Every finding on record at Capitol River Wellness & Rehabilitation

Based on interviews and record review, facility staff failed to notify the physician and/or registered dietician (RD) and failed to obtain nutritional interventions of one resident (Resident #1's) with a significant weight loss. The census was 87.1. Review of the facility's Assessment and Management of Resident Weights policy, undated, showed staff are directed as follows:-Significant weight changes will be reviewed by the Dietary Nutritional Supervisor (DNS) or designated license nurse. Significant weight changes are five percent in one (1) month, 7.5 percent in three months, and ten percent in six months;-The DNS or licensed nurse will notify the physician and dietician of significant weight changes and document notification in the nurses' notes. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/23/26, showed staff assessed the resident with severe cognitive impairment and weight loss weight loss of five percent or more in the last month, and was not on a physician-prescribed weight-loss regimen.Review of the residents' monthly weights, dated 03/03/26, showed staff documented the resident weight of 189.8 pounds.Review of the residents' monthly weights, dated 04/07/26, showed staff documented a weight of 172.6 pounds (8 percent weight loss in one month).Review of the resident's progress notes, dated 04/07/26 through 04/30/26, did not contain documentation staff notified the physician or dietician after a significant weight loss of eight percent.Review of the resident's physician's orders, dated 04/07/26 through 04/30/26, did not contain physician orders for nutritional supplements or documentation of new interventions related to the resident weight loss.Review of the resident's care plan, revised on 07/24/26, showed staff documented the resident at risk for malnutrition and staff were to notify the physician if he/she had a weight gain or loss of five percent or more in one month or ten percent or more in six months. During an interview on 07/31/26 at 9:28 A.M., Licensed Practical Nurse (LPN) A said residents are weighed monthly and based on the residents' medical needs. Staff are required to obtain a physician order for weights. The restorative aide weighs the residents, documents the weights on a form, then gives them to the DON or ADON. Staff had a weekly meeting with the dietician to discuss weight loss concerns but can call the dietician any time. The dietician and physician should be contacted the same day, if staff noticed a substantial weight loss. A resident placed on hospice services; staff should still try interventions to maintain weight.During an interview on 07/31/26 at 9:43 A.M., the administrator said staff are directed to obtain residents weight on a schedule determined by the residents' medical needs. The restorative aide weighed the residents and documents the weights somewhere and they are turned into DON or ADON. Staff should follow physician orders and dietician recommendations. If there was a substantial weight loss, staff would be expected to reweigh resident and figure out the cause of the weight loss.During an interview on 07/31/26 at 1:59 P.M. the Assistant Director of Nursing (ADON) C said he/she would expect staff to contact the physician for a weight loss greater than five percent. The ADON said they discussed weight loss during the IDT meetings. He/She said he/she would expect staff to reweigh any residents with a substantial weight change. The ADON said weights are obtained, given to the Director or Nursing (DON) and him/herself and they are entered into the electronic health records. The software does not flag a change in weight when entered, and said staff have to look at the prior weight on a different screen to verify if there was any weight change. He/She said he/she expected the person responsible for entering the weights to verify if there was a weight change. He/She said if the nurse did not check the current weight against the prior weight to verify weight changes, it would be caught by the IDT team.During an interview on 07/31/26 at 2:22 P.M., the DON said residents are weighed monthly, unless otherwise ordered. The restorative aide is responsible for obtaining the resident's weights. The restorative aide would document on a form and would then give it to a nurse. If a resident had substantial weight loss, the nurse would contact the physician and dietician to start interventions. Staff are to enter weights into the software and do not always compare the prior weights to the current weights. The nurse should be reweighing if there is a substantial weight change. He/She said there was potential for a breakdown in the process if the nurse did not review the prior weights, but the weight change should be caught during the weekly IDT meetings.During an interview on 08/06/24 at 9:19 AM, the Registered Dietician said he/she was not aware the resident had a substantial weight loss in April. The staff did not contact her. He/She said he/she would have expected to contact him/her if there was a significant weight change of five percent or more in a month. He/She said he/she was not always able to attend the IDT meeting.During an interview on 08/06/26 at 8:41 A.M., the Restorative Aide said he/she was responsible for weighing the resident's. He/She said he/she would document the information on a form and turned it in to the DON. He/She said the form showed the prior weights and he/she would add the new weights on the form. He/She said if he/she noticed the resident had a weight change, he/she was directed to re-weight the resident if there was a substantial weight loss. He/She said he/she would report the weight loss to the DON when giving the DON the form. He/She said he/she started his/her position about two weeks ago.During an interview on 08/06/26, the physician said he/she did have a note documented he/she spoke with the facility on 04/24/26 and discussed weight loss. He/She said he/she thought the staff had told him/her the resident was already on a house supplement. He/She said he/she did not know the resident was not on a house supplement until May. He/She said he/she expected staff to contact him/her within a week if a resident had a weight loss of five percent or more in a month. 3075873

Based on interview and record review, facility staff failed to provide written information to the residents and/or the residents' representative of the bed hold policy at the time of transfer to the hospital for eight residents (Resident #8, #12, #28, #47, #67, #71, and #86) out of 23 residents sampled. The facility census was 84. 1. Review of the facility policy titled, Bed Hold, dated June 2020, showed the facility notifies the resident or his/her representative, in writing, of the bed hold policy any time the resident is transferred to general acute care hospital. 2. Review of Resident #8's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and had not returned. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 3. Review of Resident #12's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 12/24/25. Review showed the resident discharged from the facility to the hospital on [DATE] and returned on 01/27/26. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 4. Review of Resident #20's medical record showed staff documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review showed the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 5. Review of Resident #28's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 03/22/26. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 6. Review of Resident #47's medical record showed staff documented the resident discharged to the hospital on [DATE] and returned on 04/16/26. Review showed the resident discharged to the hospital on [DATE] and returned on 05/19/26. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 7. Review of Resident #67's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 05/05/26. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 8. Review of Resident #71's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and returned on 05/15/26. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 9. Review of Resident #86's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and did not return to facility. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 10. During an interview on 05/20/2026 at 2:47 P.M., the administrator said he/she knows the facility is deficient with bed holds. The administrator could not provide any requested bed holds. During an interview on 05/21/26 at 11:15 A.M., Licensed Practical Nurse (LPN) H said there is an admissions staff that has the resident sign a bed hold upon admission and when they get sent out to hospital. He/She said the charge nurse changes the status in the computer when they go to hospital. He/She said the nurse does not do anything with bed holds. During an interview on 05/21/26 at 11:38 A.M., the Assistant Director of Nursing (ADON) A said as far as he/she knows the nurse should be giving the bed hold to the resident upon discharge. During an interview on 05/21/26 at 2:25 P.M., the Director of Nursing (DON) said he/she had been told once a bed hold is signed on admission another one does not need to be provided upon transfers. During an interview on 05/21/26 at 2:50 P.M., the administrator said the nurse is responsible for ensuring bed holds are obtained when a resident is sent to the hospital. He/She said the nurses have not been properly educated since he/she has been at facility.

Based on observation, interview and record review, facility staff failed to maintain a comfortable and homelike environment. The facility census was 84. 1. Review of the facility policy titled, Maintenance Services, dated August 2020, showed the Maintenance Department is responsible for maintaining the building in compliance with current federal, state, and local, regulations, and guidelines. The Director of Maintenance is responsible for conducting regular inspections of hallways and activity areas. 2. Observation on 05/19/26 at 8:36 A.M., showed the memory care unit walls below the handrails, unpainted, and missing baseboard with exposed screws. 3. Observation on 05/19/26 at 10:56 A.M., showed the main dining walls with missing base trim, exposed unfinished and unpainted drywall. 4. Observation on 05/19/26 at 10:59 A.M., showed the 100 and 300 hallway walls with missing base trim and a large hole in the drywall between rooms [ROOM NUMBERS]. 5. Observation on 05/19/26 at 12:29 P.M., showed kitchenette in the main dining rooms wall with exposed drywall, untaped and not mudded, with exposed two by four lumber, unpainted and unfinished. 6. Observation on 05/21/26 at 9:20 A.M., showed the 100 and 300 hallway walls with exposed screws and unpainted drywall at the base. Observation showed gaps between the floor and walls where the base trim had been. 7. Observation on 05/21/26 at 9:22 A.M., showed the Therapy Department short hall outside with missing base trim, exposed screws, and unpainted and unfinished drywall. 8. Observation on 05/21/26 at 9:25 A.M., showed by the nurse's station area between 100 and 300 halls with missing base trim and exposed screws. Observation showed the drywall unpainted and unfinished at base of walls and unpainted drywall patches. 9. Observation on 05/21/26 9:51 A.M., front halls with missing base trim, exposed screws and unpainted and unfinished drywall. During an interview on 05/21/26 at 9:11 A.M., Resident #50 said the baseboards haven't been fixed for over a year, they look dirty and should be cleaned up. The resident said we live here. 10. During an interview on 05/21/26 at 1:02 P.M., Certified Nurse Aide (CNA) N said he/she has been at the facility since June of 2025 and the walls have had missing base trim. The CNA said it looks bad and does not look homelike. During an interview on 05/21/26 at 1:04 P.M., Licensed Practical Nurse (LPN) L said the missing trim, unpainted drywall and exposed screws is not homelike. During an interview on 05/21/26 at 1:08 P.M., the Maintenance Director said the facility hired a company and is a relative of the last administrator and they quit, so it has been like that for over a year. During an interview on 05/21/26 at 2:16 P.M., Director of Nursing (DON) said the missing baseboards happened a long time ago, at least a year ago. The DON said he/she thinks it looks terrible. The memory care has been unpainted like that for about a month. During an interview on 05/21/26 at 2:41 P.M., the administrator said the baseboards have been gone for six months. The administrator said contractors started and then they had to leave, and they have never come back. The administrator said he/she would not consider it homelike and ultimately it is his/her responsible.

Based on record review and interviews, facility staff failed to complete a baseline care plan within 48 hours of admission for six residents (Resident #8, #35, #62, #67, #71, and #86) out 23 sampled residents. The facility census was 84.1. Review of the facility's policy titled Care Planning, dated 06/2020, showed the Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission and will include at least the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. 2. Review of Resident #8's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan was not completed.3. Review of Resident #35's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 03/04/26.4. Review of Resident #62's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 04/23/26.5. Review of Resident #67's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan was not completed.6. Review of Resident #71's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan was not completed.7. Review of Resident #86's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 04/27/26. 8. During an interview on 05/21/26 at 11:15 A.M., Licensed Practical Nurse (LPN) H said baseline care plans are completed by the charge nurse and social services designee (SSD). He/She said upon admission the care plan will be in the resident chart to complete. He/She said staff try and complete the care plan before the end of admission day or within two days. He/She baseline care plans are important, so staff know what goals the resident has and how to care for them. During an interview on 05/21/26 at 11:29 A.M., the Assistant Director of nursing (ADON) A said baseline care plans should be completed by the admitting charge nurse and SSD. He/She said he/she is supposed to ensure baseline care plans are completed. He/She said baseline care plans should be completed within 24-48 hours of admission, but he/she would rather have them completed within 24 hours. He/She said he/she could not give a reason why the baseline care plans are not completed. He/She said the importance of baseline care plans is to have the initial plan of care and build a plan of care based on initial assessment.During an interview on 05/21/26 at 11:46 A.M., the SSD said he/she tries to have the social services section completed within the first 24 hours of admission. He/She said the importance of baseline care plans is to have an idea of the resident care and what needs are needed. He/She said if he/she is gone, there is no one else to complete the social services sections of baseline care plans. During an interview on 05/21/26 at 2:30 P.M., the Director of Nursing (DON) said baseline care plans are completed by nursing and social services. He/She said baseline care plans should be completed within 48 hours of admission. He/She said the importance of baseline care plans is to establish resident care and goals. He/She said the ADON should review the health records every day to ensure they are completed. He/She said he/she was aware that some were not getting done, but they are working on it.During an interview on 05/21/26 at 2:50 P.M., the administrator said he/she expects baseline care plans to be completed within the first 24 hours of admission. He/She said the importance is so every staff knows how to care for that resident. He/She was not aware they were not getting done. He/She said the DON and himself/herself are responsible for ensuring they are being completed.

Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for four residents (Resident #5, #9, #71, and #83) who used bed rails out of 23 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Bed Rails, dated 06/2020, showed: -Before installing a bed rail, the facility must assess the resident for risk of entrapment from bed rails and ensure the beds dimensions are appropriate for the resident's size and weight; -Maintenance/Designee will assess the bed dimensions no less than quarterly; -Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or become loose over time. The facility policy did not address zone measurements for risk of entrapment. 2. Review of Resident #5's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/06/26, showed staff documented bed rails not used. Review of the resident's care plan, dated 03/08/26, showed staff documented dependent on two aides for bed mobility. Observation on 05/19/26 at 9:37 A.M., showed the resident in bed with grab bars in fixed upright position, on both sides of the bed. Observation on 05/20/26 at 9:57 A.M., showed the resident in bed with grab bars in fixed upright position on both sides of the bed. Review of the resident's medical record showed the record did not contain an entrapment assessment. 3. Review of Resident #9's Quarterly MDS, dated [DATE], showed bed rails not used. Review of the resident's care plan, dated 05/20/26, showed assist rails for help in bed mobility, turning and repositioning. Observation on 05/18/26 at 12:15 P.M., showed the resident in bed with grab bars in fixed upright position on both sides of the bed. Observation on 05/19/26 at 8:49 A.M., showed the resident's grab bars had approximately six inches of space between the bar and the mattress. At this same time, the resident said he/she had issues with the space between the grab bar and the mattress before. Observation on 05/20/26 at 10:33 A.M., showed resident in bed with fixed grab bars on both sides of the bed. There is an approximate six inch gap between the grab bar and mattress. Review of the resident's medical record showed the record did not contain an entrapment assessment. 4. Review of Resident #71's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not use bed rails. Review of the resident's care plan, revised 05/02/26, showed staff documented resident may have enabler bars to aid in bed mobility. Observation on 05/18/26 at 2:23 P.M., showed resident in bed with bilateral grab bars in upright position on the bed. Observation on 05/19/26 at 5:51 P.M., showed resident in bed with bilateral grab bars in upright position on the bed. Observation on 05/20/26 at 09:48 A.M., showed resident in bed with bilateral grab bars in upright position on the bed. Observation on 05/21/26 at 09:45 A.M., showed resident in bed with bilateral grab bars in upright position on the bed. Review of the resident's medical record showed the record did not contain an entrapment assessment. 5. Review of Resident #83's Quarterly MDS, dated [DATE], showed bed rails not used. Review of the resident's care plan, dated 05/02/26, showed staff documented the resident, may use U shaped enablers to bed to improve independence and bed mobility. Observation on 05/18/26 at 11:59 A.M., showed the resident in bed with grab bars on both sides. There is an approximate three inch gap between the mattress and grab bars. Observation on 05/19/26 at 9:29 A.M., showed the resident in bed with grab bars on both sides of the bed. Observation on 05/20/26 at 10:51 A.M., showed the resident in bed with grab bars on both sides of the bed. Review of the resident's medical record showed the record did not contain an entrapment assessment. 6. During an interview on 05/21/26 at 9:46 A.M., the Maintenance Director said he/she has worked at the facility for a month and has not been asked to complete any assessments for bed rails. He/She said he/she is unaware of any entrapment assessments and unsure what the facility policy is. He/She said he/she has not been asked to complete any bed rail measurements. During an interview on 05/21/26 at 11:15 A.M., Licensed Practical Nurse (LPN) H said if a resident requests bed rails, therapy assesses the resident and lets the nurses know what kind of rail is needed, bed rail assessments are completed by the nurses, and maintenance puts the rails on the bed. He/She is unsure who is responsible for entrapment measurements, as the charge nurse does not do anything with bed rail measurements. He/She said entrapment assessments are important for safety and ensuring nothing slides between the rails like feet or arms. During an interview on 05/21/26 at 11:40 A.M., the Assistant Director of Nursing (ADON) A said therapy assesses the resident and informs nursing what type of rail is needed, and the nurse will obtain an order and let maintenance know so the rail can be applied. He/She said maintenance should complete the entrapment measurements. During an interview on 05/21/26 at 1:05 P.M., the maintenance assistant said he/she has worked at the facility for three years. He/She said the nurses will let him/her know when a bed rail is needed and he/she will find the correct rail for the bed and will install it. He/She said he/she never knew that entrapment measurements needed to be done. He/She said not measuring for entrapment with bed rails put the residents at risk for injury if they come stuck in the rail. During an interview on 05/21/26 at 2:16 P.M., the Director of Nursing (DON) said maintenance is responsible for completing entrapment assessments, the nurses do the siderail assessments then maintenance completes the measurements. The DON said he/she doesn't know how often entrapment assessments are to be done. The DON said it is important to measure gaps for safety and positioning, to prevent the residents from getting injured or caught in the rails. During an interview on 05/21/26 at 2:41 P.M., the administrator said maintenance and nursing is responsible for entrapments assessments. The administrator said he/she knew entrapments assessments not getting done was an issue, just so many other priorities. The administrator said staff are supposed to measure gaps for safety. The administrator said ultimately, he/she is responsible to make sure the entrapment assessments get done.

Based on observation, interview, and record review, facility staff failed to ensure sanitary conditions for a urinary drainage bag (a bag attached to a tube that holds urine) when staff failed to keep the drainage bag off the floor for three residents (Resident #5, #58 and #34) out of three sampled residents. The Facility census was 84. 1. Review of the facility policy titled, Catheter-Care of, dated June 2020, showed catheter collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. Take care to ensure the collection bag does not touch the floor at any time. 2. Review of Resident #5's Annual Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 03/06/26, showed staff assessed the resident with an indwelling urinary catheter. Review of the resident's care plan, dated 04/09/26, showed the resident required a Foley Catheter (a flexible, sterile tube inserted into the bladder to continuously drain urine) and directed staff to keep urinary collection bags off floor. Observation on 05/18/26 at 11:27 A.M., showed the resident in a tilt in space wheelchair, by the nurse's station. The resident's catheter bag rested on the floor. Six staff walked past the resident with his/her catheter bag on the floor, to include the Director of Nursing (DON), Assistant Director of Nursing (ADON), Restorative Aide (RA) M, Certified Nurse Aide (CNA) K and Licensed Practical Nurse (LPN) L. The RA stopped and talked to the resident and did not identify or adjust catheter bag on the floor. Observation on 05/18/26 at 12:20 P.M., showed the resident in his/her wheelchair at the dining room table with his/her catheter bag on the floor under the resident's wheelchair. Observation on 05/19/26 at 9:37 A.M., showed CNA K and CNA N performed a bed to wheelchair mechanical lift transfer for the resident. CNA N laid the resident's catheter bag on the floor and left the room to find a dignity bag for the resident's catheter bag to go in, CNA K remained in the room with the resident and left the catheter bag on floor. At 9:49 A.M. CNA N returned to the resident's room with a dignity bag. CNA N picked the resident's catheter bag up off the floor and placed it in the dignity bag, hooked the bag under the wheelchair, and left the room. 3. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and had an indwelling catheter. Review of the resident's care plan, dated 05/08/26, showed the resident required a suprapubic catheter (a flexible tube inserted through the abdomen directly into the bladder to drain urine). Observation on 05/18/26 at 11:30 A.M., showed the resident in bed, with his/her catheter bag hung on the bedframe. The bag touched the floor mat on the floor. Observation on 05/19/26 at 9:08 A.M., showed the resident in bed with his/her catheter hung from the bedframe. The bag touched the floor mat on the floor. Observation on 05/19/26 at 2:55 P.M., showed the resident in bed with his/her catheter hung from the bedframe. The bag touched the floor mat on the floor. During an interview on 05/21/26 at 10:25 A.M., LPN H said the resident's catheter bag should not touch the floor, germs could travel up and into the bladder, it is an infection control issue. 4. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident with an indwelling urinary catheter. Review of the resident's care plan, dated 04/09/26, showed the resident required a catheter and directed staff to keep urinary collection bags off floor. Observation on 05/20/26 at 10:21 A.M., showed the resident in his/her wheelchair by the nurse's station with his/her catheter bag hung under his/her wheelchair with part of the bag on the floor. LPN L, LPN H, CNA K and CMT Q at the nurse's station and within sight of the catheter bag on the floor. Observation on 05/20/26 at 11:51 A.M., showed the resident remained at the nurse's station. An unknown staff member placed a blanket over the resident; the catheter bag continued to touch the floor. Observation on 05/20/26 at 2:17 P.M., showed the resident in his/her wheelchair at the nurse's station, with his/her catheter bag on the floor under the wheelchair. CMT Q, LPN H and CMT P were near the resident and did not pick the catheter bag up off the floor. During an interview on 05/20/26 at 2:51 P.M., LPN H said the resident's catheter bag on the floor is not appropriate, and he/she was not aware it had been left on the floor. The LPN said it's a hygiene issue, because it was dragging on the floor which can cause infections. Observation on 05/21/26 at 12:58 P.M., showed the resident in his/her wheelchair, at the dining room table. CNA N sat beside the resident to assist the resident at mealtime. The resident's catheter bag rested on the dining room floor, partially under the left wheel of the resident's wheelchair. During an interview on 05/21/26 at 12:59 P.M., CNA N said the resident's catheter bag should be hung up on the wheelchair, it should not be on the floor, because it could drag on floor and bust open, it's not safe. The CNA said he/she can see the resident's catheter bag on the floor. During an interview on 05/21/26 at 1:04 P.M., LPN L said a resident's catheter bag should never be on the floor, because of germs, it could cause infection. During an interview on 05/21/26 at 12:47 P.M., the Medical Director said catheter bags should not be on floor due to contamination issues and infection issues. 5. During an interview on 05/21/26 at 2:21 P.M., the DON said if a resident is in bed the catheter bag should be on the floor or touching the floor. He/she said staff should use a basin or bag, something to keep it from touching the floor. The DON said a resident's catheter bag should never be on the floor for infection reasons. The DON said he/she would hope staff would notice a resident's catheter bag that has been on the floor for hours. The DON said all nursing staff are responsible to make sure catheter bags are off the floor, from the aides to the nurses. The DON said he/she is responsible for making sure the nursing staff are doing that. During an interview on 05/21/26 at 2:41 P.M., the administrator said residents' catheter bags should never be on the floor, because of infection control concerns. The administrator said nursing staff are responsible for ensuring the catheter bags are not on the floor. The administrator said he/she doesn't know if the facility has given the training, or expectation on how often staff should check placement of the resident's catheter bag.

