Every finding on record at Country Club Rehab and Healthcare Center

Based on interviews, and record review the facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Service department; and failed to ensure the Dietary Department had received adequate training and/or skills competency verification to ensure they were able to prepare and serve foods to residents in accordance with planned menus and their associated recipes. This deficient practice had the potential to affect 64 of 65 residents who received oral nutrition prepared and served by the facility's dietary department. The facility census was 65 residents. Review of the facility's policy titled Dietary Department - General, revised on [DATE], showed: -Policy: The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -Procedure: --Training Program ---The Dietary Manager and/or Dietitian are responsible for planning and providing dietary staff with in-service education It is recommended that in-services take place on a monthly basis. ii. Part-time and off-duty employees are required to participate in in-services. ---In-service topics may include: Resident rights. Infection Control/Food Safety v. Sanitation. Nutritional needs of the elderly. Physician ordered diets. ---The Dietary Manager is also responsible for the day-to-day education of dietary staff regarding topics such as sanitation, food preparation, etc. ---Records of in-service training will be maintained by the Dietary Manager. Training records should include a sign in sheet, date, time, duration, description, and a copy of the material presented (if applicable). 1. Review on [DATE] at 3:08 P.M. of Dietary [NAME] P's personnel file showed: -Her/his hire date was [DATE]. -There was no signed job description in this personnel file for any position. -There was not a copy of any Food Handler's Card or any evidence of training or orientation for the [NAME] position. 2. Review on [DATE] at 3:12 P.M. of Dietary [NAME] I's personnel file showed: -Her/his hire date was [DATE]. -A Dietary Sanitation Orientation Checklist, which was checked off for successful completion of all tasks effective [DATE]. -There was no signed job description in this personnel file for any position. -There was not a copy of any Food Handler's Card. 3. Review on [DATE] at 3:16 P.M. of Dietary Aide V's personnel file showed: -Her/his hire date was [DATE]. -There was no signed job description in this personnel file for any position. -There was no copy of any Food Handler's Card or any evidence of training or orientation for this position. 4. Review on [DATE] at 3:19 P.M. of Dietary Aide J's personnel file showed: -Her/his hire date was [DATE]. -There was no signed job description in this personnel file for any position. -There was no copy of any Food Handler's Card or any evidence of training or orientation for this position. 5. Review on [DATE] at 4:02 P.M. showed: -State Food Safety Food Handlers Cards for three dietary employees. --The Dietary Manager (DM) (dated [DATE]). --Cook I (dated [DATE]). --Dietary Aide U (dated [DATE]). -A screenshot of a directive from the [NAME] County Health Department, which showed the Food Safety Training Course was required to be completed by 25% of food handlers staff on duty at any given time. During an interview on [DATE] at 4:02 P.M. the Administrator and Regional Nurse W said: -The DM and/or [NAME] I were on duty every day. -The DM's Food Safety Food Handlers Card had expired and was renewed on [DATE]. -He/She did not know when the DM's card had expired. -There were no orientation checklists for dietary staff other than [NAME] I, as s/he was the most recently hired dietary staff member. -The facility did not have staff members sign job descriptions. -The Regional Dietary Manager (RDM) came to the facility on ce a month to conduct sanitation audits and provide training to dietary staff. -The RDM did not maintain any physical records of the training. Review on [DATE] at 4:13 P.M. of communication from the RDM showed: -After the dietary manager completed training and competencies for the dietary staff utilizing the attached checklist, he/she reviewed and assessed the employee's comprehension. If further training was needed, it would be conducted by himself/herself or the dietary manager. -During weekly visits he/she would oversee the following items when present at the facility: --Menu extensions and recipes. ---If menu substitutions are needed. --Sanitation Walkthroughs with reports. --Monitoring the meal service while in building. ---Checking food temps. ---Quality of food. ---Timeliness. --Receiving feedback from residents.

