~Night shift, LPN C noted no complaints voiced. No documentation regarding the resident's tooth to oncoming nurse LPN D; No documentation LPN C notified the resident's physician. -On 2/7/11, day shift, LPN D noted voiced no complaints. Staff did not document regarding the resident's tooth to oncoming nurse. LPN D did not document he/she notified the resident's physician. Record review of the Vital Sign flow sheet and Nutrition Progress Notes showed the following information regarding the resident's weight: -On 2/2/11, the resident weighed 117 pounds; -On 2/9/11, the resident weighed 113 pounds (a four pound or 3.4% weight loss in one week). Record review of the Charting System (facility form used by the aides to document daily care) for February 2011, showed the following information; -Day shift staff placed a check mark to indicate they provided oral hygiene to the resident 21 out of 28 days. -Evening shift staff placed a check mark to indicate they provided oral hygiene to the resident 28 out of 28 day. -Night shift staff placed a check mark to indicate they provided oral hygiene to the resident 28 out of 28 days. Record review of the physician progress notes [REDACTED]. -Subjective: A little bit more tired this month. Seems to be taking more naps during the day. The nurses have expressed concern that he/she's had a four pound weight loss this week. Resident denies any pain or any other acute symptoms. -Assessment: 1. Fatigue 2. Four pound weight loss in the last week 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION] -Plan: continue to follow his/her weight loss and fatigue Given his/her multiple comorbidities, I'm inclined to not be terribly aggressive about this weight loss. He/She does not appear to be in any pain or distress. -The physician did not document regarding the resident having a toothache. The physician did not document he completed an oral assessments of the resident's mouth. Record review of the nurse's notes showed the following: -On 2/9/11: -At 1:30 P.M., LPN D noted the resident's physician here. No new orders. -At 1:45 P.M., the Director of Nursing (DON) noted he/she discussed resident's four pound weight loss with the physician. Physician asked the DON to talk to the resident's spouse. (The DON did not document he/she spoke with the resident's physician about the resident's not eating related to a toothache and did not document oral assessments of the resident's mouth). -On 2/10/11 at 11:30 A.M., the DON spoke with the resident's spouse about the four pound weight loss. (The DON did not document he/she spoke with the resident's spouse about the resident's not eating related to a toothache). -No documentation between 2/10/11 to 2/23/11, regarding the resident During an interview on 3/1/11 at 2:00 P.M., LPN D said: -The resident's physician visited monthly. Staff can call the physician at his clinic during the day or use the answering services after hours if they need anything. -If staff completed an oral assessment on a resident it should be documented in the nurse's notes. -If staff contacted the physician it should be in the nurse's notes. -The resident's physician does rounds on his own. The charge nurse lets him know what is going on with the residents. -LPN D looked at the nurse's notes, LPN D said the charge nurse on 2/6/11, left a note for the SSD. -LPN D said he/she was the charge nurse on 2/9/11, when the physician did his monthly rounds. LPN D said he/she was not aware of the physician knowing about the resident's tooth. LPN D said he/she did not tell the physician about the resident's teeth. -He/she had not ever done an oral exam on the resident. -LPN D looked at the notes on 2/6/11 and said he/she was not aware of the resident's oral pain or toothache. -Would have been appropriate to complete an oral exam on the resident, if he/she had known. (record review of the nurse's notes showed LPN D worked the day shift on 2/7/11). During an interview on 3/1/11 at 2:10 P.M., LPN B said he/she was not aware of the resident's tooth pain prior to the dental visit (2/23/11) and had never done an oral exam on the resident. (record review showed LPN B worked the evening shift on 2/6/11, and received a written report by RN A regarding the resident having tooth pain). Record review of the Vital Sign flow sheet and Nutrition Progress Notes showed that on 2/16/11, the resident weighed 113 pounds (four pound weight loss or 3.4%). Record review of the quarterly Minimum Data Set (MDS) a federally mandated assessment tool required to be completed by facility staff dated 2/21/2011, showed the following information: -Unclear speech-slurred or mumbled words; -Usually understood; -Usually understands; -Not able to recall year, month and day -Inattention, disorganized thinking (behavior present, fluctuantes). -Poor appetite for the last 2-6 days -Extensive staff assistance for transfers, dressing, toileting and personal hygiene; -Limited staff assistance for eating; -Functional limitation in range of motion to both sides of upper and lower extremities; -Diagnose of high blood pressure, heart failure, diabetes, dementia, [MEDICAL CONDITIONS], and depression; -Staff marked "no" for been on a scheduled pain medication regimen; -Staff marked "no" for received as needed pain medication in the last five days; -Staff marked "no" for received non-medication intervention for pain; -Staff asked resident "Have you had pain or hurting at any time over the last five days?" Resident said, "Yes"; -Staff asked resident, "How much of the time have you experienced pain or hurting over the last five days?" Resident replied, "Frequently"; -Staff asked resident, "Please rate the intensity of your worst pain over the last five days." Resident replied, "3 or severe"; -Weight loss of 5% or more in the last month. -Weight 113 pounds. -Under section L-Oral/Dental Status for check all that apply. Staff did not check the area for Mouth or facial pain, discomfort or difficulty with chewing. Record review of the Vital Sign flow sheet and Nutrition Progress Notes showed that on 2/23/10, dietary manager noted Quarterly review: resident on mechanical soft diet, gets ice cream or high calorie pudding with meals. Gets a house shake (high calorie supplement) with protein powder at 2:00 P.M., and at bedtime snack. Weekly weight 111.5 pounds (5.5 pound wight loss in 18 days or 4.7%). Record review of the SSD progress notes between 2/6 to 2/23/11, showed no documentation regarding follow up related to the resident's toothache. Record review of the medical record showed staff did not document further assessment or follow up to the resident's complaint of frequent and severe pain as indicated on the 2/21/11, quarterly MDS. Record review of the February 2011, Medication Record showed the following information: -No documentation between 2/6/11 to 2/28/11, that staff administered Extra Strength Tylenol to the resident for pain; -Pain assessment every shift from 2/1 to 2/28/11, staff wrote "NA" (not applicable or no pain present.) During a telephone interview on 3/10/11 at 8:51 A.M., the ADON said she did look at the quarterly MDS assessment (2/21/11) and spoke with the staff that completed the pain assessment on the resident. Some days the resident is able to verbalize pain using the pain scale, some days not. The staff person who completed the pain assessment said the resident was not sure where he/she was hurting during the assessment. The staff did not follow up on the resident's verbal complaint of pain. The staff should have let her know so she could do follow up and care plan the resident's pain. Record review of a Dental Consultation dated 2/23/11, showed a complete exam. Resident has two lower left teeth that are both abscessed. Resident will need to be on antibiotic therapy and will need to go to an oral surgeon for extraction. Resident also has two other teeth which have been decayed to root tips, they should also be extracted by the oral surgeon. Record review of the physician's orders [REDACTED]. Record review of the nurse's notes on 2/23/11, showed at 6:45 P.M., staff noted resident continues antibiotic for tooth abscess. Temperature 99.5. Ate 25% of P.M. meal. (18 days since resident first complained of tooth pain on 2/6/11. No documentation by staff between 2/6/11 to 2/23/11, regarding the resident's teeth). Record review of the care plan reviewed on 2/14/11 and last updated on 2/23/11, showed the following information: -Resident requires two staff assistance with transfers and care; -At risk for nutrition weight loss; -Mobility impaired related to [DIAGNOSES REDACTED]. -Staff did not document problems, goal, and intervention related to the resident's verbalizing frequent and severe pain as indicated on the quarterly MDS assessment. -Between 2/6 to 2/23/11, staff did not document problems, goals and interventions to address the resident's complaint of toothache and swelling of the left jaw. Record review of the Vital Sign flow sheet and Nutrition Progress Notes showed on 3/7/11, the resident weighed 111 pounds; 5.1% weight loss since 2/2/11 (This would be a severe weight loss in one month. The resident's weight had been stable since 2/25/11 of 111.5 since the resident started