Based on interview and record review, facility staff failed to ensure two resident's (Resident #1 and #2) were allowed to exercise resident's rights when staff opened their mail without the resident's present. The facility census was 81. 1. Review of facility's resident bill of right's policy, dated November 2016, showed residents have the right to send and receive mail promptly and unopened. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/12/25, showed staff assessed the resident as cognitively intact. During an interview on 4/28/25 at 10:00 A.M., the resident said the business officer manager (BOM) opened his/her mail in his/her office and then came in his/her room on 4/24/25. He/She has an audio conversation with the BOM where the BOM said he/she opens residents mail that comes from places like Medicaid and disability because it may affect the residents billing. He/She said he/she asked the BOM for the envelope to see who the envelope was addressed too and the BOM said he/she no longer had it. Review of the resident's audio recording on 4/28/25 at 10:04 A.M., showed the resident said he/she would like the envelope from the mail the BOM opened, he/she said he/she did not have the envelope anymore. The BOM said he/she opens mail from certain places like Medicaid and disability because it has the ability to affect the residents billing and payments. The BOM is the only person in the building who delivers the mail at the facility. During an interview on 4/28/25 at 12:01 P.M., Staff Member A said the BOM did open the resident's mail and that he/she had a conversation with the BOM to educate him/he you can not open resident's mail. During an interview on 4/28/25 at 12:04 P.M., the BOM said he/she only partially opened resident #1's mail one time and then went to his/her room. 3. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 4/28/25 at 11:33 A.M., the resident said the BOM will usually come to his/her room and open mail with him/her if its something important like about his/her disability. He/She said several months back the BOM has opened the mail before coming to his/her room. During an interview on 4/28/25 at 12:26 P.M., the administrator said staff should never open a residents mail and she expects staff to follow the residents bill of rights. MO00253232

Based on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document they provided colostomy care for one resident (Resident #1), catheter care for one resident (Resident #2), monitor blood glucose levels for one resident (Resident #3), or obtain weights for one resident (Resident #4) out of four sampled residents. The facility census was 81. 1. Review of the facility's Colostomy Care policy, dated 08/2017, showed staff were directed to document on treatment sheet care completed. Review of the facility's Weights policy, dated 10/2009, showed staff were directed to electronically document weights. The facility did not provide a policy in regard to catheter care or blood glucose monitoring documentation guidance. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/20/24, showed staff assessed the resident as follows: -Cognitively intact; -Did not reject care; -Used an ostomy bag (a surgical procedure that creates a temporary or permanent opening on the body surface to allow waste products to be expelled); Review of the resident's Physician Order Sheet (POS), dated 03/06/25, showed physician orders to provide routine colostomy care on day shift. Review of the resident's Medication Administration Record (MAR), dated 02/01/25 through 02/28/25, showed the MAR did not contain documentation staff provided colostomy care on 02/01/25, 02/02/25, 02/08/25, 02/09/25, 02/14/25 or 02/16/25. The MAR did not contain documentation the resident refused colostomy care treatment. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Did reject care one out of three days during the seven day look back period; -Used an indwelling catheter. Review of the resident's Physician Order Sheet (POS), dated 03/06/25, showed physician orders to empty the catheter bag and record output every shift, provide urinary catheter care every shift, and to irrigate the urinary catheter with sixty cubic centimeters of acetic acid every shift. Review of the resident's MAR, dated 02/01/25 through 02/28/25, showed the MAR did not contain documentation staff drained the resident's catheter or recorded output on 02/07/25 or 02/18/25. Review showed staff did not document they provided catheter care on 02/07/25 or 02/18/25 and did not document they irrigated the urinary catheter with 60 cubic centimetre of acetic acid on 02/07/25 or 02/18/25. 4. Review of Resident #3's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Did not reject care; -Diagnosis of Diabetes Mellitus. Review of the resident's POS, dated 03/06/25, showed physician orders to monitor blood glucose three times a day and call the doctor if blood sugar levels are under sixty or over 400. Review of the resident's MAR, dated 02/01/25 through 02/28/25, showed the MAR did not contain documentation staff monitored the resident's blood glucose levels on 02/01/25, 02/03/25, 02/08/25, 02/10/25, 02/14/25, 02/16/25, 02/17/25, 02/23/25, 02/24/25, 02/27/25, or 02/28/25. 5. Review of Resident #4's Admission Assessment MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -admitted on [DATE]; -Did not reject care; -Diagnosis of Coronary Artery Disease (damage or disease in the heart's major blood vessels). Review of the resident's POS, 03/06/25, showed physician orders to obtain daily weights every day shift for fluid retention and an order for Furosemide (to treat fluid retention) 40 milligram tablet every twenty four hours as needed for retention for weight gain of three pounds from baseline within a week. Review of the resident's MAR's, dated 02/01/25 through 02/28/25, showed the MAR did not contain documentation staff obtained the resident's daily weights on 02/16/25, 02/22/25, or 02/23/25. 6. During an interview on 03/04/25 at 6:23 A.M., Licensed Practical Nurse (LPN) A said staff are directed to document any treatments or medication administration in the resident's medical record. He/She said if there was a missed treatment or medication administration, staff should report to Director of Nursing (DON) and administrator, contact the physician and family, and check with staff to verify if they did provide treatment or medication administration. He/She said if it was not documented, then it was not done. During an interview on 03/04/25 at 8:09 A.M., the administrator said staff are directed to document any completed treatments or medication administration in the resident's medical records. He/She said if staff noticed missing treatments or medication administration in the resident's MAR, then staff would report to upper management and notify the physician of the missed medication dose. He/She said ultimately it was the responsibility of the DON and himself/herself to ensure documentation was completed. During an interview on 03/04/25 at 8:10 A.M., the DON said staff are directed to document any completed treatments or medication administration in the resident's medical records. The DON said in the past, staff had forgotten to select the save option on the electronic MAR's, so treatments and medicaion were not documented once completed. MO00249592 and MO00249765

Based on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 81. 1. Review of the Facility Assessment, dated 08/02/24, showed staff are directed as follows: -Direct care staff required to care for their facility census for an eight hour shift should include: Three day nurses, three evening nurses, three night nurses, six day Certified Nurse Aides (CNA's), six evening CNA's, five night CNA's, and two day shower aide's. -The assessment is based on the resident population and their healthcare needs and support; -The average daily census number of occupied beds was 88. Review of the employee staffing schedule from 02/01/25 through 02/28/25, with an average daily census of 88, showed: -Saturday 02/01/25- zero day shower aides, two evening nurses and five CNA's; -Monday 02/03/25- zero day shower aides and four night CNA's; -Wednesday 02/05/25- five day CNA's and zero day shower aides; -Thursday 02/06/25- one day shower aide and two night nurses; -Friday 02/07/25- five evening CNA's; -Sunday 02/09/25- zero day shower aides and four night CNA's; -Monday 02/10/25- one day shower aides and five evening CNA's; -Tuesday 02/11/25- two night nurses; -Wednesday 02/12/25- one day shower aide; -Friday 02/14/25- five evening CNA's and four night CNA's; -Sunday 02/16/25- five day CNA's and zero day shower aides; -Tuesday 02/18/25- zero day shower aides and four evening CNA's; -Wednesday 02/19/25- zero day shower aides and four night CNA's; -Thursday 02/20/25- one day shower aide and two night nurses; -Saturday 02/22/25- zero day shower aides; -Sunday 02/23/25- five day CNA's, zero shower aides and two evening nurses; -Monday 02/24/25- zero day shower aides and four evening CNA's; -Tuesday 02/25/25- one day shower aide and five evening CNA's; -Wednesday 02/26/25- two evening nurses; -Thursday 02/27/25- five day CNA's and one day shower aide; -Friday 02/28/25- one day shower aide and four evening CNA's. During an interview on 03/04/25 at 6:55 A.M., the Staffing Coordinator said he/she just started his/her position within the past two weeks and was still in training with the administrator. He/She said he/she worked with the administrator to create a staff schedule. During an interview on 03/04/25 at 8:09 A.M., the administrator said he/she assisted the Staffing Coordinator with creating the schedule. He/She said the staffing scheduled was based on the facility assessment. The administrator said he/she would ask staff to stay over, ask staff to come in to cover shifts, or utilized agency staffing when the facility was understaffed. He/She said there were numerous staff sick during the month of February. He/She said the facility did the best they could during the month of February when several staff members were out sick. MO00249592 and MO00249765

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. The facility census was 85 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2016. showed: -Food shall be stored on shelves in a clean, dry area, free from contaminants; -Foods shall be stored at proper temperatures and using appropriate methods to ensure the highest level of food safety; -Label food items held for longer than 24 hours with the name of the food, if not in original packaging, and the date by which it should be sold,consumed or discarded; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing proper refrigeration (at a temperature that ensures the internal temperature of the food is 41 degrees Fahrenheit or below); -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers; -Store raw animal foods, such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food. If they cannot be stored separately, place these products on shelves beneath cooked and ready-to-eat items. Observation on 12/16/24 at 6:10 A.M., showed the gasket seals torn on both doors to the reach-in refrigerator by the three-compartment sink. Observation showed the refrigerator contained: -An opened and undated 32 ounce (oz.) carton of honey thickened dairy drink; -An opened and undated 46 oz. carton of orange juice; -An opened 46 oz. carton of orange juice dated 12/07/24 with a handwritten use by date of 12/14/24; -A pitcher of tomato juice with a handwritten discard date of 12/13/24 -A one gallon pitcher of cranberry juice with a handwritten discard date of 12/13/24; -A one gallon pitcher of tea dated 12/03/24. Observation on 12/16/24 at 6:20 A.M., showed an opened and undated 24 oz. bag of orange gelatin mix stored inside an undated plastic resealable bag on the cart next to the stove. Observation on 12/16/24 at 6:21 A.M., showed an opened one gallon bottle of Worcestershire sauce dated 11/08/24 stored on the shelf beneath the microwave. Review of the product label showed direction to refrigerate the product after opening. Observation on 12/16/24 at 6:25 A.M., showed the walk-in freezer contained undated cases of Italian blend vegetables and bread stick dough opened to the air and a case of potato barrels stored on the floor. Observation on 12/18/24 at 10:13 A.M., showed the reach-in refrigerator by the electrical panels contained two flats of raw eggs stored over ready-to-eat food items which included a bag of chopped lettuce, a bag of shredded cheddar cheese, a bag of shredded mozzarella cheese, a bottle of Italian dressing, two 20 oz. bottles of yellow mustard, and a case of easy to spread butter. During an interview on 12/18/24 at 11:00 A.M., the Dietary Manager (DM) said everyone is responsible to ensure food is stored properly, but the cooks are responsible to check the food storage each shift and correct as needed. The DM said opened food items should be stored sealed, labeled and dated, staff should discard anything past its use by or discard date, and if food says to refrigerate after opening, then staff should refrigerate it after it is opened. The DM said food should not be stored be stored on the floor, raw foods should not be stored over ready-to-eat food items, and all dietary staff are trained on food storage requirements. The DM said he/she did not know the gasket seals on the reach-in refrigerator doors were torn. During an interview on 12/19/24 at 8:55 A.M., the administrator said he/she and the DM are responsible to ensure food is stored correctly and the DM should check the food storage daily. The administrator said opened food items should be stored in sealed containers and labeled with the name of the food, the open date and the discard date. The administrator said staff should discard food that is past its use by or discard date and if food says to refrigerate after opening, then staff should refrigerate it after it is opened. The administrator said food should not be stored on the floor, raw foods should not be stored over ready-to-eat foods, and all dietary staff are trained on food storage requirements.

Based on interview and record review, facility staff failed to prevent the commingling of 32 resident's (Resident #8, #9, #12, #17, #19, #20, #21, #22, #23, #27, #32, #35, #39, #43, #44, #46, #49, #52, #60, #65, #71, #78, #87, #89, #90, #91, #92, #93, #94, #95, #96, and #97) personal funds with the facility operating funds out of 85 sampled. The sampled residents resided in the facility. The facility census was 85. 1. Review of the facility's policy titled Collections Guidelines, undated, showed: -Requests for a refund that is a result of a credit balance on the resident's account; -Resident refunds are requested based on the following; -When a resident has discharged the facility with no anticipation of returning; -When an overpayment of funds was applied to the account and a refund is requested by the resident or responsible party; -Third Party Refunds are requested based on the following; -When a Third-party payer has made an overpayment in comparison to the amount that was billed; -When a resident has died and there is a balance of funds that are to be refunded to the state (Medicaid); -In the event a resident has died or discharged from the facility and a Social Security Income (SSI) check is addressed to the facility needs to be refunded to the Social Security; -A check request form is completed by the Business Office Manager (BOM) and then signed by the Administrator. 2. Review of the facility maintained Accounts Receivable (A/R) Aging report, dated [DATE], showed the following residents witih personal funds held in the facility operating account: Resident Amount Held in Operating Account #8 $16,460.00 #9 $3,732.68 #12 $3,791.00 #17 $2,294.34 #19 $2695.50 #20 $3,946.26 #21 $132.80 #22 $575.00 #23 $214.00 #27 $4,307.20 #32 $27,590.05 #35 $3,727.00 #39 $4,526.80 #43 $2,041.56 #44 $6,980.47 #46 $4,515.00 #49 $2,785.00 #52 $832.80 #60 $4,966.87 #65 $9,504.00 #71 $188.52 #78 $400.00 #87 $50.00; #89 $1,425.24; #90 $2,115.57; #91 $2,105.00; #92 $3,224.65; #93 $46.00; #94 $4,516.00; #95 $6,055.50; #96 $200.00; #97 $2,056.74; Total $128,001.55 During an interview on [DATE] at 11:15 A.M., the Buisness Office Manager (BOM) said he/she has been the BOM for two years, but the facility switched the computer billing system on [DATE] and he/she has not been completely trained on how to use the new system. The BOM said the new system went live on [DATE] and he/she did not get the balance forwarded to him/her from the old system until [DATE]. The BOM said it is his/her responsibility to review the A/R Aging report weekly, but he/she reviews it monthly instead.The BOM said he/she has fallen behind on refunds and it is his/her fault the refunds are not being sent timely. The BOM said refunds should be sent within 30 days of a resident discharge from the facility. The BOM said he/she does not have written authorization to hold the resident's monies. During an interview on [DATE] at 2:40 P.M., the administrator said the BOM is responsible for the AR Aging report and resident billing. The administrator said he/she expects the BOM to work the accounts all the time and he/she expects the refunds to be sent timely. The administrator said he/she does not have any reasons for why the refunds have not been sent. The administrator said credit refunds should be sent within 30 days of a resident being discharged from the facility.

Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, and ceilings of resident occupied rooms and common areas. The facility census was 85. 1. Review of the facility's policy titled Housekeeping Cleaning Procedures: Resident Room Cleaning, dated June 2018, showed staff were directed as follows: -Dust mop and damp mop floor; -Damp mop restroom floor using microfiber flat mop; -Weekly procedure to remove mineral deposits from sink and tub/shower; -Wipe walls. Review of the [NAME] Side and East Side Housekeeper checklist, undated, showed staff were directed as follows: -Remove trash, sweep and mop, spot clean walls, sweep and mop room last and leave a wet floor sign; -Mondays- dust over head lights and blinds and bathroom fans; -Tuesdays- clean filters on Packaged Terminal Air Conditioner units. Review of the environmental checklist for room cleaning, undated, showed staff were directed to evaluate high-touch room surfaces such as bed rails/controls, chair/bedside commode, sink/faucet, and bathroom handrails by toilet. Review of the policies provided by the facility did not contain a policy for reporting environmental concerns. 2. Observation on 12/16/24 at 5:46 A.M., showed resident room [ROOM NUMBER] and storage room with missing and torn dry wall. 3. Observation on 12/16/24 at 8:04 A.M., showed resident occupied room [ROOM NUMBER] floor with visible foot prints, wheelchair prints and debris. 4. Review of the facility's Maintenance Log stored at the 300 hall nurse's station, dated 11/15/24 though 12/18/24, showed staff did not document any of the identified environmental concerns listed below. 5. Observation on 12/16/24 10:02 A.M., showed resident occupied room [ROOM NUMBER] floor with a wet floor sign in the doorway. Observation showed the floor with multiple areas black sticky subtance, paper towels and debris under the bed. Observation on 12/19/24 at 8:41 A.M., showed resident occupied room [ROOM NUMBER] floor with multiple areas of black sticky substance, debris build up in the corners of the room and the rubber base trim missing between the doorframe. 6. Observation on 12/17/24 at 8:40 A.M., showed resident occupied room [ROOM NUMBER] dresser with an unknown red, dried, sticky substance by the drawers. Observation on 12/18/24 at 9:25 A.M., showed resident occupied room [ROOM NUMBER] floor with a red dry substance, in a large circle on the tile floor. Observation showed the corners of the walls by the bathroom door and wardrobe with chipped paint and missing drywall. Observation of the bathroom showed the wall with multiple black marks and the air condition with an unknown black substance. Observation on 12/19/24 at 8:34 A.M., showed resident occupied room [ROOM NUMBER] dresser with an unknown red, dried, sticky substance by the drawers. 7. Observation on 12/17/24 at 8:48 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with areas of gouged and missing paint. The bathroom door trim torn and peeled away from the wall, with exposed area of the wall. The bathroom wall by the wardrobe with multiple areas of missing paint. The vent hung from the ceiling with exposed portion of the ceiling. The bedroom floor tile broken and missing pieces under the bed by the window. The air conditioner contained multiple black areas. Observation on 12/18/24 at 9:30 A.M., showed resident occupied room [ROOM NUMBER] bathroom ceilings and walls seperated and cracked. 8. Observation on 12/17/24 at 9:00 A.M., showed resident occupied room [ROOM NUMBER] bathroom vent and light covered with cob webs. Observation on 12/18/24 at 9:36 A.M., showed resident occupied room [ROOM NUMBER] bathroom vent and light covered with cob webs. The air conditioner contained multiple black, round, porous spots on the vents. 9. Observation on 12/17/24 at 9:04 A.M., showed occupied room [ROOM NUMBER]'s bathroom vent unsecured and hung from the ceiling. Observaton showed wardrobes rubber base trim missing. The floor between the beds with missing tiles. The air conditioner vents covered in dirt and debris. 10. Observation on 12/17/24 at 9:09 A.M., showed occupied room [ROOM NUMBER] bathroom door with missing paint and drywall. The bathroom ceiling with areas of discoloration, bubbled paint and unknown porous, green substance. Observation on 12/18/24 at 9:46 A.M., showed resident occupied room [ROOM NUMBER] without an interior window. The bathroom ceiling with areas of discoloration, bubbled paint and unknown porous, green substance. 11. Observation on 12/18/24 at 9:16 A.M., showed the courtyard entrance to the rehabilitation with missing tile. 12. Observation on 12/19/24 at 8:35 A.M., showed the 300 hall ceiling tiles by the fire doors damaged. 13. Observation on 12/19/24 at 8:36 A.M., showed resident room [ROOM NUMBER] and 303 ceiling vents with built up dirt and debris. Observation of room [ROOM NUMBER] doorframe showed a moisture collection pump installed with an unpainted wall behind it. 14. Observation on 12/19/24 at 8:39 A.M., showed resident occupied room [ROOM NUMBER] doorframe with broken tile and a built up black substance. Observation showed the floor tiles by the window broken and missing. 15. Observation on 12/19/24 at 8:44 A.M., showed the 300 hall dining room floor with areas of chipped and broken tile on the corner tiles. 16. Observation on 12/19/24 at 8:49 A.M., showed the fire doors to the main dining room had missing paint. 17. Observation on 12/18/24 at 11:51 A.M., showed the memory care unit nurse's station floor with exposed old tile floor. During an interview on 12/19/24 at 8:53 A.M., Licensed Practical Nurse (LPN) N said the floor in the memory care unit across from the nurse's station has been like that since they started in the summer. He/she said he/she is unaware if this has been reported to maintenance or not. The LPN said they are not aware of the processes for notifying maintenance of repair needs and will just go tell them in person if there are maintenance needs. 18. Observation on 12/19/24 at 11:15 A.M., showed resident occupied room [ROOM NUMBER] bathroom wall with areas of a black porous substance. 19. Observation on 12/19/24 at 11:16 A.M., showed resident occupied room [ROOM NUMBER] ceiling with a black porous substance and chipped paint on both sides of the light fixture. 20. Observation on 12/19/24 at 11:17 A.M., showed resident occupied room [ROOM NUMBER] bathroom ceiling with several areas of a black porous substance. 21. Observation on 12/19/24 at 11:18 A.M., showed resident occupied room [ROOM NUMBER] bathroom ceiling with several areas of a black porous substance. 22. Observation on 12/19/24 at 11:20 A.M., showed resident occupied room [ROOM NUMBER] bathroom ceiling with several areas of a black porous substance. 23. During an interview on 12/19/24 at 11:36 A.M., the Maintenance Director said said he/she is aware of the issues with the floor tile, ceilings in rooms and bathrooms, air conditioning units, and walls. said they are aware of an issue with moisture in the ceilings from the air conditioning units. The maintenance director said they do a facility walk through every morning but only to check that exterior doors are functionally correctly. He/She said he/she knew of the issue in general and previous concerns but did not know of the current black substance and extent of the issue. He/She said he/she is aware the tile needs replaced but corporate has not approved the repairs. The maintenance director said he/she has to work on one room at a time on the 400 hall, and he/she has not gotten to the 300 hall yet. During an interview on 12/19/24 at 12:06 P.M., the Director of Nursing (DON), said he/she is aware of the piece of flooring missing from the memory care unit and it could be a trip hazard for residents. The DON said corporate has not approved the floor repairs. During an interview on 12/19/24 at 12:53 P.M., the administrator said he/she is not aware of the black porous substance in the bathrooms of the memory care unit. The administrator said they would have expected staff to report this if they observed it. He/she would not expect all staff to look up to the ceilings but housekeeping staff should have noticed it and reported it. 24. During an interview on 12/19/24 at 8:51 A.M., Certified Nurse Aide (CNA) F said staff are supposed to write maintenance issues on a list at the nurse's station. The CNA said a lot of rooms and the hallways have missing trim and torn up walls. The CNA said he/she has observed the damaged doors, floors being dirty, and base trim coming off in many areas. The CNA said housekeeping is supposed to clean the vents of the air conditioners with a duster. The CNA said he/she assumes maintenance cleans the air conditioner units.The CNA said he/she has not put anything on the maintenance log. The CNA did not say why he/she did not notify housekeeping, but said he/she should have. During an interview on 12/19/24 at 9:12 A.M., Licensed Practical Nurse (LPN) I said there is a maintenance book at nurse's station staff are supposed to fill out and sign off on. The LPN said he/she noticed some broken and chipped tile, and chipped paint, and has not put it on the maintenance log, and he/she should have. The LPN said he/she expects staff to notify housekeeping if they find something needs cleaned. During an interview on 12/19/24 at 10:27 A.M., Housekeeper J said there is a list the housekeepers use when cleaning the rooms, but he/she does not have one because someone removed it from his/her cart. The Housekeeper said he/she used to clean one hall, but now he/she has to clean two halls. The Housekeeper said since the facility switched him/her from one to two halls to clean, housekeeping has not been doing super cleans, where housekeeping gets the black grime out of the corners of the rooms. The Housekeeper said the deep cleans that are not getting done, also include cleaning blinds, air conditioners, etc. The Housekeeper said the cleaning is not getting done. The Housekeeper said he/she has noticed the built up black spots on the air conditioner units and he/she wants to clean the air conditioners, but he/she is cleaning 30 rooms by himself/herself. The housekeeper said if he/she sees something that needs fixed, he/she calls his/her supervisor and they let maintenance know. The Housekeeper said he/she noticed the damaged walls and missing and damaged base boards in the rooms. The Housekeeper said he/she told his/her supervisor and maintenance knows. During an interview on 12/19/24 at 10:58 A.M., the housekeeping director said the facility went over budget, so the housekeeping department had to cut back on staff. He/She said each housekeeper now has to clean an additional eight rooms. Housekeepers a have list they are supposed to check off when cleaning rooms, and they are supposed to hand in to the housekeeping director at end of day. The housekeeping director said if the housekeepers see anything needing fixed they are to write it on their checklist and give to him/her. The housekeeping director said then he/she reviews the cleaning check list and notifies maintenance with any concerns. The housekeeping director said he/she checks to make sure maintenance takes care of the issues. The housekeeping director said the cleaning list tells housekeepers what to clean in the rooms, it's called a Daily General Cleaning List. The housekeeping director said housekeeping has a schedule for the deep cleans and maintenance and housekeeping has been short staffed, so the schedule is not being followed. The housekeeping director said he/she has noticed the broken and chipped tile in the residents rooms and has reported it, but the facility doesn't have the proper tile to fix it. The housekeeping director said he/she has noticed the damage to the rubber base trim in the residents' room and reported it. The housekeeping director said he/she expects staff to report wall damage, and damage to doors and door frames. The housekeeping director said air conditioner units are on the housekeepers list to clean, and they should be cleaned weekly. He/She said it is not getting done. The housekeeping director said the housekeepers are supposed clean ceiling vents, but they are not because they are overwhelmed with the changes. The housekeeping director said he/she expects staff to report vents hanging down, and he/she has had no recent reports of vents in the bathrooms hanging down. The housekeeping director said the facility has a couple problematic bathroom ceilings with green growth, housekeeping cleans it, but it keeps coming back. During an interview on 12/19/24 at 11:36 A.M., the Maintenance Director said the nurse's station has a maintenance book staff can write their concerns in and they check the book daily. The Maintenance Director said he/she is aware of chipped and broken tiles in the resident rooms. He/She said they got the tile but it was wrong tile, so he/she has been working with corporate to get the right tile. The Maintenance Director said housekeeping is supposed to clean the front of the air conditioners, the filters and the tops, daily. The maintenance director said staff has not notified him/her of any black substances on the air conditioner vents in the resident rooms. He/She said maintenance would take care of that right away. He/She said staff should let him/her know if there is damage to doors, walls, or base trim, but he/she has not been notified. The maintenance director said staff is not notifying the maintenance department when they come across issues. He/She said maintenance had not been told about a missing window, and he/she would expect housekeeping to notify them, since they clean the windows. The Maintenance Director said he/she had not been made aware there is a green substance on the ceilings of the bathrooms. He/She said housekeeping is supposed to clean the ceiling vents and he/she does not know why it is not happening. He/She said staff has not reported any vents hanging from the ceiling. The Maintenance Director said he/she is not sure who reviews the request sheets when he/she signs off that Maintenance has completed the request. The Maintenance Director said he/she just keeps the request sheets for his/her records, and doesn't give them to anyone. During an interview on 12/19/24 at 12:53 P.M., the administrator said all staff are to report maintenance concerns via the maintenance book. He/She said maintenance should check the book every morning, and sign the book when the task is completed. The administrator said it is his/her responsibility to check the log book, but he/she has not done it in a while. The administrator said the housekeepers have a cleaning check list that should be reviewed by their supervisor and checked for completion. 45489 50361