Based on observation, interviews, and record review, the facility failed to designate a qualified person to serve as the Director of Food and Nutrition Services. The facility did not employ a qualified Dietitian or other clinically qualified nutrition professional on a full-time basis, The facility census was 65 residents. Review of information titled, Director of Food and Nutrition Services Qualifications, and posted on 2/16/24 by the Missouri Department of Health & Senior Services (https://ltc.health.mo.gov/archives/16528), found the following: -We have recently received in influx of questions related to the qualifications for director of food and nutrition services in skilled nursing facilities. The federal regulation requires one of the following qualifications (if a qualified dietician or other clinically qualified nutrition professional is not employed full-time): --A certified dietary manager. --A certified food service manager. --Has similar national certification for food service management and safety from a national certifying body. --Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. --Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. -Centers for Medicare & Medicaid Services (CMS) has noted that the approved certifications and course requirements would be the equivalent of a ServSafe Food Manager certification. Additional food manager courses we have found to meet the requirements include: AAA Food Handler, Learn2Serve, and State Food Safety. 1. Observation on 3/11/25 at 11:44 A.M. showed: -He/She had facial hair and was not wearing a beard guard while in the kitchen where food was being prepared. During an interview on 3/11/25 at 11:44 A.M. the Dietary Manager (DM) said: -He/She had been in the role for about a year. -He/She was currently enrolled in a Certified Dietary Manager course. During an interview on 3/11/25 at 12:26 P.M. the DM said: -He/She was able to order beard guards. -He/She did not know he/she needed them. -He/She had always worked in setting that did not require them, like restaurants. During a telephone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian (RD) said: -In January 2025, he/she took over for another RD to serve as the Consultant RD for the facility. -When he/she took over as Consultant RD for the facility, he/she tried to verify which Certified Dietary Manager or certified food service manager course that the DM was enrolled in, as it was necessary for him/her to also take over the role of the Dietary Manager's preceptor of that course. -He/She was not able to serve as the preceptor for DM E since assuming the Consultant RD duties in January. -He/she visited every other week as the Consultant RD. -He/she learned that the DM was enrolled in an out of state university course and the DM had printed off the form needed to transfer his/her (the DM) preceptorship under his/her (the RD) license. On 3/13/25 at 4:44 P.M. the surveyor requested: -Copies of licenses and/or certifications (including ServSafe certification) for the RD and the DM. -Evidence of the DM's current enrollment in an accredited course. -Evidence of routine consultation by a Registered Dietitian provided to the DM for the past 12 months or since he/she assumed the role of the DM, if it had been less than 12 months. Review of the DM's personnel file on 3/14/25 showed: -There was no position description in the DM's personnel file. -It was unclear on what date the DM formally assumed duties as the facility's Dietary Manager. -In lieu of a signed and dated position description, there was a single-page untitled document, signed by the DM as Candidate, with a handwritten date of 2/29/21. This document contained the following information: --Show competence, understanding and/or improvement in the following areas over the next 30 days. Training will be provided by members of sister facility food service team. ---Kitchen cleanliness: ----Ensure staff are completing cleaning logs every shift. ----Assist in re-organization of storage. ----All logs were completed (temp [temperature], cleaning, dishwasher etc). ----Ensure items were dated and stored in proper containers. ---Meal service: ----Ensure all residents menus are received prior to the start of meal service. ----Ensure items on always available' menu are available upon request. ----Ensure staff are using proper handling techniques. ----Ensure temps are being monitored throughout meal service and food temp log complete. ----Ensure staff are using proper portion sizes when serving. ---Meal prep/cooking: ----Create prep schedule based off menu to decrease amount of time needed to cook. ----Ensure menu is being followed and food is palatable and visually appealing. ----Ensure altered diets are correct consistency and palatable. ---Other: ----Staff schedule should be made out and available to staff at least 2 weeks in advance. Any changes that need to be made must be communicated directly with staff. ----Dietary menus/resident tickets need to be updated daily and as needed. ----Attend Care plan meetings. ----Complete User Defined Assessments (UDA) in Point Click Care (PCC an electronic health record platform). ----Attend Risk management. ----Attend daily stand up and stand down meetings. ----Monitor food costs, limit waste, over ordering/under ordering. ----Cover holes in the schedule if they can't be filled by staff. ----Staff education and in-services on a monthly basis and as needed. ----Familiar with food service regulations and health code. ----Weekly meetings with administrator on Thursday at 2:00 P.M -NOTE: The personnel file did not contain copies of any diplomas or certifications currently held by the DM as evidence that he/she was qualified to serve as a Director of Nutrition and Food Service in a long-term care facility. -There was a copy of correspondence dated 6/10/24, granting approval of tuition reimbursement for the cost of attending a course titled Nutrition and Foodservice Professional Training (NFPT) Pathway 1, which would prepare her/him for taking the Certifying Board for Dietary Managers Certified Dietary Manager (CDM) Credentialing Exam.