on antibiotic therapy beginning on 2/23/11. During the initial tour of the facility on 2/28/11 at 10:00 A.M., the ADON said the resident was alert with confusion. The resident has had weight loss, needs assistance but won't let staff feed him/her. The resident was interviewable for simple questions. Observation showed the resident was small-framed and sat in the wheelchair in the hall. During an interview with the Director of Nursing (DON) and ADON on 3/1/11 at 2:30 P.M., the DON said she expected staff to document in the nurse's notes about a resident having tooth pain and do an assessment. The weekend nurse (RN A) left a note for the SSD and the SSD got an appointment for Resident #1. During an interview on 3/1/11 at 2:55 P.M., the ADON said she spoke with RN A, LPN B, LPN C and LPN D to "pin down" what happened around 2/6/11. The ADON said: ~RN A said on 2/6/11, he/she did an oral exam of the resident's mouth but did not see anything. He/she did not document that in the notes. ~LPN B said he/she did not complete an oral exam on the resident. ~LPN C said he/she did not complete an oral exam on the resident. ~LPN D said he/she did not complete an oral exam on the resident. The ADON pointed to the report sheet for 2/6/11 and said,"They (staff) had to have known about the toothache, it is right here on the sheet". During observation and interview on 3/2/11 at 8:40 A.M., the resident sat in the wheelchair in his/her room. The resident was pleasant with mumbled speech. Surveyor asked the resident about his/her teeth. Resident said, "I had a tooth that's been botherin' me but doesn't hurt to bad right now." (Record review showed the resident had received 26 doses of antibiotic since it was started on 2/23/11.) During an interview on 3/3/11 at 9:15 A.M., the SSD said: -If staff suspected the resident of having a dental problem, they let her know or if on the weekend they leave her note. -She then talks to the staff, resident and the resident's family. -The resident's cognition is "not good." -The resident's spouse told her that "sometimes he/she says it hurts and sometimes he/she doesn't" The spouse was not in a "hurry." -In January the facility took another resident to the dentist and there was a note on the door that the dentist was gone. The SSD had been looking for one, but it has been difficult to find one. -In February she found a new dentist and Resident #1 was sent to that dentist on 2/23/11. -The SSD said she did not note the dentist appointment or the conversation with the resident's spouse in the medical record but should have. -The ADON called the resident's physician. The physician said he couldn't recall looking in the resident's mouth or knowing about the resident's tooth pain. During an interview on 3/3/11 at 10:45 A.M., the resident's spouse said he/she attends the care plan meetings every three months and the staff will call him/her when there are problems. The spouse said,"Getting a dentist appointment around here is like pulling hen's teeth". The resident's been to the dentist at a previous facility in the past and did not have any problems until recently. The spouse said, "Probably not eating good because of his/her teeth hurting." Sometimes the resident can tell you if he/she is hurting and sometimes not. The resident has been taking an antibiotic, "so I think he/she's feeling better". During a telephone interview and record review on 3/10/11 at 9:23 A.M., the SSD reviewed the note she received from RN A (nurse notes showed staff gave the note to SSD on 2/6/11). SSD said the note was not dated and said to "check on Resident #1 possible dental appointment". SSD said the note did not indicate the resident had tooth pain and swelling. If she would have known she would have reported the symptoms to the dental office when she made the appointment. With the dentist she used in the past, if she had a resident with a problem she would try to get them in sooner. The SSD attends the care plan meetings. SSD said she was aware the resident had lost weight and was not eating well. During an interview on 3/15/11 at 9:15 A.M., the resident's physician said he did monthly rounds at the facility to see residents. He receives verbal report from the staff about the residents. Staff should usually report to him if a resident had tooth pain. It is possible that the staff told him about the tooth but he could not recall it. The staff should have put the tooth pain and the resident's recent weight loss together so he could have assessed the resident. The resident had been gradually losing weight for some time. Unfortunate that it happened.