Based on observation and interview, facility staff failed to respect the dignity of two residents (Resident #22 and #24) out of 22 sampled residents during meal time. The facility census was 85. 1. Review of the policy titled The Dining Experience: Staff Roles, dated 2016, showed staff will be discouraged from standing over the resident while assisting them to eat and staff will promote resident dignity in the dining room. Review of the facility policy titled Resident [NAME] of Rights, reviewed January 2015, showed residents will be treated with consideration to respect, and full recognition to the residents dignity. 2. Observation on 12/16/24 at 8:46 A.M., showed Resident #22 and Resident #24 in the dining room at the same table. Observation showed Certified Nurse Aide (CNA) M placed meal trays in front of Resident #22 and Resident #24. CNA M stood over the residents, while he/she assisted them with bites of food. During an interview on 12/16/24 at 8:46 A.M., CNA M said Resident #22 and Resident #24 are feeders and are hard to manage with only two CNA's working. 3. Observation on 12/17/24 at 8:25 A.M., showed Resident #24 at the dining room table. Observation showed CNA R placed a meal tray in front of the resident and shouted the resident is a feeder. 4. Observation on 12/17/24 at 8:25 A.M., showed Licensed Practical Nurse (LPN) N in the dining room and shouted at Resident #22 to eat his/her breakfast three times. Observation showed LPN N shouted to CNA R the resident can feed himself/herself but he/she won't, so he/she needs to be fed. During an interview on 12/19/24 at 8:40 A.M., CNA R said staff should not stand over residents when assisting them at meals, he/she said staff should sit next to the resident at eye level. The CNA said if a resident requires assistance with eating they would be referred to as a feeder. During an interview on 12/19/24 at 8:53 A.M., LPN N said staff should not call residents feeders. The LPN said staff should not stand over residents when they are feeding them. 5. Observation on 12/18/24 at 1:28 P.M., showed Resident #22 at the dining table and CNA R stood over the resident to feed him/her. 6. During an interview on 12/16/24 at 8:33 A.M., CNA O said he/she had two feeders and identified Resident #22 and #24 while he/she sat at the living room table with other residents. During an interview on 12/19/24 at 12:15 P.M., the Director of Nursing (DON) said staff should sit next to the residents and provide assistance with eating. The DON said they would not expect staff to refer to residents needing assistance with eating as feeders. The DON said he/she did not know why staff stood over residents to help them eat and did not know staff were calling the residents feeders. During an interview on 12/19/24 at 12:53 P.M., the administrator said staff should not stand over residents to provide assistance with eating. He/She said staff should sit next to them at eye level and visit with them throughout the process. The administrator said staff should not call residents feeders and should instead say they need assistance with eating.

Based on observation, interview and record review, the facility staff failed to reheat pureed food items in accordance with the standardized recipes to prevent the growth of food-borne pathogens and potential for food-borne illness. The facility staff also failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit ( F) or higher upon service to the residents. The facility census was 87. 1. Review of the facility's Monitoring Food Temperatures for Meal Service, dated 2016, showed: -Prior to serving a meal, food temperatures will be taken and documented for cold and hot foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below; -If the serving/holding temperature of a hot food item is not at 135 F or higher when checked, they will be reheated to at least 165 F for a minimum of 15 seconds, only once and discarded or consumed within two hours; -Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. 2. Review of the facility's Pureed Food Preparation policy, dated 2020, showed the policy directed staff to prepare pureed foods in accordance with standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value and to heat pureed foods to a minimum of 165 F before service. 3. Review of the facility menus, dated 02/05/24 (Week 4, Day 23), showed the menus directed staff to provide the residents on pureed diets with pureed barbecue pork loin, pureed pinto beans, pureed vegetable medley and pureed yellow cake with frosting at the lunch meal. Review of the facility's standardized recipes for the pureed barbecue pork loin, pureed pinto beans and pureed vegetable medley, signed by the registered dietician on 12/12/23, showed the recipes directed staff to reheat the pureed food items' internal temperature to greater than 165 F for at least 15 seconds after they are made and to maintain the internal temperature at 135 F or above during service. Observation on 02/05/24 from 11:53 A.M. to 12:07 P.M., showed Cook A added four prepared pieces of pork loin, two slices of bread, 3/4 cup water and chicken broth to the food processor and blended. Observation showed the dietary manager (DM) then added more chicken broth and blended the pork loin until smooth. Observation showed the DM scooped the pureed pork loin into a metal pan and, without checking the internal temperature of the pureed food, placed the pan in the steamtable and walked away. Observation showed the internal temperature of the pureed pork loin when placed on the steamtable measured 99.3 F. Observation on 02/05/24 at 12:21 P.M., showed the DM placed prepared portions of the vegetable medley with broth into the food processor and blended until smooth. Observation showed the DM scooped the pureed vegetables into a metal pan, and without checking the internal temperature of the pureed food, placed the pan in the steamtable and walked away. Observation showed the internal temperature of the pureed vegetables when placed on the steamtable measured 107.4 F. Observation on 02/05/24 at 12:53 P.M., showed the DM placed portions of prepared pinto beans and broth into the food processor and blended until smooth. Observation showed the DM scooped the pureed pinto beans into a metal pan, and without checking the internal temperature of the pureed food, placed the pan in the steamtable and walked away. Observation showed the internal temperature of the pureed vegetables when placed on the steamtable measured 114 F. Observation on 02/05/24 during the lunch meal service which began at 12:15 P.M., showed Cook A, did not check internal temperatures, served the pureed food items to residents who received pureed diets. Observation showed at the time of service to the residents from the steamtable, the internal temperature of the pureed pork loin measured 108 F, the internal temperature of the pureed vegetable medley measured 141 F, and the internal temperature of the pureed pinto beans measured 108 F. During an interview on 02/05/24 at 1:23 P.M., Cook A said the cooks are supposed to take the internal temperatures of the food items prior to service. The cook said he/she did not check the internal temperature of the pureed food items before service because he/she was in a hurry and thought since the DM made them, their temperatures were okay. 4. Review of facility's standardized recipes for meatballs with marinara, egg noodles, mixed vegetables, baked chicken and mashed potatoes, signed by the registered dietician on 12/12/23, showed the recipes directed staff to maintain the internal temperature of the food items at 135 F after preparation. Observation on 02/07/24 at 12:51 P.M. showed one staff person served food trays to residents who ate in their room on the 200 hall. Observation on 02/07/24 at 12:52 P.M. showed staff delivered a tray of food to Resident #87 on the 200 hall from an open, wheeled cart delivered from the kitchen. Observation showed the internal temperature of the baked chicken thigh measured 110 F, and the internal temperature of the mashed potatoes measured 108 F. Observation on 02/07/24 at 12:55 P.M., showed staff delivered a tray of food to Resident #92 on the 200 hall from an open, wheeled cart delivered from the kitchen. Observation showed the internal temperatures of the meatballs with marinara, egg noodles and mixed vegetables measured 100 F. Observation on 02/07/24 at 1:26 P.M., showed staff delivered a tray of food to Resident #65 on the 300 hall. Observation showed the internal temperature of the mechanically altered meatballs measured 115.8 F, the internal temperature of the buttered egg noodles measured 114 F, and the internal temperature of the mixed vegetables measured 115 F. Observation on 02/07/24 at 1:38 P.M., showed staff delivered a tray of pureed food to Resident #14 on the 300 hall. Observation showed the internal temperature of the pureed meatballs measured 94.2 F, the internal temperature of the pureed noodles measured 87.7 F and the internal temperature of the pureed vegetables measured 91.6 F. 5. Review of the facility's standardized recipes for egg of choice, breakfast meat, hot cereal and biscuits with gravy, signed by the registered dietician on 12/12/23, showed the recipes directed staff to maintain the internal temperature of the food items at 135 F after preparation. Observation on 02/08/24 at 7:55 A.M., showed staff delivered a tray of food to the 200 hall from an open, wheeled cart delivered from the kitchen. Observation showed one staff person served trays of food to residents who ate in their rooms on the 200 hall. Observation on 02/08/24 at 7:58 A.M. showed staff delivered a tray of food to Resident #87 on the 200 hall and the internal temperature of the oatmeal measured 110 F. Observation on 02/08/24 at 8:00 A.M. showed staff delivered a tray of food to Resident #92 on the 200 hall. Observation showed the internal temperature of the scrambled eggs measured 100 F, and the internal temperature of the biscuit with white gravy measured 95 F. 6. During an interview on 02/08/24 at 10:51 A.M., the DM said the temperature of prepared hot foods should be at least 165 F on the steamtable and 145 F or higher upon service to the residents. The DM said if a food is cooked to the proper temperature and then the food's temperature drops into the danger zone, the food needs to be reheated to 165 F. The DM said pureed foods should be reheated to 165 F before service, but he/she was just flustered and did not reheat them. The DM said there is no expectation for staff to check the temperature of food items served as room trays once they have left the kitchen, but if they have set for a long time before they are passed, staff should bring them back to the kitchen to be reheated. 7. During an interview on 02/08/24 at 12:09 P.M., the administrator said the temperature of hot foods should be at least 135 F and staff should check the food temperatures before service. The administrator said staff should also check the internal temperature of modified textured foods after they are made and if they are not hot enough, staff should reheat them to 165 F. The administrator said the dietary staff are trained on proper food temperatures and when to reheat food items. The administrator said room trays should be served immediately when they are delivered from the kitchen, but if they sit in the hall for a while before they are served, then dietary should check the temperatures of the foods on the trays and take them back to the kitchen to be reheated if they are not hot enough. 37131 45489

Based on observation, interview and record review, facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff failed to properly sanitize manually washed kitchenware to prevent cross-contamination. The facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff also failed to maintain food delivery equipment in a clean and sanitary manner to prevent the growth of food-borne pathogens and prevent cross-contamination. The facility census was 87. 1. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2016, showed: -All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines; -All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between tasks; -Employees will wash hands before and after handling foods, after touching any part of uniform, face, or hair, and before and after working with an individual residents; -The proper procedure for washing hands included instruction to wet hands, apply soap and scrub for 15 to 20 seconds or more, rinse and dry hands, and turn the faucet off with a paper towel. Review of the facility's Dishwashing: Machine Operation policy, dated 2020, showed the policy directed staff to use clean, washed hands to put away clean dishes. Observations on 02/05/24 at 9:49 A.M., 10:09 A.M., and 10:14 A.M. showed dietary aide (DA) D washed soiled dishes in the mechanical dishwashing station and then put away sanitized dishes from the clean side of the station without performing hand hygiene. During an interview on 02/05/24 at 10:20 A.M., DA D said staff trained him/her on hand hygiene procedures upon hire. The DA said staff should wash their hands between handling dirty and clean dishes and he/she just forgot to wash his/her hands. Observation on 02/05/24 at 11:38 A.M., showed Cook A washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap for two seconds, rinsed his/her hands, turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands. Observation showed the cook then returned to stove and continued to prepare chicken and dumplings for service to residents at the noon meal. Observation on 02/05/24 at 12:38 P.M., showed Cook A removed his/her cellphone from his/her pocket with his/her bare hand and used the phone. Observation showed the cook washed his/her hands at the handwashing sink by scrubbing his/her hands with soap under running water for three seconds, turned the faucet off with his/her bare hands, and then returned to serve food to residents from the steamtable with wet hands. Observation on 02/08/24 at 9:16 A.M., showed Cook A touched his/her facemask with his/her bare hand and then put away sanitized dishes from the clean side of the mechanical dishwashing station while wet without performing hand hygiene. Observation on 02/08/24 at 9:26 A.M., showed Cook A washed his/her hands at the handwashing sink. Observation showed the cook turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands. During an interview on 02/08/24 at 9:27 A.M., Cook A said staff are to turn the faucet off with a paper towel after they wash their hands so you do not get your hands dirty again. The cook said he/she did not think about that using the same paper towel to dry his/her hands that he/she used to turn off the faucet would make his/her hands dirty again. During an interview on 02/08/24 at 9:38 A.M., Cook A said he/she had worked at the facility since November 2023 and staff did not train him/her on hand hygiene procedures when hired, but staff are to wash their hands as instructed by the sign posted at the handwashing sink. The cook said staff should wash their hands after they touch something dirty, which would include their facemasks and he/she did not realize that he/she did not perform hand hygiene after he/she touched his/her facemask. The cook said staff should not scrub their hands with soap while under running water and he/she just did not think about it. Observation on 02/05/24 at 1:33 P.M., showed Cook B washed his/her hands at the handwashing sink and then turned the faucet off with his/her bare hand. Observation showed the cook then returned to stove to prepare food items for service to residents at the evening meal. Observation on 02/05/24 at 1:25 P.M., showed DA C left the kitchen with his/her facemask on over his/her mouth and nose and then returned to the kitchen with his/her facemask on below his/her chin. Observation showed the DA used his/her bare hand to pull his/her facemask up over his/her mouth and nose and then, without performing hand hygiene, returned to portioning cake into bowls for service to residents. Observation showed the DA picked up a bowl with his/her finger inside bowl and then placed cake in the bowl for service. Observation showed the DA used his/her bare hands to lift the trash can lid to dispose of trash and then, without performing hand hygiene, he/she continued to serve food to residents. Observation on 02/08/24 at 9:45 A.M., showed a handwashing instruction sign posted above the handwashing sink which included instruction for staff to: -Use a generous amount of soap; -Apply with vigorous contact on all surfaces of the hands; -Wash hands for at least 20 seconds; -Clean under and around fingernails; -Rinse with your hands down, so that runoff goes into the sink, and not down your arms; -Dry well with paper towels; -Use a towel to turn off the water. During an interview on 02/08/24 at 10:36 A.M., the DM said staff should wash their hands when they enter the kitchen, before they touch anything clean, between tasks, after they touch something dirty which would include dirty dishes, facemasks, and cellphones. The DM said staff should wash their hands by lathering soap on their hands for at least 20 seconds out of the water, rinse, dry and then turn the faucet off with a paper towel so they do not recontaminate their hands. The DM said all staff are trained on hand hygiene procedures upon hire and as needed. During an interview on 02/08/24 at 11:43 A.M., the administrator said staff should perform hand hygiene when they enter the kitchen and after they touch anything dirty which would include dirty dishes, trash cans, facemasks and cellphones. The administrator said staff should wash their hands by scrubbing their hands with soap for 20 to 30 seconds out of the water, rinse, dry and then turn the faucet off with a clean paper towel. The administrator said staff should not use same towel to turn off faucet and dry hands so they do not recontaminate their hands. The administrator said staff are trained on hand hygiene procedures upon hire. 2. Review of the facility's Dishwashing: Machine Operation policy, dated 2020, showed the policy directed staff to allow washed dishes to air dry before they are put away for storage. Observation on 02/05/24 at 9:49 A.M., showed DA D removed sanitized food service trays and plates from the clean side of the mechanical dishwashing station while wet, stacked them together and put them away in their storage areas. Observation 02/08/24 at 9:12 A.M., showed Cook A removed a sanitized metal food service pan from the clean side of the mechanical dishwashing station while wet and stacked it on top of other clean pans on the shelf above the three-compartment sink. Observation on 02/08/24 at 9:16 A.M., showed Cook A put away sanitized plates from the clean side of the mechanical dishwashing station while wet. Observation also showed multiple plastic glasses stacked together wet in a rack by the handwashing sink. During an interview on 02/08/24 9:18 A.M., Cook A said clean dishes should be dry before they are put away and he/she thought the dishes were mostly dry. Observation on 02/08/24 at 9:35 A.M., showed Cook A removed sanitized food service trays from the clean side of the mechanical dishwashing station while wet, stacked them together and put them in the storage cart. During an interview on 02/08/24 at 9:36 A.M., Cook A said he/she thought the trays were dry enough and did not know why dishes needed to be dry before they were stacked together. During an interview on 02/08/24 at 10:41 A.M., the DM said staff should allow dishes to air dry before they are put away and staff have been trained on this requirement. During an interview on 02/08/24 at 11:48 A.M., the administrator said staff should allow dishes to air dry before they are put away and staff are trained on this requirement. The administrator said he/she and the dietary manager are responsible to make monitoring rounds in the kitchen at least three times a week and he/she had not found wet dishes to be a problem during his/her rounds. 3. Review of the facility's Dishwashing: Manual policy, dated 2020, showed the policy directed staff to wash dishes in a hot detergent solution in the first sink compartment, rinse them in clean warm water in the second sink compartment, and sanitize them by either heat or chemicals in the third sink compartment. Review showed the policy directed staff to test the concentration of chemicals or the temperature of hot water before they wash dishes. Review also showed direction for staff to drain and air dry the dishes on the drain counter or designated drying rack after they are washed. Review showed the policy did not contain instruction to staff on how long dishes should remain in the third sink compartment to ensure the dishes were properly sanitized. Review of the facility's Sanitizing Equipment and Food Contact Surfaces policy, dated 2016, showed the policy directed staff to sanitize equipment and food contact surfaces with the proper sanitizing solution and to follow the sanitizing recommendations and procedures for each piece of equipment or food contact surface as directed in the cleaning guidelines or per the manufacturer's recommendation. Observation on 02/05/24 at 9:59 A.M., showed the three-compartment sink set up to wash, rinse and sanitize soiled dishes. Observation showed a quaternary ammonium (QUAT) based sanitizer used to create the sanitizing solution in the third compartment of the sink. Review of the QUAT sanitizer product label, showed direction to immerse washed and rinsed dishes in the sanitizing solution for at least one minute. Observation on 02/05/24 at 12:24 P.M., showed the DM washed spatulas in the three-compartment sink. Observation showed after he/she washed and rinsed the spatulas, the DM dipped them in the sanitizing solution and immediately removed. Observation showed the DM shook excess water off of one of the spatulas and then used the spatula to scoop pureed vegetables from food processor into a pan and then placed the pan onto the steamtable for service at the noon meal. During an interview on 02/08/24 at 10:43 A.M., the DM said when dishes are washed in the three-compartment sink, the staff should allow the dishes to remain in in the sanitizing solution for at least one minute before they are removed and then the dishes should air dry. The DM said he/she did not leave the dishes in the sanitizer as long as needed or allow them to air dry because they were in a rush. During an interview on 02/08/24 at 11:51 A.M., the administrator said when staff manually wash dishes, they should wash them with soapy water, rinse them with clean water, put them in the sanitizing solution and then remove and allow the dishes to air dry before they are put away or used. The administrator said he/she is responsible to monitor for proper dishwashing procedures during his/her rounds and, while he/she did not know how long staff should leave dishes in the sanitizing solution before they are removed, staff are trained on how to manually wash dishes upon hire. 4. Review of the facility's Food Storage (Dry, Refrigerated and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants; -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Observation on 02/05/24 at 10:25 A.M., showed three unlabeled and undated bulk food bins that contained food items removed from their original packaging. Observation showed the covers of the bins put on upside down which created open holes and left the contents of the bins opened to air. During an interview on 02/05/24 at 10:30 A.M., Cook A said he/she filled one of the bins on 01/20/24 and the other bins on 01/23/24. The cook said he/she did not know that the bins of food needed to be dated and labeled and he/she did not realize lids were not on correctly. During an interview on 02/05/24 at 10:33 A.M., the DM said opened food items should be dated with the date they are opened and labeled with what is inside. The DM said he/she did not know the bulk containers were not dated or labeled and he/she did not notice the lids were on upside down and exposing the contents to the air. Observation on 02/05/24 at 10:39 A.M., showed an opened and undated five pound bag of egg noodles stored in the dry goods pantry. Observation on 02/05/24 at 10:45 A.M., showed the the walk-in freezer contained bags of tater tots and beef riblets, a case of dinner roll dough, and a case of cobbler crust opened to the air and undated. Observation on 02/08/24 at 9:04 A.M., showed a case of pasteurized eggs stored on the floor by the stove. Observation on 02/08/24 at 9:06 A.M., showed an opened and undated five pound bag of cocoa powder stored in the dry goods pantry. Observation on 02/08/24 at 9:07 A.M., showed a case of beef patties and a case of dinner roll dough opened to the air and undated stored in the walk-in freezer. During an interview on 02/08/24 at 9:23 A.M., Cook E said he/she put the case of eggs on the floor that morning to make for breakfast because they were heavy and he/she did not have room to put them on the counter. The cook said food should not be stored on the floor. During an interview on 02/08/24 at 10:44 A.M., the DM said opened food items should be stored off the floor, sealed tightly, labeled with what it is, dated with a use by date and staff are trained on those requirements. The DM said he/she is responsible to monitor the food storage as part of a checklist that he/she is to complete daily and staff are frequently reminded about proper food storage procedures. The DM said he/she did not do his/her checklist that morning, but he/she did check the food storage and only found an container of apple juice and box of sausages opened and undated in the refrigerators. During an interview on 02/08/24 at 11:56 A.M., the administrator said opened food items should be labeled, dated, and stored covered and staff are trained on this requirement. The administrator said he/she is responsible to monitor food storage during my rounds, he/she knew they had some issues in that area and staff are reminded daily on food storage requirements. 5. Review of the facility's Cleaning Rotation policy, dated 2016, showed the policy directed staff to clean the food carts daily. Observation on 02/05/24 at 11:26 A.M., showed a milky dripped residue, food debris and dried liquid on the interior of two of two enclosed food carts, especially at the bottom behind the racks. Observation also showed dried food and liquid debris on the rungs of the wheeled sheet pan racks. Observation on 02/05/24 during the noon meal service, showed staff used the soiled enclosed food carts and wheeled sheet pan racks to deliver trays of prepared food to residents who ate in their rooms. Observation on 02/08/24 at 10:49 A.M., showed a milky dripped residue, food debris and dried liquid on the interior of two of two enclosed food carts, especially at the bottom behind the racks. During an interview on 02/08/24 at 10:49 A.M., the DM said the food carts should be cleaned after each meal and staff are trained to clean the carts, but not to clean behind the racks because he/she did not know the racks inside the carts could be removed. During an interview on 02/08/24 at 11:58 A.M., the administrator said food carts should be cleaned when visibly soiled and staff should remove racks inside the carts when they clean them. The administrator said he/she did not know that staff did not know that the racks in the carts could be removed.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 87. 1. Review of the facility's Organizational Plan and Roles of Key Staff policy, dated 2016, showed The Director of Food and Nutrition Services credentials will follow state regulations. The Director of Food and Nutrition Services credentials may include a Sanitation Certification, a 90-hour approved Dietary Manager's Course, or a two or four year degree in nutrition or food service as approved by the state. Review of the dietary manager's (DM) personnel records, showed a hire date for the DM position listed as 11/19/23. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 02/05/24 at 9:13 A.M., the DM said he/she became the DM just a couple of months ago, he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said he/she enrolled in food service management certification course that morning and he/she had not started any of the lessons. The DM said the facility has a part-time consultant registered dietician that comes to the facility two to three days a week and they did not have any certified or clinically qualified nutritional staff employed full-time. Review of a computer website print out provided by the administrator, dated 02/07/24, showed the DM enrolled in a Food Protection Manager certification course on 02/05/24 and had completed zero assignments in the course to date. During an interview on 02/08/24 at 11:37 A.M., the administrator said he/she could not provide documentation to show that the DM met the requirements to be the Director of Food and Nutritional Services. The administrator said the facility has a part-time consultant registered dietician and they did not have any certified or clinically qualified nutritional staff employed full-time. The administrator said when the DM discussed taking the position with him/her, the DM said that he/she had prior experience in dietary, but he/she did not follow-up on the DM's experience background. The administrator said he/she discussed the need for the DM to get enrolled in a food manager's course shortly after the DM took the position and he/she could not say why the DM did not get enrolled in a course until 02/05/24, because he/she did not follow-up with the DM on his/her course enrollment.