Based on observation, interview, record review, the facility failed to ensure meals were prepared in accordance with planned menus approved by the Consultant Dietitian using the corresponding recipes for the menu items, which resulted in foods not being attractive and palatable when served. This deficient practice had the potential to affect 64 of 65 residents who received oral nutrition prepared and served by the facility's dietary department. The facility census was 65 residents. Review of the facility's policy titled Dietary Department - General, revised on 10/24/22, showed: -Policy: The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: --Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. --Provision of effective supervision and training of food service personnel. -Organizational Structure --The Administrator is responsible for the overall operation of the Facility. The Dietary Manager reports to the Administrator. --The Dietary Manager is responsible for the oversight of the dietary department In the Dietary manager's absence, the cook on duty assumes oversight responsibility for the dietary department. --Cooks and dietary aides report to the Dietary Manager. Dietary aides are held accountable by the cooks for the implementation of meals. --The Dietitian assumes the professional and ethical responsibility of the overall nutritional care of the residents. The Dietitian may make recommendations for departmental organization, but does not have the authority to implement such recommendations. 1. Review of the Diet Spreadsheet that included 3/11/25's lunch meal showed: -Residents with a diet order for regular texture food were to receive: --Beef & Broccoli Stir Fry - #8 dip x 2 (was equivalent to one (1) cup serving size) --Vegetable Fried [NAME] - #8 dip (#8 dip was equivalent to one-half (1/2) cup serving size). --Egg Roll - 1. --Banana Pudding - #8 dip. -Residents with a diet order for mechanical soft food were to receive: --Ground Beef & Broccoli Stir Fry w/Gravy - #8 dip x 2 with Gravy. --Rice with Gravy - #8 dip. --Bread & Margarine - 1 slice/1 teaspoon. --Banana Pudding - #8 dip. -Residents with a diet order for pureed food were to receive: --Pureed Beef & Broccoli Stir Fry w/Sauce - #8 dip x 2. --Pureed Vegetable Fried [NAME] - #10 dip (three-eights (3/8) cup serving size) --Pureed Banana Pudding - #8 dip. Observation on 3/11/25 of the steamtable prior to the start of the trayline for the lunch meal showed: -At 11:53 A.M. [NAME] I began measuring hot food holding temperatures with the following results: --White rice - 177 F (degrees Fahrenheit). --Broccoli - 191 F. --Ground beef in a sauce, which [NAME] I called Teriyaki Beef - 193 F. --Egg roll - 143 F. --Brown gravy - 191 F. --Temperatures were not measured for pureed foods at that time, as these items had not yet been prepared. --The ground beef in sauce and the broccoli were prepared, hot-held, and served separately. Broccoli was plated next to the white rice, the Teriyaki Beef was spooned over the rice, and an egg roll was placed on the plate. --No Vegetable Fried [NAME] was prepared or served, although at least one bag of this frozen product was observed during a tour of the walk-in freezer at 11:07 a.m. on 3/11/25. 2. Observation on 3/11/25 at 2:14 P.M. showed Resident #30: -Was in her/his room sitting on the edge of the bed in front of a plate of food on the overbed table. -On the resident's plate was white rice, ground beef, and an egg roll cut into small pieces. During an interview on 3/11/25 at 2:14 P.M. the resident who was in his/her room said: -The meal was OK if you liked rice. 3. Review on 3/13/25 at 12:45 P.M. of the recipes for the food items served for lunch on 3/11/25 showed: -The Beef & Broccoli Stir Fry and the Vegetable Fried [NAME] menu items were not prepared and served in accordance with the recipes for this meal. -The instructions for preparing this entree were as follows: --In a large bowl, combine cornstarch (1st listed), water, and garlic powder with wire whisk; mix well until smooth. Set aside until ready to use. --Toss beef with cornstarch mixture to coat beef evenly. --Heat oil (1st listed) in saucepan or stockpot. Add beef and stir fry until no red juice remains and desired internal temperature is reached. --Remove beef from pan with slotted spoon and place in a clean and sanitized food processor. Grind to size of fine hamburger. Add small amount of prepared beef broth to moisten and reheat to 165 F for < [greater than] 1 second. Cover and hold until ready to use. --In same saucepan or stockpot, heat oil (2nd listed) in skillet. Add thawed broccoli and onion. Stir fry until vegetables are crisp-tender; return ground beef to