37131 Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, door frames, trim, handrails, and windows in good repair. The facility census was 87. Review of the policies provided by the facility did not contain a policy for environmental concerns. 1. Review of the Maintenance Clipboard, showed it did not contain maintenance requests for the disrepair listed below. 2. Observation on 02/05/24 at 9:51 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with chipped paint. Observation showed the corner by the bathroom with chipped paint and exposed drywall. 3. Observation on 02/05/24 at 9:56 A.M. showed the 100 Hall walls and handrails with black marks. Observation showed between room [ROOM NUMBER] and 106 trim with the wood chipped off. 4. Observation on 02/05/24 at 10:06 A.M., showed resident occupied room [ROOM NUMBER] wall behind the headboard of the bed with areas of gouged and chipped paint. Observation showed the bathroom door and trim with chipped paint. 5. Observation on 02/05/24 at 10:10 A.M., showed resident occupied room [ROOM NUMBER] with a brown substance on the outside of the can. Observation showed the privacy curtain with a red stain. 6. Observation on 02/05/24 at 10:12 A.M., showed room [ROOM NUMBER] bathroom door with chipped paint. 7. Observation on 02/05/24 at 10:17 A.M., showed room [ROOM NUMBER] bathroom wall with chipped paint and wood chipped off the trim around the bathroom door. 8. Observation on 02/05/24 at 10:39 A.M., showed resident occupied room [ROOM NUMBER] wall by window andn bathroom door with pieces of drywall and paint missing. Observation showed the drywall and paint missing behind the headboard. 9. Observation on 02/05/24 at 10:48 A.M., showed room [ROOM NUMBER] with black marks on the bathroom door and chipped paint on the trim around the bathroom door. 10. Observation on 02/05/24 at 10:52 A.M., showed room [ROOM NUMBER] with black marks along the wall beside the bed by the door. 11. Observation on 02/05/24 at 10:56 A.M., showed resident occupied room [ROOM NUMBER] with a large piece of drywall cut out from under the bathroom sink with exposed pipes. 12. Observation on 02/05/24 at 10:59 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with missing paint. 13. Observation on 02/05/24 at 11:12 A.M., showed room [ROOM NUMBER] bathroom door with black marks, paint missing on the wall to the right and left of the bathroom door, and the sheets on the bed closest to the door had brown stains. 14. Observation on 02/05/24 at 11:52 A.M., showed an area of the floor in front of the Memory Care Unit (MCU) dirty utility room missing. 15. Observation on 02/05/24 at 12:40 P.M., showed the gray double doors from the 300 hall into the main dining room with several areas of chipped paint. Observation showed the wall passed the double doors with trim missing. 16. Observation on 02/05/24 at 1:04 P.M., showed the kitchenette in the main dining room corner without trim and an exposed nail which stuck out from the area without trim. 17. Observation on 02/05/24 at 1:29 P.M., showed the kitchen exit door and ceiling with a brown substance. 18. Observation on 02/06/24 at 10:11 A.M., showed room [ROOM NUMBER] door with a loose doorknob. 19. Observations on 02/07/24 during the Life Safety Code tour, showed the windows in resident rooms 207, 311, 313 and 315 did not contain window screens. Observation also showed a crack in the exterior window of resident room [ROOM NUMBER]. 20. Observation on 02/08/24 at 9:34 A.M., showed resident occupied room [ROOM NUMBER] with damaged dry wall behind the head of the bed closest to the window. During an interview on 02/08/24 at 11:39 A.M. Certified Nurse Aide (CNA) T said he/she had noticed the damage to walls in the rooms and it has been like that for months. The CNA said he/she had put in maintenance requests but the damages had not been addressed. During an interview on 02/08/24 at 2:42 P.M., Licensed Practical Nurse (LPN) O said no one has ever shown him/her a maintenance request or told him/her how to fill one out. The LPN said he/she notifies maintenance if he/she sees an issue. LPN said he/she has not made any maintenance requests. During an interview on 02/08/24 at 3:04 P.M., Housekeeper V said if he/she sees something that needs repaired he/she writes it on his/her cleaning list, or lets maintenance know. He/She said he/she is not familiar with the maintenance request process. He/She said he/she has not filled out a maintenance request. He/She said he/she had not noticed any issues with drywall, doors or doorframes in the rooms. During an interview on 02/08/24 at 3:20 P.M., Maintenance Director said when staff see something that needs fixed it should be reported on the clip board by the nurse's station. The Maintenance Director said the facility has started using the TELS (Electronic Communication for Maintenance Request) system. The Maintenance Director said he/she was aware of the issues, he/she had just started working on the 300 hall rooms in January and has only gotten two rooms completed, he/she waits for rooms to come open to redo the room then. During an interview on 02/08/24 at 4:01 P.M., the administrator said there is a clip board by the nurse's station for staff to fill out maintenance requests. Maintenance checks the clipboard daily. The administrator said there is a way to put the information in the TELS system, but he/she doesn't know how to do that. The administrator said he/she doesn't check the clipboard. The administrator said, I guess, I don't know if maintenance is getting requests done. The administrator said he/she is not aware of the all of the issues, but did know of some of the issues. The administrator said maintenance had just started working on the 300 hall, but waits for residents to discharge or change rooms to go in and complete the remodel of the rooms. 45489 48982

45489 Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for nine residents (Resident #4, #6, #10, #31, #46, #58, #83, #92, and #302). The facility census was 87. 1. Review of the facility's policy, titled Comprehensive Person Centered Care Plans, dated March 2018, showed staff were directed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The comprehensive person centered care plan shall be fully developed within seven days after completion of the Admission Minimum Data Set (MDS) Assessment, a federally mandated assessment tool to be completed by facility staff; -The interdisciplinary team (IDT) along with the resident and/or Resident representative will identify resident problems, needs, strengths, life history, preferences and goals; -For each problem, need, or strength a resident-centered goal is developed; goals should be measurable (i.e. walk from the nurses' station to room by (date); -Staff approaches are to be developed for each problem/strength/need; assigned disciplines will be identified to carry out the intervention; -Upon a change in condition, the Comprehensive Person Centered Care Plan will be updated. Review of the facility's policy, titled Social History/Psychosocial Assessment, dated October 2022, showed staff are directed to: -A social history including trauma screening will be completed on every resident in order to gather and utilize specific information about a resident's life; -The Social History including trauma screening should be completed within fourteen days of admission in conjunction with the Comprehensive Resident Assessment; identify resident trigger(s) which may retraumatize the resident and address on the Comprehensive Care Plan. 2. Review of Resident #4's Quarterly MDS, a federally mandated assessment tool, dated 01/08/24, showed staff assessed the resident as severely cognitively impaired with a diagnosis of Post Traumatic Stress Disorder ((PTSD) a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) . Review of the resident's comprehensive care plan, dated 01/18/24, showed staff documented the resident received antipsychotic medications (medication that alters mental status) due to diagnoses of paranoid schizophrenia, generalized anxiety disorder, PTSD, and depression. The care plan did not contain specific triggers or interventions related to the resident's PTSD. During an interview on 02/08/24 at 8:48 A.M., Licensed Practical Nurse (LPN) O said he/she would expect PTSD triggers, and appropriate interventions in the resident's care plan. The LPN said he/she does not know what the resident's triggers are, but the resident does get impulsive and does not have a lot of patience. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Rejection of care not exhibited; -Dependent on staff for bathing, toilet hygiene and transfers. Review of the resident's Physician Order Sheet (POS), dated February 2024, showed an order for Ketoconazole 2% Shampoo use twice weekly with showers. Review of the resident's care plan, dated 02/01/24, showed the care plan did not contain direction for staff in regard to the resident's prescribed shampoo. During an interview 02/08/24 at 11:17 A.M., Certified Nurse Aide (CNA) S said he/she uses the facility's shampoo and body wash for the resident. The CNA said the resident does not have his/her own shampoo. The CNA said if the resident should use a specific shampoo it should in the care plan. During an interview on 02/08/24 at 2:42 P.M., Licensed Practical Nurse (LPN) O said he/she had not looked at the resident's care plan and did not know the resident's personal hygiene preferences. The LPN said specialized shampoo should be in the care plan. During an interview on 02/08/24 04:01 P.M., the administrator said if the resident has an order for a prescription shampoo it should be on care plan. 4. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Rejection of care not exhibited; -Maximal assist from staff member for personal hygiene; Review of the resident's POS, dated February 2024, showed an order for Ketoconazole 2% Shampoo use twice weekly with showers. Review of the resident's care plan, dated 01/19/24, showed it did not contain direction for staff in regard to the resident's need for prescription shampoo during bathing. During an interview on 02/08/24 at 2:42 P.M., LPN O said he/she had not looked at the resident's care plan. The LPN said resident's specialized shampoo and fingernail preferences should be in care plan under personal hygiene. During an interview on 02/08/24 04:01 P.M., the administrator said said if the resident needs a prescription shampoo it should be on care plan. 5. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Rejection of care not exhibited; -Indwelling urinary catheter; -Diagnoses of neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), and quadriplegia (paralysis of all four limbs). Review of the resident's POS, dated February 2024, showed an order for catheter care daily. Review of the resident's care plan, dated 01/31/24 , showed it did not contain documenation to address the resident's urinary catheter or catheter care. Observation on 02/05/24 at 9:51 A.M., showed the resident sat in a wheelchair in his/her room. The resident's catheter bag in a dignity bag on the right side of wheelchair. During an interview on 02/08/24 at 2:42 P.M., LPN O said he/she had not looked at the resident's care plan. LPN O said if a resident has a catheter it should be listed on the care plan. During an interview on 02/08/24 04:01 P.M., the administrator said if a resident has a catheter it should be immediately updated on the care plan. 6. Review of Resident #46's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required moderate assistance for hygiene, toileting, dressing, and showers; -Has a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of the resident's care plan, revised 11/2023 showed staff documented the resident with cognitive memory loss, and may not respond appropriately related to Alzheimer's disease. Review showed staff documented the residents needs vary with levels of assistance with Activities of Daily Living (ADL's). Reviews showed the care plan did not contain direction for staff in regard to the resident's need for assistance with meals, showers, or personal hygiene/dressing and the residents resistance with care. Observation on 02/05/24 at 1:07 P.M., showed staff set up the resident's lunch tray. During an interview on 02/07/24 at 8:39 A.M., CNA Z said he/she is the shower aide and has to assist the resident to shower. The CNA said the resident can be resistive to cares, especially showers. During an interview on 02/08/24 at 1:30 P.M., CNA Y said the resident frequently resists care. The CNA said he/she would expect this to be on the resident's care plan. The CNA said a resident's care plan should have resident specific information so staff knows how to care for each resident. He/She said if a resident resist care then another staff member should attempt to assist the resident. He/She said if the resident is resistive to both staff members then staff should let the nurse know. 7. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Requires maximum assistance for meals; -Used a wheelchair; -Totally dependent on staff for hygiene, toileting, dressing, bathing, bed mobility, transfers, and wheelchair mobility; -Has a diagnosis of dementia (a brain disorder that slowly destroys memory and thinking skills). Review of the resident's care plan, dated 04/01/2021, showed it did not contain interventions with meals, bed mobility, transfers, hygiene, dressing or showers. Review showed the care plac did not contain direction for the resident's use of a high back wheelchair. Observation on 02/05/24 at 10:30 A.M., showed the resident sat in his/her room in a high back wheelchair and leaned to the right. The wheelchair had positioning pads on both sides and a pad for the resident's head. During an interview on 02/08/24 at 1:30 P.M., CNA Y said the resident requires total care of all ADL's and has to be fed by staff. The CNA said the resident needs assistance from two staff members to transfer. He/She said the resident has a high back wheelchair and special padding to keep him/her positioned correctly. CNA Y said he/she would expect to see all these things on the resident's care plan so staff know how to care for the resident. The CNA said that each resident has a printed paper care plan in their chart that staff look at to know what care the resident requires. 8. Review of Resident #83's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of anxiety, depression, Bipolar Disease, fibromyalgia (a chronic condition that causes pain and tenderness throughout the body), and PTSD. Review of the resident's care plan, dated 01/10/24, showed the care plan did not address the PTSD, triggers or appropriate interventions. During an interview on 02/08/24 at 8:43 A.M., LPN W said he/she would expect to see the resident's behavioral triggers, behaviors, and interventions on the care plan. The LPN said he/she did not know the resident had PTSD, or what triggered episodes or behaviors. The LPN said he/she knows the resident has anxiety due a recent amputation of the right leg. The LPN said it would be good to know the resident's triggers to help prevent episodes related to the PTSD or to help the resident through any issues. During an interview on 02/08/24 at 1:31 P.M., the Social Services Designee (SSD) said if a resident is admitted with PTSD, he/she completes the trauma informed questionnaire to find out if they have any issues or triggers. The SSD said he/she would expect PTSD to be on the care plan, even if not in active crisis because it is important to know of any triggers and behaviors related to the PTSD. The SSD said the MDS coordinator completes the care plans, and he/she does the behavior tracking log. 9. Review of Resident #92's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively Intact; -Used wheelchair; -Dependent on staff for toileting and chair to bed transfers; -Required substantial/maximum assistance for showers and mobility; -Required partial to moderate assistance for personal hygiene; -Occasionally incontinent of urine; -Received insulin seven out of seven days in the look back period (a time period used in MDS assessments to capture a resident's status or condition); -Received the following high risk medications: anticoagulants (a group of medications that reduce the ability of blood to clot), antibiotics, diuretics (medicines that help reduce fluid buildup in the body), opioids, and hypoglycemics (a group of drugs used to help reduce the amount of sugar present in the blood); -Diagnoses of high blood pressure, left above the knee amputation, atrial fibrillation (an irregular and often very rapid heart rhythm), deep vein thrombosis (a blood clot in a deep vein, usually in the legs), Multi Drug Resistant Organism (MDRO - bacteria that are resistant to many antibiotics), septicemia (a serious bloodstream infection caused by bacteria), wound infection, diabetes, arthritis, anxiety and depression. Review of the resident's medical record did not contain a comprehensive care plan. 10. Review of Resident #302's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Uses a walker; -Required set up assistance for meals, upper body dressing, bed mobility, and transfers; -Required supervision for ambulation; -Required moderate assistance for lower body dressing, hygiene, and bathing; -Has an indwelling catheter; -Has a diagnosis of Alzheimer's disease; -Received Antipsychotic, Antibiotic, Antiplatelet, and Hypoglycemic medications. Review of the resident's medical record showed it did not contain a comprehensive care plan. 11. During an interview on 02/08/24 at 1:44 P.M., LPN AA said there is a paper copy of the care plan in the resident's chart. The LPN said the care plan should be individualized for each resident and contain information such as the amount of care a resident needs for each ADL's, behaviors such as being resistive to care, assistive devices including high back wheelchairs, positioning devices, and catheters. During an interview on 02/08/24 at 2:02 P.M., the Memory Care Unit (MCU) supervisor said the care plan should be individualized to each resident, and should contain information such as catheters, amount of care a resident needs for ADL's, assistive devices such as high back wheelchairs and divided plates, positioning devices, and behaviors such as being resistive to care. He/She said the MDS Coordinator is responsible to update the care plans. During an interview on 02/08/24 at 2:26 P.M., the Assistant Director of Nursing (ADON) said the resident's care plan should be individualized. The ADON said he/she would expect to see thing such as if the resident is a fall risk, catheters, any behaviors such as being resistive to care, and the amount of assistance required for ADL's. He/She said the MDS Coordinator is responsible to update the care plans. During an interview on 02/08/24 at 4:00 P.M., the administrator said the MDS Coordinator is responsible for completing the MDS's and care plans. The care plan should contain things that are specific to each resident. Staff should be able to look at a care plan and know who the resident is. All the goals and interventions should be measurable. The administrator said care plans should be revised and updated with any new events such as a fall, a new catheter, any new assistive device, and risks. The care plans should be updated at least quarterly and annually if there are no changes during that time. The administrator said he/she expects to see things on the care plan such as how much care a resident requires for ADL's, behaviors such as being resistive to care, catheters, positioning devices, and assistive devices. During an interview on 02/13/24 at 12:17 P.M., the MDS Coordinator said he/she is responsible for completing all of the MDS's and care plans in the facility. A comprehensive care plan should be completed within six days of the Admission MDS completion. The MDS coordinator said he/she missed Resident #92 and Resident #302's care plans, so it did not get done timely. All care plans are to be updated quarterly and annually, and he/she has been updating them weekly for any changes made such as a new catheter or fall. A care plan should be individualized for each resident, and should contain things such as assistive devices, positioning devices, catheters, behaviors such as being resistive to care, interventions for falls, and ADL care requirements. The MDS coordinator said he/she has started adding PTSD to the care plans and does not have them all updated yet. 48982

Based on Based on observation, interview, and record review, facility staff failed to meet professional standards of care when staff failed to document neurological checks and fall follow-up for six residents (Resident #18, #46, #50, #58, #67, and #302), and failed to ensure physicians orders were followed for two residents (Resident #18, and #302). The facility census was 87. 1. Review of the facility's policy titled Accident and Incident Documentation and Investigation Resident Incident, revised 07/2018, showed staff are directed to do the following: -Licensed Nurse assigned at the time of the resident care accident/incident is responsible for documenting the incident in the resident's medical record; -Nurse's notes could contain the following documentation: Date and time of incident; Clear, objective facts of what happened; An evaluation of the resident's condition at the time of the accident/incident including vital signs, physical characteristics apparent as a result of the accident/incident; The resident outcome and information concerning the incident. Review of the facility's policy titled Neurological Evaluation, revised 01/2015, showed it is the policy of the facility to perform a neurological vital sign evaluation when indicated by resident condition and subsequent to a witnessed or unwitnessed fall with a suspected head injury. Review showed licensed nurses are responsible to perform neurological checks with the frequency as ordered. Review showed staff are directed to: -Document on the Neurological Evaluation Flow Sheet, determine state of consciousness, take temperature, pulse, respirations, and blood pressure, check pupil reaction; -Determine motor ability; -Have resident plantar and dorsiflex feet; -Determine sensation in extremities; -Have resident smile to determine if there is facial drooping; -Document findings; -Notify the physician of any changes in the resident's neurological status; -Notify the supervisor if the resident refuses. Review of the facility's policy titled Prescriber Medication Orders, revised 08/2016, showed staff are directed to do the following: -Responsibility of all nursing staff; -Medication orders are entered specifying the resident name, date of order, name of medication, name of prescriber, name of person transmitting the order, strength of medication, dosage, time or frequency of administration, route of administration, quantity or duration of therapy, and diagnosis or indication of use. -Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order; -The order is recorded on the Physician Order Sheet (POS), for Electronic Medication Administration Record (eMAR) the order is entered on the Physicians Order Screen; -Enter the new medication orders on the pharmacy communication record (if applicable), call and/or fax the orders to the pharmacy; -Transcribe newly prescribed orders on the Medication Administration Record (MAR) or treatment record; -The first dose of medication is scheduled to be given after the next regular pharmacy delivery is made. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/05/23, showed staff assessed the resident as severely cognitively impaired with a history of falls. Review of the resident's care plan, dated 11/03/22, showed staff assessed the resident at risk for falls. Review showed the resident fell on [DATE] and wears a brace on the left hand during the day. Review of the resident's Morse Fall Scale (an assessment used to determine likelihood of falls), dated 12/26/23, showed staff documented a score of 75 which indicates at high risk for falls. Review of nurse's notes showed staff documented: -12/27/23 at 3:38 P.M., late entry note for 12/26/23 at 9:30 P.M., documented by the Assistant Director of Nursing (ADON), Resident stood up to go to the bathroom and feet became tangled in his/her blankets causing him/her to lose balance and fall; Documented Vitals signs (VS) as follows: Blood Pressure (BP) 118/70, Pulse (P) 92, Respirations (R) 20, Temperature (T) 98.4, Oxygen saturation (O2 sat) 97 percent (%). Review showed the nurse's note did not contain documentation if the fall was witnessed, unwitnessed, or if the resident hit their head; -12/27/23 at 11:34 A.M., showed Licensed Practical Nurse (LPN) FF documented, No pain,Vital Signs were normal;Range of motion (ROM) normal. Review showed the notes did not contain documentation in regard to the resident's fall after 12/27/23 at 11:34 A.M. Review of the Neurological Evaluation Flow Sheet, dated 12/26/23, showed staff did not document neurological checks or fall follow up after 12/27/23 at 4:15 A.M. Less than 24 hours after the resident fell . Review of the POS, dated 02/2024, showed an order for Occupational Therapy (OT) evaluation and treat for a new brace to left hand dated 07/27/23. Observation on 02/06/24 at 9:32 A.M., showed the resident in bed without a left-hand brace on. Observation on 02/07/24 at 8:24 A.M., showed the resident in his/her bed without a left-hand brace on. Observation on 02/07/24 at 2:05 P.M., showed the resident in his/her bed without a left-hand brace on. Observation on 02/08/24 at 8:07 A.M., showed the resident in his/her wheelchair and did not have his/her left hand brace on. Observation on 02/08/24 at 10:58 A.M., showed the resident in his/her bed with a washcloth rolled up in his/her left hand. During an interview on 02/08/24 at 1:30 P.M., Certified Nurse Assistant (CNA) Y said the resident refuses to wear the left-hand brace most of the time. During an interview on 02/08/24 at 1:44 P.M., LPN AA said he/she was not aware the resident had an order for a left-hand brace. The LPN said he/she is not sure why the resident was not wearing it. During an interview on 02/08/24 at 2:02 P.M., the Memory Care Unit (MCU) manager said he/she was aware the resident had an order for a left-hand brace. He/She thought one had to be ordered but he/she was not sure if it had arrived. During an interview on 02/08/24 at 2:26 P.M., the ADON said he/she was not aware the resident had an order for a left-hand brace. During an interview on 02/08/24 at 3:00 P.M., Occupational Therapist (OT) EE said he/she was aware the resident had an order to wear a left-hand brace. The OT said he/she was not aware the resident did not have one, but a shipment came in on 02/07/24 and he/she would get one for the resident to wear. During an interview on 02/08/24 at 4:00 P.M., the administrator said he/she ordered some hand braces and the facility should have them. He/She was not aware the resident needed one. 3. Review of Resident #46's MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's care plan, revised 11/2023 showed staff documented the resident is at risk for falls with falls on 05/25/23 and 12/06/23. Review of the resident's Morse Fall Scale showed staff documented a score of 65 for the resident on 02/06/23 and 12/06/23, indicating the resident is at high risk for falls. Review of nurse's notes showed staff documented: -12/06/23 at 2:55 P.M., showed LPN GG documented the resident had an unwitnessed fall in the dining room at 8:45 A.M., and was noncooperative with vital signs until 9:10 A.M., VS: BP 114/63, P 83, R 19, T 97.6, O2 sat 93%. The LPN documented the resident as noncoopertive with neurological checks and guarded his/her right knee and had a limp. -12/06/23 at 7:33 P.M., showed LPN GG documented x-ray results normal, residents continues to be noncooperative with vital signs and neurological checks. No visible injuries. Review showed the nurses's notes did not contain any further fall follow up documentation after 12/06/23 at 7:33 P.M., and did not contain notes regarding the resident's fall on 02/06/24. Review of the resident's medical record did not contain a Neurological Evaluation Flow Sheet for the resident's falls on 12/06/23 or 02/06/24. Observation on 02/06/24 at 10:14 A.M., showed a family member alerted LPN AA that he/she witnessed the resident fall in the main lobby area of the MCU. The family member, at this time, said the resident tried to sit in a chair, missed the chair, and hit his/her head on the railing. LPN AA helped the resident off the floor and did not complete an assessment or vital signs prior to assisting him/her up. Observation showed the resident said my head hurts. LPN AA assisted the resident to sit in a chair, attempted to check the resident's vital signs complete an assessment but the resident refused most of the assessment. 4. Review of Resident #50's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired, with no falls. Review of the resident's More Fall Scale showed staff documented the resident scored a 55 on 12/28/23, placing him/her at risk for fall. Review of the resident's care plan, dated 02/16/23, showed staff documented the resident fell on [DATE], 06/08/23, 06/16/23, 06/28/23, 07/02/23, 07/04/23, 09/28/23, 09/29/23, 12/26/23, 01/09/24, 02/01/24. Review of the resident's nurse's notes showed staff documented the following: -12/15/23 at 3:57 A.M., showed LPN JJ documented an unwitnessed fall at 5:48 P.M., on 12/14/23, VS: BP 129/99, P 74, R 16, T 98.0, O2 sat 97%. Ambulance called at 8:00 P.M. and taken to St Mary's hospital due to decreased alertness. Resident returned to the facility at 1:54 A.M., VS: BP 153/99, P 67, R 18, T 97.0, O2 sat 97%. Review of the Neurological Evaluation Flow Sheet, dated 12/14/23 through 12/15/23, showed staff did not complete the neurological flow sheet. Review of the nurse's notes showed staff documented: -12/27/23 at 11:32 A.M., showed a fall follow up note documented by LPN FF documented a fall follow up note. No pain or distress, vitals signs normal. Review showed the nurses note did not contain any further fall follow up documentation; -12/27/23 at 4:40 P.M., showed the ADON documented a late fall entry on 12/2/23 at 8:10 P.M., witnessed fall on patio. documented by the ADON. Vital Signs: BP 124/83, P 71, R 18, T 97.1; Review of the nurses notes showed staff did not document for 72 hours after the resident's fall. Review of the Neurological Evaluation Flow Sheet, dated 12/26/23, showed staff did not complete the neurological flow sheet. Review of the nurse's notes showed staff documented: -01/10/24 at 4:04 P.M., showed the MCU manager documented a late entry on 01/09/24 at 12:05 P.M., resident was found on the floor in the living room bleeding from the left side of his/her head. Vital signs: BP 147/88, P 79, R 18, T 97.9. Pressure applied to left side of his/her head and 911 called; -01/10/24 at 4:09 P.M., showed the MCU manager documented a late entry for 01/09/24 at 4:50 P.M., Returned to the facility from hospital, received four staples to the left side of his/her head. No pain or bruising with normal ROM. Vital signs: BP 162/85, P 63, R 18, T 97.9.Staff did not document neurological checks; -01/10/24 at 4:11 P.M., showed the MCU manager documented the resident has no pain or discomfort, staples to the left side of the resident's head were intact with no redness or swelling. ROM normal. Vital signs: BP 142/70, P 72, R 18, T 97.9 Staff did not document neurological checks; -01/10/24 at 10:30 P.M., showed LPN KK documented, no discomfort, bruising or swelling. Staff did not document any vital signs, or neurological checks; -01/11/24 at 4:36 A.M., showed LPN LL documented no bruising or swelling. Staff did not document any vital signs, or neurological checks; -01/12/24 at 7:15 A.M., showed LPN AA documented no bruising or swelling, and no complaints of pain. Staff did not document any vital signs, or neurological checks. Review of the Neurological Evaluation Flow Sheet, dated 01/09/24, showed staff did not complete the flow sheet. Review of the resident's nurse's notes showed staff document on: -02/01/24 at 10:27 A.M., showed LPN AA documented the resident was found lying on the floor at 10:00 A.M., with the call light wrapped around his/her legs. Resident complained of right arm pain, and had a hematoma on the right arm below the elbow with a skin tear. Vital signs: BP 111/71, P 56, O2 sat 95%. Staff did not document neurological checks, or notification of the physician; -02/01/24 at 11:15 A.M., LPN AA documented the resident was found lying on the floor at 10:45 A.M., bleeding from the left side of his/her head. Noted an abrasion to the left elbow. Vital signs: BP 111/71, P 56, R 17, T 98.1, O2 sat 95%. Sent by ambulance to hospital. Staff did not document neurological checks, or notification of physician; -02/01/24 at 10:22 P.M., LPN AA documented the resident returned to the facility at 9:45 P.M., and received four staples to the left side of his/her head. Staff did not document vital signs or neurological checks; -02/02/24 at 1:13 P.M., showed LPN AA documented the resident up ad lib, and complained of a headache. Staff did not document vital signs or neurological checks; -02/03/24 at 8:59 A.M., showed LPN MM documented no bruising, staples intact to the left side of head. Staff did not document vital signs or neurological checks; -02/04/24 at 10:49 A.M., showed RN NN documented the resident denied pain, staples to scalp remain dry and intact. Staff did not document vital signs or neurological checks. 5. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition, and did not haved falls. Review of the resident's care plan, dated 04/01/21, showed staff documented the resident at risk for falls. Review of the resident's Morse Fall Scale, dated 02/01/24, showed staff scored the resident a 75, at high risk for falls. Review of nurse's notes showed staff documented on: -02/01/24 at 2:30 A.M., showed a fall documented on a handwritten note. Resident was found on the floor in the fetal position beside his/her bed. Small red lesion to his/her right hip. Vital signs BP 164/86, P 86, R 18, T 97.6. Did not contain any further fall follow up notes after 02/01/24 at 2:30 A.M. Review of the Neurological Evaluation Flow Sheet, undated, showed staff documented vital signs from 2:30 A.M., to 7:30 A.M. The flow sheet did not contain any further documentation. 6. Review of Resident #67's Admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and did not have falls. Review of the resident's care plan, dated 11/10/23, showed staff documented at risk for falls with a fall on 12/15/23. Review of the resident's Morse Fall Scale, dated 12/15/23, showed staff documented the resident scored 105, at high risk for falls. Review of nurse's notes showed it did not contain documentation of the fall on 12/15/23 documented in the care plan. Observation on 02/06/24 at 9:49 A.M., showed the resident on the floor in the MCU dining room after an unwitnessed fall. Observation showed CNA P notified LPN AA the resident was on the floor. Observation showed LPN AA, CNA PP and PT BB assisted the resident off the floor. Observation showed LPN AA did not complete an assessment or vital signs prior to assisting the resident up. The three staff members attempted to walk the resident to his/her room. The resident became weak, his/her knees buckled, and staff assisted him/her to sit in a chair. LPN AA checked the resident's vital signs. Observation on 02/06/24 at 9:57 A.M., MCU manager came to see the resident. Observation showed LPN AA, the MCU manager, and CNA Y stood the resident and ambulated her to his/her room. Observation showed LPN AA or the MCU manager did not do an assessment or vital signs prior to assisting him/her. Review of the nurses's notes, dated 02/06/24, did not contain staff documenation of the resident's fall. Review of the Neurological Evaluation Flow Sheet, undated, showed staff did not document neurological checks. During an interview on 02/07/24 at 11:04 A.M., LPN AA said the resident's physician gave new orders for labs. The LPN said he/she does not know how to put orders in and has been instructed to have the MCU manager enter the orders, so he/she gave the orders to the MCU manager to enter. During an interview on 02/07/24 at 4:40 P.M., LPN AA said he/she has sent the resident to Capital Region hospital for an evaluation. 7. Review of Resident #302's Admission MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition and no falls. Review of the resident's baseline care plan, dated 01/15/24, showed staff documented the resident has a history of falls with a fall on 01/16/24. Review of the resident's Morse Fall Scale dated 01/16/24, showed staff documented the resident scored a 50, at high risk for falls. Review of nurse's notes showed staff documented: -01/16/24 at 11:55 P.M., LPN II documented the resident found on the floor by an aide in the lounge area, vital signs checked, did not visible injury and resident denies pain. Neurological checks in place; -01/17/24 at 9:25 A.M., LPN AA documented a late entry fall follow-up. Review showed the note did not contain vital signs or neurological checks; -01/17/24 at 9:28 A.M., showed LPN AA documented fall follow up. Review showed the note did not contain vital signs or neurological checks; -01/18/24 at 12:16 A.M., showed LPN II documented a late entry for fall follow up 01/16/24. Review showed the note did not contain vital signs or neurological checks; -01/18/24 at 12:34 A.M., showed LPN II documented a late entry for fall follow up. Review showed the note did not contain vital signs or neurological checks; Review showed no further fall follow up notes after 01/18/24 at 12:34 A.M. Review of the Neurological Evaluation Flow Sheet, dated 01/16/24 showed staff did not complete the neurological flow sheet. Review of the resident's transfer orders, dated 01/09/24, showed an order for Cefpodoxime (an antibiotic used to treat infection) 200 milligram (mg) one table every 12 hours for 10 days for a Urinary Tract Infection (UTI). The order showed a start date of 01/05/24 and a discontinue date of 01/15/24. Review of the POS's, dated 01/2024 and 2/2024, showed an order for Cefpodoxime 200 mg one tablet every 12 hours. Review of the Medication Administration Record (MAR), dated 01/2024, showed the resident received Cefpodoxime 200 mg one tablet every 12 hours each day beginning 01/16/24 through 01/31/24. Review of the MAR, dated 02/2024, showed the resident received Cefpodoxime 200 mg one tablet on 02/08/24, 02/02/24, and 02/04/24. Review showed the resident received two tablets of Cefpodoxime 200 mg on 02/03/24. Review of the nurse's noted, dated 02/07/24 at 11:10 A.M., showed the MCU manager documented he/she contacted the resident's physician and received new orders to discontinue the Cefpodoxime, and he/she notified the responsible party. During an interview on 02/08/24 at 2:02 P.M., the MCU manager said he/she entered the residents admission orders and missed the discontinuation date at that time. The MCU manager said he/she found out the resident received Cefpodoxime past the discontinue date on 02/07/24 and he/she contacted the resident's physician and responsible party at that time. The MCU manager said this would be considered a medication error. During an interview on 02/08/24 at 2:26 P.M., the ADON said he/she did not know the resident was admitted with antibiotic orders or that the antibiotic has no been discontinued. The ADON said that would constitute a medication error if given past the prescribed discontinue date. 8. During an interview on 02/06/24 at 11:12 A.M., LPN AA said when a resident falls staff should assess the resident and complete vital signs prior to assisting the resident off of the floor. LPN AA said he/she does not know why he/she did not assess the resident prior to helping him/her off the floor. The LPN said the facility's policy is if it is a witnessed fall staff are to complete an assessment and vital signs. If it is an unwitnessed fall, or the resident hits their head, staff are to complete an assessment, vital signs, and neurological checks. Neurological checks should include vital signs, pupil size, hand grip strength, cognition, etc. LPN AA said neurological checks should be completed every 15 minutes times four, and documented on the neurological check flow sheet. The LPN did not know how often neurological checks should be completed after the first hour, but he/she said he/she knows all falls should be documented on daily for at least three days following the fall. The LPN said he/she is a contract nurse on an eight-week assignment, and he/she did not get a formal orientation to the facility. If he/she has questions he/she has to ask a supervisor. During an interview on 02/08/24 at 2:02 P.M., the MCU manager said he/she is responsible got entering admission orders for all new residents, as well as rounding with the physicians when they visit. He/She said he/she oversees the MCU in general. The charge nurse is responsible for obtaining and entering any other new orders needed for a resident. The MCU manager said because LPN AA is a contracted staff and he/she is not allowed to obtain or enter new orders, so he/she has been doing that as well. The MCU manager said the charge nurse is responsible for completing assessments and vital signs for residents if they fall, and he/she expects it done prior to moving the resident off the floor. If a resident has an unwitnessed fall or a fall where they hit their head staff are expected to also complete neurological assessments. The MCU manager said he/she is not sure of the facility's policy in regard to neurological checks and vital signs after a fall. He/She said he/she knows it should be completed every 15 minutes times four, every 30 minutes times four, every hour times four, and then daily for 72 hours. The charge nurse is responsible for completing these assessments and documenting the assessments in the residents' charts. The MCU manager said he/she expects fall documentation to include the type of fall, any injuries, assessments completed, vital signs and any other pertinent details, such as notifying the physician and responsible party. All falls are monitored by the DON and unit manager. During an interview on 02/08/24 at 2:26 P.M., the ADON said the charge nurse is responsible for assessing and obtaining vital signs if a resident falls, and he/she expects it to be done prior to moving the resident off the floor. The ADON said it is the facility's policy that if a resident has an unwitnessed fall, or a fall where they hit their head that staff are expected to complete neurological checks. The ADON said he/she expects neurological checks to be completed every 15 minutes times four, every 30 minutes times four, every hour times four, and each shift for 72 hours . The ADON said it is the responsibility of the charge nurse to document in the nurses notes and neurological flow sheet. The ADON said if there is no documentation then it was not done. The ADON said the charge nurse is responsible for contacting the physician and obtaining any new orders needed and entering the orders into the system. The ADON said all orders should be followed up on and monitored by the unit mangers, ADON, and DON. The ADON said a medication error consists of a medication given at the wrong time, wrong dose, not given if ordered, given past the discontinued date, wrong resident, etc. The ADON said if a medication error is made the charge nurse is responsible for letting a unit manager, the ADON, or DON know, along with contacting the physician, monitoring for three days, and documenting in the nurse's notes. The ADON said there is a form they are supposed to fill out in order to track medication errors, but he/she was not sure of the process for this or who completed it. During an interview on 02/08/24 at 4:00 P.M., the administrator said all staff are expected to follow physician's orders. The charge nurse is responsible for obtaining, transcribing, and implementing the physician's orders for each resident. The DON oversees the charge nurse to ensure they are doing that. The Administrator said there is a 24-hour report sheet each staff are responsible to check, and staff can run a report to check for any new orders as well. He/She said if a medication is not discontinued on the date it is ordered to be that it is an error. He/She said medication errors are to be documented by the charge nurse, the charge nurse is responsible for notifying the physician, responsible party, DON, and Administrator of any errors. The administrator said he/she expects staff to monitor the resident after a medication error and document any outcomes. He/She said if a resident falls the charge is responsible for completing an assessment and vital signs before the resident is assisted off the floor. He/SHethis is not done prior to moving the resident there may be an injury not seen. If a resident has an unwitnessed fall or a witnessed fall and hits their head staff are expected to complete neurological checks and vital signs. The administrator said he/she is not sure what the facility policy is for neurological check times, but he/she expects at least every 15 minutes times four, then every 30 minutes times four, then every hour times four. Staff need to document shiftly for 72 hours after the fall as well. The administrator said he/she expects staff to document assessment findings, neurological checks, vital signs, any injury, date at time of the fall, witnessed or unwitnessed, if the resident hit their head, and who was notified. He/She said he/she expects staff to notify the physician, responsible party, DON, and Administrator of any falls.

Based on observation, interview, and record review, facility staff failed to follow up on Urinalysis and Culture with Sensitivity (UA C&S) (lab work to rule out Urinary Tract Infection (UTI) and begin treatment timely for two residents (Resident #18 and #50). The facility census was 87. 1. Review of the facility's policy titled Surveillance for Healthcare Associated Infections, revised 09/2019, showed it is the responsibility of the Director of Nursing (DON), Infection Control Designee, Licensed Nurse to report suspected infections to the physician and obtain a diagnosis. Review of the facility's policy titled Laboratory Tests, revised 11/2017, directed staff as follows: -Lab tests are completed as ordered by the physician or physician extender (Nurse Practitioner (NP), Physician Assistant (PA), or Clinical Nurse Specialist (CNS)); -Licensed Nurse, or designee, shall obtain the labs ordered by the physician, complete the lab requisition form, and add the information to the Lab Scheduling/Tracking form; -Any newly ordered labs needing immediate attention will be added to the Lab Scheduling/Tracking form and obtained as ordered; -When the lab is obtained the nurse indicates this on the Lab Scheduling/Tracking form; -All labs not obtained will be rescheduled by the Licensed Nurse; -The Licensed Nurse, or designee, will indicate when lab results are returned to the facility on the Lab Scheduling/Tracking form; -The Licensed Nurse, or designee, will promptly notify the physician of abnormal lab results; -The Licensed Nurse, or designee, will review all labs scheduled routinely to ensure all labs have been drawn and results received, if a lab is found to be missing the Licensed Nurse will call the lab to obtain the results. Review of the facility's policy titled Prescriber Medication Orders, revised 08/2016, showed all nursing staff are responsible. Review showed medication orders are entered specifying the following: -Resident name; -Date of order; -Name of medication, prescriber, person transmitting the order; -Strength of medication; -Dosage; -Time or frequency of administration; -Route of administration; -Quantity or duration of therapy; -Diagnosis or indication for use. -Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order; -The order is recorded on the Physician Order Sheet (POS), for Electronic Medication Administration Record (eMAR) the order is entered on the Physicians Order Screen; -Enter the new medication orders on the pharmacy communication record (if applicable), call and/or fax the orders to the pharmacy; -Transcribe newly prescribed orders on the Medication Administration Record (MAR) or treatment record; -The first dose of medication is scheduled to be given after the next regular pharmacy delivery is made. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/05/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Having an indwelling catheter (tubing draining the bladder); -Diagnosis of Obstructive Uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). Review of the resident's care plan, revised 10/31/23, showed staff were directed to do the following: -Foley catheter due to obstructive uropathy; -Will remain free of infections; -Perform proper catheter hygiene to prevent infections; -Keep the urinary drainage bag off the floor, below the level of the bladder, and tubing free of kinks; -Replace the system every 30 days and as needed; -Encourage to drink plenty of fluids. Review of the resident's Physicin Order Sheet (POS), dated 01/2024, showed an order for Foley Catheter. Review showed a physician order directed staff to administered Cefdinir (an antibiotic used to treat infections) 300 milligrams (mg) two times a day for seven days with a start date of 01/23/24 and end date of 01/30/24. Review of the nurse's note, dated 01/23/24 at 7:30 A.M., showed the Memory Care Unit (MCU) manger documented he/she contacted the physician and received orders for Cefdinir 300 mg BID for seven days. Review of the Medication Administration Record (MAR), dated 01/2024, showed the MAR did not contain the order for Cefdinir 300 mg two times a day for seven days . During an interview on 02/08/24 at 2:02 P.M., the MCU manager said he/she is not sure why the Cefdinir orders were not on the MAR. He/She did contact the physician and thought he/she put the orders on the MAR. During an interview on 02/08/24 at 2:26 P.M., the Assistant Director of Nursing (ADON) said he/she did not know why the Cefdinir did not get put on the resident's MAR. He/She said if something is not documented that means it was not given. 3. Review of Resident #50's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Having an indwelling catheter; -Diagnosis of Obstructive uropathy, and Benign Prostatic Hyperplasia (an enlarged prostate); -Received an antibiotic. Review of the resident's care plan, revised 01/31/24, showed staff were directed to do the following: -Foley catheter due to obstructive uropathy; -Will remain free of infections; -Perform proper catheter hygiene to prevent infections; -Keep the urinary drainage bag off the floor, below the level of the bladder, and tubing free of kinks; -Replace the system every 30 days and as needed; -Encourage to drink plenty of fluids. Review of the resident's POS, dated 01/2024, showed an order for foley catheter. Review of the POS showed a physician order directed staff to adminster Bactrim DS (an antibiotic used to treat infection) one tablet twice a day for seven days with a start date of 01/24/24 and end date of 01/31/24. Review of the UA C&S lab report showed the following: -Urine specimen collected on 01/16/24; -Urine culture report received 01/19/24. Review of the MAR, dated 01/2024, showed Bactrim DS one tablet BID for 7 days was started on 01/24/24 and stopped on 01/31/24. Review of the nurse's note, dated 02/02/24 at 10:01 P.M., showed Licensed Practical Nurse (LPN) AA documented the resident completed his/her antibiotic therapy. During an interview on 02/07/24 at 11:27 A.M., the MCU manager said he/she works Monday through Thursday and is the supervisor of the MCU during those days. He/She said if he/she is off the charge nurse is responsible to contact the physician for any orders needed. He/She said 01/19/24 was a Friday and he/she was not working the day the C&S came back for the resident. He/She said he/she returned to work on Monday 01/22/24 but was not sure why he/she did not follow up with the physician regarding C&S results for those residents until Tuesday 01/23/24. He/She said the charge nurse should have called the physician the day the C&S results were received to obtain orders. The MCU manager said he/she did contact the physician on 01/23/24 and obtain antibiotic orders for the resident. 4. During an interview on 02/07/24 at 10:45 A.M., the Assistant Director of Nursing (ADON) said he/she is not sure why it would have taken staff so many days to start an antibiotic after receiving the lab results. He/She said it is the facility's policy to collect a UA the day it is ordered and send it to the lab. He/She said once the C&S results are obtained staff are to contact the physician with the results and begin the treatment ordered. He/She said delaying treatment can cause an increased risk of infection, falls, and potential sepsis. He/She said the facility has an emergency drug kit (e-kit) staff can pull antibiotics from as well. The ADON said he/she expects staff to start an antibiotic and not delay treatment. During an interview on 02/07/24 at 11:27 A.M., the MCU manager said it is the facility's policy to obtain treatment timely. He/she staff to collect a UA the day it is ordered and send it to the lab. He/She said once the C&S results are obtained, he/she expects staff to contact the physician with the results and begin the treatment ordered. He/She said delaying treatment can cause an increased risk of infection, falls, and potential sepsis. He/She said the facility has an emergency drug kit (e-kit) staff can pull antibiotics from as well. During an interview on 02/08/24 at 2:26 P.M., the ADON said the charge nurse is responsible to get orders, including lab orders, and enter them in the eMAR. He/She said the charge nurse is responsible to obtain the UA specimen, put it in the refrigerator, to call the lab to pick it up and print a lab requisition. The ADON said if the lab fails to pick up a specimen the he/she expects the charge nurse to get a new specimen and contact the lab for it to be picked up. During an interview on 02/08/24 at 4:00 P.M., the administrator said the charge nurse is responsible for contacting the physician and entering new orders. He/She said the unit managers, ADON, and DON oversee the charge nurse and units. He/She said he/she expects staff to obtain a UA the day it is ordered and if they are not able to then he/she expects them to notify the physician. The administrator said if the lab fails to pick up a specimen, he/she expects staff to obtain a new specimen and contact the lab and the resident's physician. He/She said any lab results should be sent or called to a physician the day they are received. He/She said he/she was not aware of it taking multiple days to contact the physician once a lab result was received. He/She said regarding a UA C&S lab result delaying treatment could cause the resident to become septic and possibly death. He/She said any medications orders are to be on the resident's POS and MAR. He/She if a medication is not documented then it was not given.

Based on interview and record review, the facility staff failed to provide 24-hour protective oversight for one sampled resident (Resident #1) when they failed to conduct visual checks on the resident on 09/22/23 from 6:45 P.M. to 8:26 A.M. At that time, staff found the resident in his/her room on the floor with blood on his/her hands and face. Hospital staff determined the resident suffered a fracture to the right sixth rib. Facility census was 93. The Administrator was notified on 9/27/23 at 4:23 P.M., of an Immediate Jeopardy (IJ) which began on 9/22/23. The IJ was removed on 9/24/23 as confirmed by surveyor onsite verification. 1. Review showed the facility did not have a policy on monitoring or rounding on residents. During an interview on 9/26/23 at 12:55 P.M., the administrator said the facility did not have a policy on monitoring or rounding on residents, but staff followed standard practices. This included completing walking rounds from room to room, at the beginning of each shift. Staff should continue to check on residents at least every two hours until the next shift comes on. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/10/23, showed staff assessed the resident as: -Cognitively intact; -Independent for toileting and transfers; -At risk for falls. Review of the resident's plan of care, dated September 2023, showed staff assessed the resident as independent for toileting and transfers. Review showed staff assessed the resident wanders into other residents' rooms and staff are directed to redirect the resident and assist the resident to his/her room if he/she was looking for it. The plan of care did not contain interventions on how often to check on the resident. Review of the resident's nursing notes, dated 9/20/23, showed staff documented the resident had a room change to the Memory Care Unit (MCU), after lunch around 2:00 P.M. due to the resident's increased wandering and going through other residents personal items. Review of the Pocket Care Guide (for staff to direct the care needed for each resident), dated 9/21/23, showed Resident #1 occupied a room on the MCU and was a fall risk with interventions which directed staff to ensure the resident was wearing appropriate footwear, to keep the call light within reach and encourage the resident to use it as needed to request assistance. The Pocket Care Guide did not contain interventions on how often to check the resident. Review of the facility's video surveillance footage showed between 09/22/23 at 6:45 P.M. and 09/23/23 at 8:26 A.M., the resident's door remained shut and staff did not enter the resident's room. Review showed staff passed the resident's room to enter the laundry room located across from the resident's room at 7:04 P.M., 7:11 P.M., 2:58 A.M., 3:34 A.M., 6:23 A.M., 6:30 A.M., 7:13 A.M., 8:09 A.M., and 8:15 A.M., and did not enter or open the resident's door. Review of the resident's nursing notes, dated 9/23/23, showed Registered Nurse (RN) H documented staff notified him/her at approximately 7:50 A.M., they found the resident on his/her abdomen on the floor with blood observed on his/her hands and face. (Note: the video surveillance showed the resident's door remained shut and staff did not enter the room from 6:45 P.M. on 9/22/23 until 8:26 A.M. on 9/23/23.) Staff assessed the resident was alert and breathing with his/her vital signs within normal limits. The resident complained of generalized pain. Staff assessed the resident had cuts on both hands and his/her upper lip, and bruising on both arms and his/her right shoulder. Staff called EMS at approximately 8:05 A.M. who arrived and transferred the resident to the hospital. Review of the resident's hospital records, dated 9/23/23, showed hospital staff assessed the resident with multiple contusions (injured tissue or skin in which blood capillaries have been ruptured) to his/her face and hands and a fracture to the right sixth rib. During an interview on 9/23/23 at 7:38 P.M., the emergency room nurse practitioner said the resident arrived in the emergency roiagnom on [DATE] around 10:00 A.M Upon assessments and diagnostic testing, they found the resident had bruises on his/her face and both arms, a busted lip, dried blood on his/her face, swollen knees, a rib fracture, and two symmetrical golf ball sized hematomas (a collection of clotted blood outside of a vessel due to an injury of the vessel wall) to both shoulders. Review of the facility's investigation, dated 9/24/23, showed staff documented Licensed Practical Nurse (LPN) C and Nursing Assistant (NA) B failed to conduct visual checks during their scheduled shift. During an interview on 9/26/23 at 9:05 A.M., Nurse Aide (NA) B said he/she did not get a Pocket Care Guide from the linen closet on the MCU, because he/she was overwhelmed and went straight to work. He/She said they are supposed to go room to room for report, but CNA A did not want to go room to room and stood at the front for report on 9/22/23. During interviews on 09/24/23 and 9/26/23 at 9:26 A.M., Certified Nurse Aide (CNA) A said he/she gave a verbal report to NA B on 9/22/23 and told the NA that the resident moved to the end of the hall, because NA B just stood at the front. He/She said staff are supposed to go room to room for report and check on residents every two hours. He/She said he/she assisted Resident #1, before his/her shift ended on 9/22/23. He/She said he/she assisted the resident in the bathroom and when he/she left the room, the resident was in his/her wheelchair with his/her call light within reach. During an interview on 9/24/23 at 3:10 P.M., NA B said he/she did not recall being told the resident had been moved to the last room on the hallway during report from CNA A. During an interview on 9/26/23 at 9:05 A.M., NA B said the doors on the last two rooms were always shut and no residents had lived in them. He/She said staff should check closed doors, but he/she didn't because he/she was not missing any residents, because he/she didn't know the resident had moved back to the unit. He/She said he/she rounded on the residents every two hours. During an interview on 9/24/23 at 9:06 P.M., LPN C said he/she was the nurse for the Rehab unit and was responsible for the MCU. He/She said he/she was aware the resident was moved to the MCU. He/She said he/she passed medications and took vital signs of other residents but did not lay eyes on Resident #1. He/She said he/she should have checked on all residents as part of his/her nursing responsibilities. During an interview on 9/24/23 at 10:26 A.M., CNA A said he/she did not receive report from NA B on the morning of 9/23/23, because when he/she came in, residents were soiled and calling for help. He/She said when he/she made it down to the resident's room, he/she opened the door to find the resident on the floor. During an interview on 9/26/23 at 4:34 P.M., Registered Nurse (RN) H said CNA A came and got him/her to assess the resident. He/She said the resident was face down on the floor, over his/her walker, with blood on his/her hands and face. He/She said he/she assessed the resident to have a busted lip and lacerations to his/her hands. He/She said he/she did not get report from any staff and was working as a Certified Medication Tech (CMT) on 9/23/23. During an interview on 9/25/23 at 4:29 P.M., the administrator said staff are expected to go room to room for report and check on residents at least every two hours. During an interview on 9/25/23 at 4:29 P.M., the Director of Nurses (DON) said staff are expected to walk room to room to give report and round on the residents every two hours. During an interview on 9/24/23 at 11:39 A.M., the administrator said he/she did not know the last time staff had checked on the resident before he/she was found on the floor the morning of 9/23/23. Staff are expected to check on resident's at least every two hours. During an interview on 9/26/23 at 12:55 P.M., the administrator said upon reviewing the camera footage, he/she saw the resident's door closed and did not see staff enter the resident room or open the door. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00224885

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate positive COVID-19 residents from residents who had tested negative for COVID-19 or had only been exposed to COVID-19, for three residents (Resident #2, Resident #4, and Resident #6), at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 86. The Administrator was notified on 3/02/23 at 3:00 P.M., of an Immediate Jeopardy (IJ) which began on 2/22/23. The IJ was removed on 3/03/23 as confirmed by surveyor onsite verification. 1. Review of the Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated Sept. 23, 2022, showed a patient with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Facilities could consider designating entire units within the facility, with dedicated health care professional (HCP), to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes. Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. Review of the facility's Coronavirus (COVID-19) Policy, revised 10/22/22, showed an infected resident in a private room can remain in his/her current room on precautions with the door closed. If in a semiprivate room, refer to the Resident and Staff Isolation/Quarantine guideline for placement. Every effort will be made to minimize movement of the infected resident and suspected resident within the facility. (Residents with confirmed Coronavirus may be cohorted in the same room if necessary.) While on Transmission Based Precautions, residents are to be confined to their room as much as possible and should not attend communal activities/dining. Review of the facility's Resident and Staff Isolation/Quarantine Guidance, revised 10/22/22, showed residents with a COVID positive test, new admission or readmission or in-house newly identified as positive COVID, staff are directed to place resident in Transmission Based Precaution (TBP) in a single room if available or cohort with a similar status resident with room door closed, if safe to do so, until 24 hours with no fever without medications, improvement in symptoms and at least ten days passed since symptoms first appear or asymptomatic at least ten days. Residents to wear a face mask. Residents asymptomatic with close contact who do not consistently wear mask or are immunocompromised or reside near others who are severely immunocompromised or reside on a unit with ongoing COVID transmission are to be placed on TBP for seven days (count day of exposure as day zero) and negative test. Test on days one, three, and five. Discontinue TBP if negative. TBP for ten days if no negative test. Residents to wear a face mask. 2. Review of Resident #1's COVID test results form, dated 2/22/23, showed a positive result. Observation on 3/01/23 at 2:10 P.M., showed Resident #1 in a room with Resident #2. Review of the facility testing report showed Resident #1 tested positive for COVID on 2/22/23. Review of the report showed Resident #2 tested negative for COVID on 2/22/23 and on 2/23/22. Review showed Resident #2 tested positive for COVID on 2/25/23. During an interview on 3/01/23, at 2:00 P.M., the Director of Nursing (DON) said Resident #2 remained in the room with Resident #1 after Resident #1 tested positive on 2/22/23. During an interview on 3/03/23 at 8:31 A.M., Resident #2's responsible party said the facility did notify him/her the resident had been exposed to COVID. He/She said they also did not provide him/her with education of the risks for the resident to stay in the room. The responsible party said he/she would not have given consent for the resident to stay in a room with a resident who tested positive for COVID. 3. Review of Resident #3's COVID test results form, dated 2/22/23, showed a positive result. Observation on 3/01/23 at 2:11 P.M., showed Resident #3, who tested positive for COVID on 2/22/23, in a room with Resident #4, who tested negative for COVID on 2/22/23, 2/23/23, 2/25/23, and 2/28/23. Review showed Resident #4 tested positive for COVID on 3/01/23. During an interview on 3/03/23 at 8:27 A.M., Resident #4's responsible party said the facility did notify him/her the resident had been exposed to COVID. He/She said staff told him/her the resident would be on isolation for ten days, but never offered to move the resident. He/She would have expected staff to move the resident out of the room if the resident was exposed. He/She said the facility did not offer any education of the risk for the exposed resident to stay in the room. 4. Review of Resident #5's COVID test results form, dated 2/23/23, showed a positive result. Observation on 3/01/23 at 2:12 P.M., showed Resident #5, who tested positive for COVID on 2/23/23, in a room with Resident #6, who tested negative for COVID on 2/22/23, 2/23/23, 2/25/23, 2/28/23, 3/01/23, and 3/03/23. Observation showed Resident #5 and #6 did not have a face mask on. During an interview on 3/03/23 at 8:34 A.M., Resident #6's guardian said the facility did not notify him/her the resident had been exposed to COVID and did not provide any education to him/her on the risk of the exposed resident to stay in that room. He/She said if staff had notified him/her then he/she would have advised staff to move the resident to a different room. 5. During an interview on 3/01/23 at 1:50 P.M., the Infection Preventionist said they did not remove residents who tested negative for COVID after their roommate tested positive for COVID, because the residents were already exposed. During an interview on 3/01/23 at 2:00 P.M., the DON said staff did not remove residents who tested negative for COVID after their roommate tested positive for COVID, because the residents were already exposed. He/She said staff did not want to expose other residents throughout the building. During an interview on 3/01/23 at 3:40 P.M., the administrator and DON said they did not remove residents who tested negative for COVID after their roommate tested positive for COVID, because the residents were already exposed. The administrator and DON said they did not have any open rooms in which to move the residents. The DON said they had one unoccupied room, but the call light did not work. He/She said the rooms in the rehabilitation hall are all private rooms, and they did not consider moving residents who paid for private rooms. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00214682

Based on record review and interview, facility staff failed to implement polices and procedures to ensure all staff were fully vaccinated for Coronavirus 2019 (COVID-19), failed to ensure the medical exemption for one provider under contract or other arrangement included the required information and failed to ensure providers under contract or other arrangement were vaccinated or exempt from vaccination. The facility had 4% of employees not fully vaccinated or with an approved exemption, four resident COVID-19 infections in the previous four weeks, and zero resident hospitalization s. The facility census was 84. 1. Review of facility's Vaccination for COVID-19 policy, dated January 2022, showed: -Vaccination of facility staff: Regardless of clinical responsibility or resident contact the following facility staff who provide any care, treatment or other services is to receive the vaccine: -Individuals who provide care, treatment or other services for the facility and/or its residents under contract or by other arrangements; -Contractual or arranged workers may include: hospice, [CONDITION(S)], physical and other therapy contractors, mental health professionals, social workers, etc. are included in staff for whom vaccination is now required as a condition for continued provision of those services for the facility and/or its residents; -Track the vaccination status of all staff identified above including those for whom there is a temporary delay in vaccination. Examples of acceptable proof of documentation include CDC COVID-19 vaccination record card (or legible photo of the card), documentation of vaccination from health care provider or electronic health record, and state immunization information system record. -For staff who are approved for exemption or are considered temporarily delayed, employees are to wear a N95 mask while giving care and are to be tested weekly or more frequently if required by state requirements for COVID-19. For unvaccinated staff they are not to be assigned to work with known or suspected COVID positive residents. Staff are to be encouraged to socially distance when appropriate. Review of the Centers for Disease Control and Prevention (CDC's) Summary Document for Interim Clinical Considerations for use of COVID-19 Vaccines Currently Authorized or Approved in the United States, dated 11/08/2021, showed the required interval between primary series doses as Pfizer-BioNtech three weeks (21 days) and Moderna one month (28 days). The facility did not provide a complete list of other providers under contract or other arrangement, a policy for documenting follow up procedures for these providers, or documentation of efforts to ensure these providers were in compliance with vaccination requirements. 2. Review of the facility's COVID-19 Staff Vaccination Status for Providers on 8/17/22 showed staff documented: -113 total direct hire staff; -96% of staff have received the necessary doses to complete the vaccine series or had a pending/approved exemption; -One direct hire staff received a first vaccine dose on 2/10/22 and had not received a second dose; -One direct hire staff received a first vaccine dose on 6/3/22 and had not received a second dose; -Two direct hire staff pending exemption received a first vaccine dose on 12/20/20 and had not received a second dose or exemption. -100% of eight total Other (Contracted or other arrangement, or exempted) staff have received the necessary doses to complete the vaccine series or had a pending/approved exemption. Review of the facility's reported outbreak data showed four resident diagnosed with COVID-19 in the previous four weeks, with zero hospitalization s. 3. Review of the medical exemption for one provider (non-direct care vending machine supplier) under contract or other arrangement showed it did not include: -Information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; -A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications. Review of the facility's Contractor/Consultant Entry Log, dated 8/10/22, showed five other providers under contract or other arrangement, entered the facility to provide services. Further review showed the providers were not listed as part of the Other staff roster, and did not have documentation or verification of vaccination status. Additional review, showed one hospice provider reported they had not been vaccinated. 4. During an interview on 8/16/22 at 1:17 P.M., Licensed Practical Nurse (LPN) E said the Infection Preventionist keeps up with the paper part of COVID vaccinations. During an interview on 8/15/22 at 2:35 P.M., the Infection Preventionist said contracted provider vaccination status is provided by individuals as they sign in on log sheet. He/she said he/she is not sure of written agreement with providers since the front office sent out letters to vendors. He/She said he/she had not contacted hospice about staff vaccination status. During an interview on 8/17/22 at 9:21 A.M., Registered Nurse (RN) D said the facility has a once per month vaccination clinic. He/She said a first vaccine will let staff start working and the staff member is required to have second within next clinic period. He/She said the infection preventionist is responsible for ensuring the second vaccine dose is done. He/She said providers under contract or other arrangement are not considered staff. During an interview on 8/16/22 at 1:21 P.M., the Director of Nursing (DON) said staff COVID vaccination status is reviewed on hire. He/She said the infection preventionist is responsible for follow-up. He/She said the infection preventionist also has vendor records . He/She also said medical exemptions should include name, reason for exemption, be signed and dated by practitioner. During an interview on 8/17/22 at 2:00 P.M., the administrator said medical exemptions should include the reason for the exemption and the staff's providers signature. The director of nursing is responsible for vaccination status for staff and residents.

Based on observation, interview, and record review, facility staff failed to transcribe hospital discharge orders for daily weights and leg measurements to monitor fluid overload due to [MEDICAL CONDITION] over to the physician's orders [REDACTED].#1) who required admission and treatment in the hospital. The facility census was 75. 1. Review of Resident #1's admission Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 03/12/18, showed staff assessed the resident as follows: -Cognitively intact; -Did not have any mood indicators; -Did not have any behaviors; -Required extensive assistance of two or more staff with bed mobility, transfers, and toilet use; -Required extensive assistance of one or more staff with dressing and personal hygiene; -Independent with eating; -[DIAGNOSES REDACTED]. -Shortness of breath with exertion or lying flat; -Received an anti depressant 7 days per week; -Used oxygen; - Bilevel Positive Airway Pressure ([MEDICAL CONDITION], a non-invasive form of therapy for patients suffering from sleep apnea) machine. Review of the resident's hospital discharge orders, dated 08/07/18, showed staff are directed to administer oxygen at 4 liters per minute by nasal cannula when at rest and 6 liters per minute during activities, weigh the resident daily and notify the physician with changes in weight for more than three pounds in a day or five pounds in a week. Further review showed staff are directed to administer the [MEDICAL CONDITION] as ordered. Additional review showed staff are directed to check as needed (PRN) for respiratory distress or a change in the resident's condition per nurse assessment. Review of the resident's nurses' notes, dated 08/07/18, showed staff documented the resident readmitted to the facility from the hospital for chronic [MEDICAL CONDITION], all previous care orders and medications to continue, and staff are directed to weigh the resident daily before breakfast and notify the doctor of a three pound weight difference in one day and a five pound difference in a week. Review of the resident's physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Further review showed staff did not transcribe the order to complete daily weights on the MAR indicated [REDACTED]. Additional review showed staff documented they administered [MEDICATION NAME] (antianxiety medication) to the resident on 08/15/18 at 2:15 P.M. and on 08/16/18 at 3:45 P.M. for anxiety, but did not document follow-up to show if the medication was effective. Review of the resident's physician's orders [REDACTED]. Further review showed staff are directed to administer [MEDICATION NAME] 2.5mg every six hours PRN for shortness of breath. Additional review showed staff did not transfer the following hospital discharge orders, dated 08/07/18 to the resident's current POS: -Weigh the resident daily and notify the physician with changes in weight for more than three pounds in a day or five pounds in a week; -[MEDICAL CONDITION] administration instructions; -Check for respiratory distress PRN. Observation and interview on 08/13/18 at 3:00 P.M., showed the resident lie in bed with a nasal cannula in place and an oxygen concentrator next to his/her bed. Additional observation showed a [MEDICAL CONDITION] machine on the table next to the resident's bed. The resident said he/she is usually on 2-3 liters of oxygen, he/she receives nebulizer treatments, and he/she has a [MEDICAL CONDITION] machine. He/She said the [MEDICAL CONDITION] machine has not been working and he/she has been trying to contact the supplier for help. Review of the resident's weight change history, dated 08/15/18, showed staff documented the following: -528 lbs. on 08/03/18 -529 lbs. on 08/09/18. Additional review showed staff did not document weights for 08/10/18, 08/11/18, 08/12/18, 08/13/18, 08/14/18, 08/15/18, and 08/16/18. During an interview on 08/16/18 at 6:00 P.M., the Corporate Advisor said he/she is not sure where staff documented the resident's daily weights but they should be listed on the TAR. During an interview on 08/16/18 at 6:00 P.M., the Corporate Vice President said the hospital discharge orders do list daily weights under general instructions but those are blanket instructions for all discharge orders so staff did not transfer them over to the resident's POS. Review of the resident's nurses' notes, dated 08/17/18 late entry for 8/16/18, showed staff documented the resident was short of breath, assessment done, and treatment given. Further review showed staff administered [MEDICATION NAME] for anxiety and called the physician for orders to send the resident to the hospital. Observation on 08/15/18 at 11:38 A.M., showed the resident lie in bed with a nasal cannula in place and an oxygen concentrator next to his/her bed. Additional observation showed a [MEDICAL CONDITION] machine on the table next to the resident's bed. Observation and interview on 08/15/18 at 8:19 P.M., showed the resident lie in bed with nasal cannula in place connected to a portable oxygen tank. Further observation showed the resident took deep breaths when he/she spoke. Additional observation showed the filter on the oxygen concentrator clogged with debris. The resident said his/her oxygen concentrator is not working so staff brought him/her a portable tank. He/She said he/she is having trouble breathing and he/she thinks it is because he/she is on a portable tank instead of an oxygen concentrator. He/She said he/she has not been weighed today. Observation and interview on 8/16/18 at 3:30 P.M., showed the resident lie in bed with nasal cannula in place. He/She appeared to struggle to breathe and had a difficult time talking due to shortness of breath. He/She had the oxygen concentrator at eight liters. He/She had his/her own pulse oximeter and was monitoring his/her oxygen saturation level. Certified Nurse Assistant (CNA) C entered the room and helped the resident put on his/her [MEDICAL CONDITION] mask to see if it would help but the resident's oxygen saturation level dropped to 67%. The resident removed the [MEDICAL CONDITION] and put the nasal cannula back on with the oxygen set at eight liters. Survey staff from Department of Health and Senior Services (DHSS) intervened and asked CNA C to get a nurse and let them know the resident was having trouble breathing. Licensed Practical Nurse (LPN) G entered the room and observed the resident. The LPN did not listen to the resident's lung sounds, take the resident's vital signs, or complete an assessment. The resident said he/she is having trouble keeping his/her oxygen saturation level above 90% even with the oxygen set at eight liters. Observation and interview on 08/16/18 at 3:53 P.M., showed the resident lie in bed with nasal cannula in place connected to the concentrator set at eight liters. Further observation showed the resident using an oximeter to track his/her oxygen saturation. Additional observation showed the resident take deep breaths and struggled to talk. His/Her oxygen saturation was at 89%. LPN G entered the room and looked at the resident's oxygen saturation reading on the oximeter and said it had improved. The resident said his/her oxygen saturation level is at 90% with eight liters of oxygen but he/she still feels like he/she cannot breathe. He/She said he/she wants his/her [MEDICAL CONDITION] to work but the person from the respiratory care supplier is not at the facility. LPN G said he/she does not know how to work the machine but he/she thinks the facility has a contract with a respiratory therapist. LPN G did not take the resident's vitals, check his/her lung sounds, or assist with his/her [MEDICAL CONDITION] machine. During an interview on 08/16/18 at 3:53 P.M., LPN G said he/she is unsure whether the resident has a [MEDICAL CONDITION] or [MEDICAL CONDITION] and he/she does not know if it is working or not. He/She said he/she thinks they contract with a respiratory therapy company to help with the equipment. He/She said the resident's oxygen level seems to be coming up from earlier. During an interview on 8/16/18 at 4:50 P.M., LPN G said he/she knew the resident was having difficulty breathing and he/she had given him/her an [MEDICATION NAME] (anxiety medication). When asked if he/she had assessed the resident LPN G said no because he/she was passing medications so the charge nurse would have done the assessment. During an interview on 8/16/18 at 4:53 P.M., LPN H (the charge nurse) said he/she had not assessed the resident because he/she thought LPN G had done it before he/she gave the resident medication. During an interview on 8/16/18 at 4:55 P.M., the Director of Nursing (DON) said he/she was just informed of the situation. The DON said he/she asked LPN G to go now and assess the resident and listen to his/her lungs. During an interview on 8/16/18 at 4:59 P.M., LPN G said the resident's lungs sounded clear. He/She said staff did not contact the physician about the resident's shortness of breath. During an interview on 8/16/18 at 5:00 P.M., the resident said staff did not complete daily weights on him/her. Observation on 08/16/18 at 5:05 P.M., showed staff did not contact the physician about the resident's decreased oxygen saturation level and difficulty breathing until this time, and the physician directed staff to send the resident out to the hospital. Review of the resident's emergency department records, dated 8/16/18, showed the following: -Chief complaint of respiratory distress: increased shortness of breath; -Was discharged from our facility about 1 week ago after an admission with acute on chronic [MEDICAL CONDITION] and was [MEDICATION NAME] (increase urine excretion) and discharged on increased dose of [MEDICATION NAME] (a water pill that treats fluid build-up due to heart failure or kidney disease); -The resident's stated that 1st day or 2 after leaving the hospital he/she did pretty well and then last couple days his/her shortness of breath has worsened. States that today they placed her/him from nasal cannula onto a [MEDICAL CONDITION] and his/her oxygen saturations dropped down to 60%; -The resident said that he/she is not sure that the oxygen and entire machine is hooked up correctly; -Weight 545 lbs (247.2 kg); -Sp 02 (blood saturation of oxygen) at 93%; -blood gases arterial: pc02 arterial 62 (high carbon [MEDICATION NAME] in the blood); p02 arterial 63 (low oxygen in the blood), oxygen saturation 91 (low), HCO3 ([MEDICATION NAME] -maintains the body's pH) arterial 34 (High); base excess arterial 6.6 (high), TC02 (total carbon [MEDICATION NAME] in the blood) arterial 36 (high); -admitted for IV (intravenous or through the bloodstream) diuresis and further evaluation care; -Final Diagnoses: [REDACTED]. Review of the resident's hospital records, admitted [DATE] and expected discharge date of [DATE], showed the resident was admitted and hospital staff documented the following: -Diagnosis: [REDACTED]. -Weight 545 pounds; -C02 30mmol/L (high) on 8/18/18; -Chest x-ray 8/16/18 diffuse severe airspace disease, similar in appearance to the previous exam on 8/3/18; -Discharge Diagnosis: [REDACTED]. -Following admission IV diuresis and [MEDICAL CONDITION] was provided with significant results within 24 hours. At time of discharge, the resident's was at his/her baseline cardiopulmonary status. This is concerning for an environmental effect as this is a recurrent pattern of markedly improving within 24-48 hours of hospitalization . We spoke about habits and care at the facility. Education was provided. Further review of the resident's hospital records, admitted [DATE] and discharge date [DATE], showed the following physician orders [REDACTED].>-Oxygen saturation - check as needed for respiratory distress or change in patients condition per Registered Nurse (RN) assessment; -Notify physician of respirations per minute greater than 28 or less than 12; -Notify physician if patients weight increases or decreases by 3 lbs in one day or 3 lbs in one week; -Oxygen at 3-4 L/minute by nasal cannula continuously; -[MEDICAL CONDITION] at bedtime per specific setting orders until late into the morning every day; and as needed with naps; -[MEDICATION NAME]: 80 mg tablet one tablet by mouth two times a day; -Continue taking [MEDICATION NAME] 0.083% nebulizer solution inhale 2.5mg by mouth every 6 hours as needed for shortness of breath or wheezing. Further review of the resident's hospital records, admitted [DATE] and discharge date on 8/18/18, showed the physician documented the resident has had multiple admissions and is close to baseline after [MEDICAL CONDITION] and initial management. The physician documented he/she discussed the resident's current setup and schedule of [MEDICAL CONDITION] and oxygen sustentation at the nursing home and there appears to be an issue with his/her home [MEDICAL CONDITION] and then he/she got into trouble. Further review of the resident's hospital records, admitted [DATE] and discharge date [DATE], showed the social worker documented the resident said he/she had an issue operating their [MEDICAL CONDITION] at the facility. The resident said he/she called the respiratory care supplier to come out and check the [MEDICAL CONDITION] but had not gotten a response. The social worker documented he/she called the supplier and the social worker at the facility notifying them of the issue with [MEDICAL CONDITION]. Further review of the resident's hospital records, showed the Chaplain documented on 8/17/17 that the resident said if the nursing home would just keep up with his/her weight and medication he/she wouldn't have to keep returning to the hospital. During an interview on 08/17/18 at 8:30 A.M., hospital staff said the resident was admitted for acute chronic [MEDICAL CONDITION] with hypercapnia (elevated carbon [MEDICATION NAME] levels in the body). He/She said the resident was 545 pounds upon admission and his/her carbon [MEDICATION NAME] level was 60 (Normal carbon [MEDICATION NAME] levels are 23 -29). During an interview on 08/17/18 at 3:29 P.M., CNA C said he/she is very familiar with the resident. He/She said staff weigh the resident only when the Registered Dietician asks but he/she knows staff are supposed to do it every morning. He/She said the resident told him/her the day staff was not doing his/her daily weights. He/she said the resident went out to the hospital last week because his/her weight went up and he/she could not breathe. He/She said the resident called the ambulance himself/herself last time. He/She said the resident told him/her that he/she was having trouble breathing for three days. CNA C said he/she went and got the nurse each time. He/She said the nurse would take the resident's blood pressure and check his/her oxygen saturation levels but nothing else. He/She never saw staff listen to the resident's lungs. He/She said the resident struggled for breath every time he/she went in to care for him/her. He/She said the resident asked him/her to turn his/her oxygen to eight even though it is supposed to be at six. He/she said the resident told him/her he/she thinks the portable oxygen tanks work better than the concentrator does. During an interview on 08/17/18 at 3:57 P.M., LPN G said he/she has worked here for two weeks. He/She said he/she is somewhat familiar with the resident. He/She said the resident's daily weights are done on day shift and he/she has never worked on day shift prior to yesterday so he/she does not know if they are being done or not. He/She said staff use the great big lift to weigh the resident. He/She said the weights are documented in his/her chart probably on the TAR. He/She said the hospital ordered daily weights on 8/7/18 because he/she had gained a lot of weight. He/She said he/she was here when the resident went out last time. He/She said the resident called 911 him/herself. He/She believes staff assessed the resident that time then came down to call for an ambulance but the resident called first. He/She said staff was calling the ambulance due to low oxygen saturation levels. He/She said staff would have contacted the physician for orders to send the resident out if he/she wouldn't have called himself/herself. He/She said staff should have documented the resident's condition and that he/she called 911 and went to the hospital and he/she is unsure why it was not documented. He/She said yesterday no one notified him/her the resident had trouble breathing but LPN H was the charge nurse so he/she followed him/her down to the resident's room. He/She said the physician should be contacted if the resident's oxygen level falls below 90 without correction with oxygen. He/She said the resident is supposed to be on 4 liters while in bed and up to 6 liters with exertion. He/She said the resident may be able to get 6 liters and increase it to 8 himself/herself. He/She said a new concentrator was brought in last week because it went up to 10 liters. He/She said if a resident does have an order for [REDACTED]. He/She said the resident was gasping for breath and thought the [MEDICATION NAME] might help the resident take slower steady breaths. He/She was keeping an eye on the resident's breathing after he/she administered the [MEDICATION NAME]. He/She said a nebulizer treatment had been given an hour prior to when he/she administered the [MEDICATION NAME]. He/She said the treatment should have been documented he/she said the previous staff member only told him/her about the treatment during report. He/She said the previous staff member did not mention any respiratory distress during report. He/She said the physician should be notified if the facility is unable to take care of the resident using the orders and tools they have available. He/She did asked the resident if he/she wanted to be sent out and he/she said no. He/She said staff should listen to the resident's lungs during any assessment. He/She said he/she is unsure who maintains the concentrators. He/She said he/she is unsure if the resident's [MEDICAL CONDITION] is broken or not. During an interview on 08/17/18 at 4:23 P.M., the DON said the resident did have an order for [REDACTED]. He/She said staff weigh the resident between 6-7 A.M. every morning so they can have night and day shift both available to help. He/She said staff used the bariatric lift to weigh the resident and they tell the nurse who documents on the TAR. He/She said the bariatric lift is working as far as they know. He/she said the resident called EMS herself last week due to being short of breath and becoming anxious. He/She said the past hospital stay should be documented in nurse's notes. He/She is unsure why the last hospital visit was not documented. He/she is unsure if staff contacted the physician the last time the resident was sent out but if he/she was it should be documented. He/She said the nurses make sure the hospital orders are carried over to the current POS and he/she is responsible for reviewing them to make sure everything is transferred over correctly. He/She said staff did not report the resident having shortness of breathe yesterday. He/She expects staff to assess them listen to lungs, use oximeter to check oxygen saturation, and call the doctor if needed for residents reporting shortness of breathe. He/She said staff should contact the physician if they cannot get oxygen levels up or if the order says to. He/she staff should call the physician to clarify and get a specific order for the liter flow of oxygen needed. He/She said staff should follow policy due to how many liters per nasal cannula and he/she does not know why they did not. Review of the respiratory care supplier's documentation on 8/20/18, showed the supplier reinstructed the resident on trilogy vent, proper procedure for putting on full face mask. Reinstructed on how to connect tubing or oxygen to unit. Reinstructed on the humidifier - trilogy vent functioning properly. Further review showed inspection of the [MEDICAL CONDITION] did not occur until four days after the resident complained of trouble breathing. During an interview on 8/20/18 at 12:00 P.M., the Administrator said staff should assess the resident and notify the physician as soon as staff notice the resident had difficulty breathing or appears to have respiratory distress. The Administrator said he/she is not aware that the resident has an order for [REDACTED]. The Administrator said there are no issues with hoyer weight scales. He/She said that the CNAs had come to him/her to tell her they don't work and he/she showed them that the mechanical lift scales do work multiple times. During an interview on 8/20/18 at 12:32 P.M., the DON said staff should assess the resident's respiratory status every shift including pulse oximeter, listen to his/her lung sounds, check oxygen saturation, and ensure the oxygen concentrator is working. The DON said if the resident is having problems breathing they should assess the resident and then call the physician, but not give an antianxiety medication without doing an assessment of the resident's respiratory status. The DON said staff should assess and notify the physician immediately not 30 minutes later. During an interview on 08/17/18 at 2:07 P.M., the Nurse Practitioner said he/she would expect staff to transfer hospital orders over to the resident's POS and fax them to his/her office. He/She said daily weights have to be done no matter how difficult it is because they can make a huge difference for the resident. He/She said the resident has never refused daily weights and he/she wants them done. He/She said there should be no reason the facility cannot weigh the resident daily and the order to do daily weights should not be discontinued. He/She said he/she was unaware the hospital had ordered leg measurements but he/she would expect the facility to do them daily if instructed by the hospital. He/She said he/she would expect staff to notify him/her of any weight changes but he/she has not been notified lately. He/She said he/she expects staff to contact him/her if the resident is having trouble with his/her [MEDICAL CONDITION] and they should also contact the [MEDICAL CONDITION] provider to have it looked at. He/She said the [MEDICAL CONDITION] not working could be a sign of fluid retention from [MEDICAL CONDITION] because it cannot push air through. He/She said staff should contact his/her office if the resident is having shortness of breath and let them know if the resident needs more than the six liters of oxygen on his/her POS. He/She said staff should have assessed the resident by listening to his/her lungs, counting his/her respiratory rate, check his/her oxygen saturations, and check for speech dyspnea if his/her oxygen saturation dropped into the 60's. He/She said he/she was in the facility the day the resident was sent to the hospital but no one made him/her aware the resident was having trouble breathing. He/She said if staff would have notified him/her he/she could have assessed the resident. He/She said the hospitalization could have been avoided if the staff had weighed the resident daily and notified him/her. He/She said not monitoring the resident's weight could result in death since he/she is respiratory compromised and is dependent on daily weights.

Based on observation, interview, and record review, facility staff failed to implement interventions to prevent falls, as directed by the plan of care, resulting in a fractured nose; and failed to implement new interventions to prevent future falls for one resident (Resident #4) of eight sampled residents. The facility census was 69. 1. Review of Resident #4's plan of care, updated 9/07/10, showed staff assessed/planned the following: - Very impaired vision and glasses did not help him/her; - Required extensive assistance with all Activities of Daily Living (ADLs); - Ensure resident wore proper footwear; - Keep room free of clutter; - Keep call light within reach- refuses to use-check needs frequently; - One to two staff transfer with assistance of gait belt; - Orient to surroundings when able. Keep bed in low position with wheels locked; - No side rails; - Monitor resident's ability to transfer- monitor for decline; - Provide contour mattress; - Provide "landing strips"; - Apply personal alarm to wheelchair; - Maintain uncluttered environment free of obstacles and safety hazards; - Place frequently used items within reach and visual field of resident; - Provide assistance with ADLs dining and transfers as needed. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/20/10, showed staff assessed the resident with the following: - Severely impaired vision; - No documentation for Cognitive Patterns; - Required extensive assistance and two plus persons physical assistance for transfers, dressing and toilet use; - Required extensive assistance and one person physical assistance for hygiene; - Required physical help and one person assistance for bathing activity; - Incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - No falls following admission or prior assessment. Review of the resident's nurse's notes showed the following information: - On 1/05/11 at 2:01 P.M. staff recorded the resident continued to eat at a table in the dining room "but kind of to self due to his/her spitting," sometimes projective and other times it is over his/her wheelchair and other residents get upset. - On 1/11/11 at 6:01 P.M. staff recorded the resident had been in a "very distraught mood." Resident "screamed" out for his/her mother. - On 2/02/11 at 4:57 P.M. staff recorded the resident had periods of time where he/she "hollered out loudly" and others where he/she sang. - On 2/07/11 at 9:21 P.M. staff recorded they assisted the resident to the main dining room for the evening meal. The resident "screamed" at something staff could not see to "get the hell away from me." There was a "dull thud" and then the resident "moaned." At 4:40 P.M. staff found the resident was found laying sprawled out on his/her stomach holding his/her nose. The resident had large pool of blood under his/her face. Staff assessed a skin tear on the left side of the resident's nose and on his/her left forearm. Staff assessed the resident and assisted him/her back into the wheelchair. Staff notified the Assistant Director of Nursing (ADON), the resident's family, and his/her Physician. Staff send the resident to the hospital for evaluation and treatment of [REDACTED]. Review of the resident's Resident Transfer Form, dated 2/07/11, showed staff documented the resident, "fell on face". Further review showed staff documented the resident had skin tears on his/her arm and nose. Review of the resident's "Instant" Care Plan, dated 2/07/11, showed staff did not implement any new interventions for the resident to prevent further accidents or injuries. Review of the resident's Risk Evaluation for Falls, dated 2/07/11, showed staff assessed the resident with a score of 14 (assessment listed a score of ten or above as high risk for falls). Review of the resident's Skin and Wound Assessment Form, dated 2/07/11, showed staff documented bruises on both arms and hands and skin tear on back of right leg. Observation on 2/09/11 at 10:40 A.M. showed the resident in his/her room in his/her wheelchair. Observation showed dark purple bruising under the resident's right eye, several dark purple bruises up each arm, and a blood soaked bandage on his/her left ring finger. Further observation showed the resident's call light located under the resident's sheet and bedspread out of the resident's reach. Observation on 2/09/11 at 11:15 A.M. showed the resident in his/her room in his/her wheelchair. Further observation showed the resident's call light located under the resident's sheet and bedspread out of the resident's reach, and he/she did not have a personal alarm attached to alert staff of the resident's attempts to stand unassisted. Observation on 2/09/11 at 12:03 P.M. showed the resident in the Special Care Unit dining room seated apart from other residents facing a counter. Further observation showed the resident did not have a personal alarm attached to his/her chair to alert staff of the resident's attempts to stand unassisted. Observation on 2/09/11 at 12:50 P.M. showed the resident in the Special Care Unit dining room. Observation showed the resident did not have a personal alarm attached to his/her chair to alert staff of his/her attempts to stand unassisted. Observation on 2/09/11 at 1:20 P.M. showed the resident in his/her bed. Further observation showed the resident's bed elevated to a standard height (not low as directed in the plan of care). During an interview on 2/09/11 at 1:25 P.M. Certified Nurse Aide (CNA) C said the following: - The resident required assistance of one to two staff with transfers and he/she could be combative; - The resident has an unsteady gait and did not ambulate more than one or two steps unassisted; - He/she did not work on the day the resident fell ; - The resident had fallen in the past; - He/she "thinks" the staff were "working on getting the resident landing strips and a bed alarm"; - The resident did not have a personal or bed alarm; - The resident was not in a low bed. During an interview on 2/09/11 at 1:30 P.M. Licensed Practical Nurse (LPN) B said the following: - The resident could stand and pivot but needed staff assistance with transfers; - The resident "yelled out" at things that were not there due to his/her blindness; - Staff "try" to place the resident's call light in his/her lap; - Staff did not have interventions to prevent the resident from falling prior to the resident's fall on 2/07/11; - Staff did not plan any new interventions for the resident to prevent future falls; - The resident "probably needs a chair alarm"; - He/she "should have" implemented new interventions for the resident to prevent future falls. MO 136

Based on observation, interview, and record review, facility staff failed to provide care in a manner to prevent pressure ulcer development and promote healing of existing pressure ulcers for two (Residents #5 and #6) out of five sampled residents with pressure ulcers. Staff failed to record assessments to show on-going monitoring for improvement or decline of pressure ulcers, failed to follow physician orders [REDACTED].#6). Staff failed to obtain a physician order [REDACTED]. 1. Review of Resident #6's Pressure Ulcer Risk assessment, dated 12/23/10, showed staff assessed the resident at risk to develop pressure ulcers. Review of the the resident's nurses' notes showed staff recorded the following: -On 12/27/10 staff recorded the Certified Nurse Aides (CNAs) found a four centimeter (cm) by 1.2 cm blood filled blister on the resident's right flank; the coccyx (tailbone) pressure ulcer measured 4 cm by 3 cm with bloody drainage. Staff did not record information to show they notified the resident's physician of the newly identified area on the resident's right flank. -On 1/3/11 staff recorded the resident's right flank wound measured 3.5 cm by 1.5 cm and was "beefy red"; The "upper" coccyx pressure ulcer measured 0.9 cm by 2.1 cm by 0.5 cm. During a telephone interview on 2/22/11 at 1:30 P.M. Licensed Practical Nurse (LPN) I said the resident acquired a Stage II pressure ulcer on his/her upper coccyx while at the facility. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/7/11, showed staff assessed the resident with the following: - Severely impaired cognitive skills for daily decision making; - Required extensive assistance with bed mobility and hygiene; - Required total assistance with transfer, dressing, and toilet use; - Did not walk; - Incontinent of bowel; - Five Stage II ( partial thickness skin loss involving epidermis, dermis, or both that is superficial & presents clinically as an abrasion, blister, or shallow crater) pressure ulcers. Review of the resident's nurses' notes, dated 1/9/11 showed staff recorded the resident's right flank wound measured 2.2 cm by 1.5 cm and the "upper" coccyx pressure ulcer measured 1.4 cm by 0.3 cm by 0.3 cm with slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy). Staff did not record assessments of the other three pressure ulcers staff identified in the resident's MDS on 1/7/11 to show on-going monitoring for improvement or decline. Review of the resident's plan of care, dated 1/9/11, showed staff planned to apply heel protectors at all times to both heels. Review of the resident's nurses' notes and skin assessments showed staff did not record assessments of the resident's heels. Review of the resident's plan of care, dated 1/14/11, showed staff planned to apply a low air loss mattress to the resident's bed. Review of the resident's nurses' notes, dated 1/16/11, showed staff recorded the the resident's right flank wound measured 2.2 cm by 1.5 cm and the "upper" coccyx pressure ulcer increased in size and now measured 3.2 cm by 0.6 cm by 0.1 cm and was "beefy red." Staff did not record assessments of the other three pressure ulcers staff identified in the resident's MDS on 1/7/11 to show on-going monitoring for improvement or decline. Review of the resident's plan of care showed staff updated the plan on 1/21/11, including the following interventions: - "Float" heels when in bed; - Complete a skin assessment weekly and as needed; - Turn and reposition at least every two hours. Review of the resident's Physician order [REDACTED]. - Apply Hydrogel (dressing used to provide moist wound environment) and Mepore (absorbant dressing) to left heel until healed; - On 1/18/11 a new order to apply Mesalt (used to absorb bacteria, drainage, and dead tissue) to lower coccyx (tailbone) and cover with Mepore every day and as needed; - The POS did not contain a physician's orders [REDACTED]. - Review showed the POS did not contain a physician's orders [REDACTED]. Review of the medical record showed a faxed order from the Physician, dated 1/11/11, which instructed the staff to complete the following: - Apply Silver Sulfadazine cream (used to prevent and treat infection in wounds) and Mepore to both heels and the wound on the resident's right flank (first recorded physician's orders [REDACTED]. - Apply Santyl ([MEDICATION NAME] ointment used to allow healthy tissue to grow) to the resident's wound on the lower coccyx and cover with Mepore. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Staff did not record they completed the treatment the resident's physician ordered on [DATE] to apply Silver Sulfadazine cream and Mepore to both heels and the wound on the resident's right flank from 1/11/11 through 1/31/11; - Staff did not record they completed the treatment the resident's physician ordered from 1/11/11 through 1/31/11 to apply Santyl and Mepore to the pressure ulcer on the resident's "lower" coccyx. Staff did not record any assessment of the resident's pressure ulcers during the week of 1/23 through 1/29/11 to show on-going monitoring for improvement of decline. Review of the resident's nurses' notes, dated 2/4/11, showed staff recorded the resident's right flank wound measured 2 cm by 1 cm, the "upper" coccyx pressure ulcer increased in size and now measured 3 cm by 1 cm, and first recorded an assessment of the "lower" coccyx pressure ulcer that measured 3.8 cm by 2 cm by 1 cm. Staff did not record an assessment of the other two pressure ulcers identified in the resident's MDS to show on-going monitoring for improvement or decline. Review of the resident's POS, dated 2/1/11 through 2/28/11, showed the resident's physician directed staff to complete the following: - Apply Hydrogel to left and right heel and Mepore, cover until healed; - Review showed the current POS did not contain a physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR), dated 2/1/11 through 2/28/11, showed the following: - Staff marked the resident's right and left heel pressure ulcers as "healed"; - Staff recorded they applied skin prep every day to the right and left heels (no order for this on the POS); - Staff recorded they applied Hydrogel (instead of Silver Sulfadazine cream) and Mepore to the resident's right flank wound nine days. Observation on 2/8/11 at 10:30 A.M. showed the resident in bed. The resident did not have on heel protectors as directed in the plan of care. Observation on 2/8/11 at 1:00 P.M. showed the resident in bed. The resident did not have on heel protectors as directed in the plan of care. At this time, the resident said, "ouch, my butt!" Observation on 2/9/11 at 6:30 A.M. showed the resident in bed. The resident did not have on heel protectors as directed in the plan of care. Observation on 2/9/11 at 6:50 A.M. showed the resident in bed. The resident did not have on heel protectors as directed in the plan of care. Observation showed a half-dollar sized pressure ulcer on the upper coccyx, and a quarter sized pressure ulcer to the lower coccyx. The dressings to the coccyx areas were saturated with pink colored drainage from the wounds. The resident's left heel was healed, and the right heel contained a callous. During an interview at this time, Certified Nurse Assistant (CNA) H said they used to apply heel protectors on the resident, but they had not recently. CNA H found the heel protectors in the resident's closet at this time. CNA H said they were not supposed to apply the heel protectors at night. Observation on 2/10/11 at 2:10 P.M. showed the resident in bed and his/her heel protectors on the bedside chair. Observation on 2/10/11 at 12:30 P.M., showed the Assistant Director of Nursing (ADON) performed treatments to the resident's wounds. Observation showed: - an approximately 3 cm by 1 cm pressure ulcer to the resident's right flank, 100% yellow slough. The ADON applied Hydrogel and Mepore (not the current Physician ordered treatment). - Stage III (full thickness skin loss) pressure ulcer to the "upper" coccyx, the ADON applied Hydrogel and Mepore. - Unstageable pressure ulcer to the lower coccyx with yellow slough; the ADON applied Mesalt (instead of Santyl as ordered) and Mepore. During an interview on 2/10/11 at 12:20 P.M., the ADON said staff believe a wrinkled sheet probably caused the wound to the resident's right flank. She said staff did not use heel protectors on the resident. During an interview on 2/10/11 at 2:00 P.M. the Director of Nursing (DON) said there was no order on the current POS for treatment to the resident's right flank pressure ulcer. During a telephone interview on 2/22/11 at 1:30 P.M. LPN I said the resident went to the hospital in December and returned with the facility acquired, Stage II pressure ulcer on his/her upper coccyx "much worse", and an additional wound to the lower coccyx near the rectum. LPN I said both wounds were Stage II when the resident returned to the facility, but now they are "worse." LPN I said the Physician faxed orders on 1/11/11 to treat the wounds, but staff did not transcribe the orders to the POS or treatment sheets. LPN I said staff did not provide the physician ordered treatments to those areas. 2. Review of Resident #5's Minimum Data Set (MDS), a comprehensive assessment completed by staff and used for planning care, dated 02/01/2011, showed staff assessed the resident: -cognitively impaired; -difficulty communicating; -required extensive assistance of two staff to turn and reposition in bed. Review of the resident's corresponding plan of care showed staff planned the following care to address the dependent resident's bed mobility limitations: -provide turning and repositioning every two hours and PRN (as necessary) while in bed. Review of the resident's nurses' notes dated 02/05/2011 showed staff assessed the resident with "wounds" on both his/her heels. Review of the resident's Discharge Order and Summary Sheet (received at the time of the resident's admission to the facility from the hospital) dated 02/05/2011, showed the discharging physician directed facility staff to provide the following wound care: -"Decubitus care with wound team" Review of the resident's admission "Skin and Wound Assessment Form" dated 02/05/2011 showed staff assessed the resident's feet as "wrapped with dressing, orders received for wound team nurse to assess." Review of the resident's "Wound Evaluation Form" dated 02/06/2011 showed staff planned the following care to address the resident's identified pressure ulcers: -reposition the resident every two hours and as needed; -provide heel protectors (padded device placed on heels to prevent additional pressure from the mattress). Review of the resident's Treatment Administration Record (TAR) dated 02/2011 showed staff are directed to provide the following treatment on the resident's left heel: -"left heel iodine" (a nonprescription first-aide antiseptic product), cover with an absorbent dressing Review of the TAR showed staff initialed providing the resident's left heel treatment on; 02/06, 02/07, 02/80, and 02/09/11. Review of the resident's Physician order [REDACTED]. Review showed the POS did not contain any information regarding treatment for [REDACTED]. Staff did not contact the "wound care team" as directed by the hospital discharging physician on 2/5/11, to ensure evaluation and appropriate treatment were provided to promote healing of the resident's left heel pressure ulcer. Observation on 02/10/2011 at 12:20 PM, showed the resident's left heel contained a stage II (partial thickness loss of skin) pressure ulcer which measured approximately 3.0 cm by 2.0 cm, and did not contain a dressing or any covering. The resident's left leg lay propped on a pillow beneath the calf area, but his/her heel lay directly against the mattress. During an interview at this time, RN A said the resident's left heel pressure ulcer is assessed as a stage II (partial thickness loss of skin) and caused from "pressure." Observation on 2/10/2011 at 1:20 PM, showed the resident remained in bed on his/her back. The resident's left heel remained in the same position directly against the mattress. During this time the resident's heel protectors lay in a bedside chair at the foot of the resident's bed. Observation on 2/10/2011 at 3:30 PM, showed the resident remained in the same position with his/her left heel directly against the mattress. Staff did not assist the dependent resident to change his/her position in bed for at least three hours and 10 minutes, as planned to address the resident's bed mobility limitations, and to prevent further decline in the resident's skin condition. During an interview on 02/10/2011 at 11:00 the Assistant Director of Nursing (ADON) said the wound care team has not assessed the resident's heel pressure ulcer. The ADON also said staff have not requested or "set up" the wound care team for the resident and have not notified the resident's Physician requesting a treatment order. MO 143

Based on observation, interview and record review, facility staff failed to properly secure indwelling urinary catheter tubing (inserted into the bladder to drain urine) as directed in the facility's Catheter Care Policy for three residents (Residents #1, #2, and #3) of three residents whose care was reviewed. Staff failed to secure the catheter tubing to the residents' thighs resulting in dorsal erosion (external or internal destruction of a surface layer by physical or [MEDICAL CONDITION] processes) of one resident's (Resident #1) catheter insertion site; failed to document urinary catheter output every shift for three of three sampled residents (Resident #1, #2 and #3) as directed in the facility's urinary catheter Intake and Output policy; failed to document they completed urinary catheter care every shift for three (Resident #1, #2 and #3) of three sampled residents. The facility census was 65. 1. Review of the facility's Catheter Care policy dated August 2003 showed the policy directed staff to provide the resident with the following catheter care: - Secure catheter tubing to thigh; - Cleanse around the area where the catheter enters the urethral meatus with soap and water daily; - Monitor resident's output; - Maintain below the level of the bladder. 2. Review of the facility's Intake and Output policy dated September 2003 showed the policy directed staff to provide the resident with the following: - Record total output in the treatment sheets on a 24-hour basis. - Nurses should record output for Foley catheters on the treatment sheet. 3. Review of Resident #1's nurses notes dated 10/17/10 at 6:39 P.M., showed staff documented the resident was "still complaining" of pain at the catheter insertion site. Staff recorded they assessed "open sores noted in the area." Additional review showed the facility staff did not document they notified the resident's physician of his/her condition. Review of the resident's nurses notes dated 11/24/10 at 11:03 P.M., showed staff documented the resident's catheter insertion site was "raw and excoriated on top side" and "the bottom" of the insertion site had "a flap that is hard. Bottom is raw and bleeding." Additional review showed the facility staff did not document they notified the resident's physician of his/her condition. Record review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/29/10 showed staff assessed the resident as follows: - Confused; - Dependent on staff for assistance for toileting needs including management of his/her indwelling Foley urinary catheter. Review of the resident's care plans updated December 2010 showed staff planned the following interventions: - Provide catheter care every shift and as needed; - Secure catheter to thigh to prevent pulling on tubing; - Change catheter monthly and as needed; - Continue to re-educate on importance of complying with care; - Keep collection bag below level of bladder. Review of the resident's nurses notes dated 12/09/10 at 11:21 P.M., showed staff documented the "resident noted to have severe laceration x 2" to the catheter insertion site "with dark tissue noted. No drainage or bleeding. Extreme pain with cleansing of area with warm compresses. Urology consult request sent to resident's physician." Review of the resident's nurses notes dated 12/13/10 at 9:04 A.M., showed staff documented a "late entry" for 12/10/10. Staff recorded they assessed the condition of the resident's catheter insertion site was "caused from long term Foley catheter use. The resident's physician was notified. No new orders at this time." Review of the resident's treatment record dated 12/01/10 through 12/31/10 staff transcribed physician orders [REDACTED]. - Change Foley catheter every month; - Record Foley catheter output every shift; - Provide Foley catheter care every shift and as needed. Further review of the December 2010 treatment record showed staff documented they only provided Foley catheter care a total of 55 times out of a possible 66 opportunities for catheter care. In addition, staff documented they only measured catheter output 59 times out of a possible 72 opportunities. Record review of the resident's medical record showed he/she was transferred to the hospital on [DATE] unrelated to problems with his/her catheter. Review of the resident's hospital consultation report dated 12/15/10 showed the resident's hospital physicians recorded the following information: - [MEDICAL CONDITION]: "Has chronic kidney failure with a Foley catheter in place with Foley erosion" to his/her "meatus." - Skin comments: The patient's catheter insertion site was "red, inflamed, bleeding noted, black area noted to tip, scant bleeding noted. Looks as though the (insertion site) is eroded on anterior side." Review of the resident's hospital urology consultation report dated 12/16/10 showed the urologist recorded the following information: -"The nursing staff here reports that the catheter was in poor condition" when the resident arrived. - Genitalia: "Dorsal erosion" (external or internal destruction of a surface layer by physical or [MEDICAL CONDITION] processes) of the catheter insertion site from "chronic traction of the Foley catheter. There really was no discernible (gender specific anatomy). The catheter essentially eroded through the entire (gender specific anatomy)" at the catheter insertion site. - "Adequate nursing care with relief of the traction on the catheter would prevent further erosion." During an interview on 01/04/11 at 12:20 P.M., Licensed Practical Nurse (LPN) A said he/she expected all three shifts to document Foley completion of catheter care and catheter changes on the treatment record. During an interview on 01/04/11 at 12:25 P.M., Certified Nurse Assistant (CNA) B said he/she completed catheter care when he/she completed perineal cleansing. CNA B said staff should "strap" the resident's catheter tubing to his/her thigh. During an interview on 01/04/11 at 1:20 P.M., LPN C said when he/she assessed the resident's catheter insertion site on 12/10/10, there was a "fistula" (an abnormal tubelike passage from a normal cavity to another cavity) "about the size of a pea." LPN A said the "fistula" was caused by pulling or tugging on the catheter tubing. LPN C said he/she would see the resident in his/her wheelchair "squirming" around and the resident would say he/she was in pain from the catheter tubing being pulled on. Observation on 01/04/11 at 7:45 A.M, showed the resident sat in his/her wheelchair in his/her room. Additional observation showed cloudy yellow urine with sediment in his/her Foley catheter tubing. CNA D and LPN C transferred the resident to bed. CNA D placed the resident's Foley catheter bag on the resident's bed, threaded the catheter bag and tubing through the resident's pants leg then held the catheter bag above the resident's head (allows urine in the tubing to flow back into the bladder increasing the risk of infection) as he/she continued to remove the resident's pants. CNA D did not follow the facility's Foley catheter care policy by not maintaining the catheter bag below the resident's bladder level. In addition, the resident's Foley catheter tubing was not secured to his/her thigh as directed by the facility's Foley catheter care policy and the resident's plan of care. During an interview on 01/06/11 at 8:30 A.M., LPN E, the consulting urologist's nurse, said he/she assessed the resident on 12/16/10 while the resident was in the hospital. LPN E said dorsal erosion of the catheter insertion site was caused by pulling or tugging on the urinary catheter tubing. LPN E said dorsal erosion was also caused by the catheter tubing not being anchored securely and correctly to the resident's thigh. LPN E said the tubing should be positioned in alignment with the insertion site and guided away from the insertion site, not towards the insertion site which causes pressure from the tubing being pulled against the site. LPN E said the erosion was a slow process caused by long term catheter use. 4. Record review of Resident #2's physician's orders [REDACTED]. - Insert Foley catheter due to [MEDICAL CONDITION]; - Change the catheter monthly and as needed; - Provide Foley catheter care every shift. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/07/11 showed staff assessed the resident as follows: - Confused; - Dependent on staff for assistance with toileting needs including management of his/her indwelling urinary catheter. Review of the resident's plan of care updated January, 2011 showed staff planned the following interventions for the resident: - Secure catheter to thigh to prevent pulling on tubing; - Change catheter monthly. Observation on 01/04/11 at 7:00 A.M., showed the resident lay in bed. The resident's Foley catheter tubing was not secured to his/her thigh as directed by the facility's Foley catheter care policy and the resident's plan of care. Observation on 01/04/11 at 3:00 P.M., showed the resident lay in bed. The resident's Foley catheter tubing was not secured to his/her thigh as directed by the facility's Foley catheter care policy and the resident's plan of care. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Provide Foley catheter care every shift; - Measure Foley catheter output every shift; - Change the catheter every month and as needed. Further review of the resident ' s November 2010 MAR indicated [REDACTED]. Staff only documented they completed catheter care 81 times out of a possible 90 opportunities for catheter care. In addition, staff only documented they measured catheter output 81 times out of a possible 90 opportunities. Review of the resident's MARs dated 12/01/10 through 12/31/10 showed staff transcribed physician orders [REDACTED]. - Measure Foley catheter output every shift; - Change the Foley catheter every month. Further review of the resident ' s December 2010 MAR indicated [REDACTED]. In addition, staff only documented they measured Foley catheter output 47 times out of a possible 72 opportunities. 5. Record review of the Resident #3's physician's orders [REDACTED]. - Insert Foley catheter due to [MEDICAL CONDITION]; - Change the catheter monthly and as needed; - Provide Foley catheter care every shift. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/02/10 showed staff assessed the resident as follows: - Frequently incontinent of urine; - Required extensive assistance of staff for toileting; - Did not have an indwelling urinary catheter. Review of the resident's plan of care updated January, 2011 showed staff planned the following interventions for the resident: - Apply leg strap to secure catheter tubing in place; - Provide Foley catheter care every shift and as needed; - Change catheter monthly. Observation on 01/04/11 at 9:45 A.M, showed the resident lay in bed. The resident's Foley catheter tubing was not secured to his/her leg as directed by the facility's Catheter Care policy and the resident's plan of care. Observation on 01/04/11 at 1:40 P.M, showed the resident lay in bed. The resident's Foley catheter tubing was not secured to his/her leg as directed by the facility's Catheter Care policy and the resident's plan of care. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Provide Foley catheter care every shift and as needed; - Measure Foley catheter output every shift; - Change the Foley catheter every month. Further review of the resident ' s November 2010 MAR indicated [REDACTED]. In addition, staff only documented they measured Foley catheter output 76 times out of a possible 90 opportunities. Staff only documented they provided catheter care 76 times out of a possible 90 opportunities. Review of the resident's MAR indicated [REDACTED] - Provide Foley catheter care every shift and as needed; - Measure Foley catheter output every shift; - Change the Foley catheter every month. Additional review of the resident ' s December 2010 MAR indicated [REDACTED]. Staff only documented they provided catheter care 81 times out of a possible 93 opportunities. 6. During an interview on 01/07/11 at 1:30 P.M., the Director of Nursing (DON) said she expected staff to follow physician's orders [REDACTED]. The DON said she expected staff to follow the facility's Foley catheter care policy. The DON said she expected staff to notify the physician of changes in condition. MO 367