saucepan. --In bowl, whisk together soy sauce, brown sugar, cornstarch (2nd listed), ginger, and water (2nd listed) with wire whisk until smooth. Add to skillet with ground beef. --Cook 3-5 minutes, stirring frequently until desired internal temperature is reached. -The Regular Textured Vegetable Fried [NAME] instructions for preparing this side dish were: --Prepare Vegetable Fried [NAME] according to the package instructions. -The [NAME] with Gravy, which was to have been served to only those residents with orders for mechanical soft diets instructions for preparing the side dish were: --Place rice in pans; add salt, oil and margarine. Pour hot water over rice; stir. --Cover with foil and bake for 1 hour or steam uncovered for 40 minutes. Fluff with a fork. --Portion #8 dip cup rice onto plate; ladle 2 oz [ounce] prepared gravy over rice. -The Pureed Beef & Broccoli Stir Fry w/Sauce instructions for preparing this entree were: --Combine water and beef base to make broth. --Place prepared beef and broccoli stir fry in a washed and sanitized food processor; gradually add broth. --Blend until smooth. --The entree was to be plated, with the prepared sauce ladled over it. -The Pureed Vegetable Fried [NAME] instructions for preparing this side dish were: --Place prepared rice in a washed and sanitized food processor. --Mix chicken base and hot water to make broth. --Gradually add broth to mixture and blend until smooth. During an interview on 3/13/25 at 1:19 P.M. [NAME] I (who had prepared the lunch meal on 3/11/25) said: -The only meat he/she used to prepare all textures of this meal was hamburger. -He/She did not know they were supposed to prepare Vegetable Fried Rice. -He/She did not have the recipes for any of the food items on the menu for that meal. -He/She did not always have access to the recipes. 4. Observation on 3/12/25 evening meal showed: -At 5:54 P.M. Resident #43 was lying in bed with her/his overbed table within reach. -On the overbed table was a black dinner plate on which were two scoops of pasta with a stiff cream sauce (no liquid noted) and one breadstick. -On a cafeteria tray on the overbed table was a Styrofoam bowl containing four slices of pears covered with a red powder. -The meal ticket identified that the resident had a diet order for a Regular Diet, with Regular Texture, and Thin Liquids. -The menu on the meal ticket identified that the resident was to have been served: Chicken [NAME] over Pasta, Caesar Salad, Blushing Pears, Breadstick, and Milk/Beverage. During an interview on 3/12/25 at 5:54 P.M. the resident said he/she had not been served a salad with the meal. During an interview on 3/13/25 at 1:54 P.M. the DM and [NAME] P said: -Resident #43's meal ticket showed the resident was on a Regular Diet with Regular Texture, and Thin Liquids; no items were circled on the tray ticket to identify the resident's personal preferences. -The resident received two scoops of pasta mixture, a single breadstick, blushing pears, and no Caesar salad. -Resident #43 had the option to be served the following regular menu items: Chicken [NAME] over Pasta, Caesar Salad, Blushing Pears, and a Breadstick. -If the meal ticket was not filled out, we were supposed to ask, or have someone ask the resident what they wanted in order to not take away their right to choose. 5. During an interview on 3/12/25 at 5:58 P.M. Resident #17 said the pasta was dry. I don't like Caesar salad. The breadstick wasn't hard like the last time. The pears were good. 6. Observation on 3/12/25 at 6:00 P.M. showed: -Resident #30 was in her/his room as he/she was eating dinner. -He/She was served a scoop of pasta mixture (from which he/she had already consumed some the entree), a salad, and pears. 7. During an interview on 3/13/25 at 1:58 P.M. [NAME] P said: -He/She prepared plates on 3/12/25 evening meal. -The resident's who were served mechanical soft diets were the ones that had sauce poured over the noodles. -He/She had not followed the recipe he/she just mixed it all together. During a telephone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian (RD) said: -He/She had assumed responsibility for the facility in January 2025 and that s/he had been watching meal service with respect to timeliness of meal service. -He/She expected staff to follow planned recipes to correspond with the planned menus for each meal. MO00249108

Based on observation, interview, record review and performance of test trays to evaluate the quality of foods at the point of service, the facility failed to develop and implement a process for ensuring residents received foods that were flavorful, palatable, attractive, and at a safe and appetizing temperature. The facility census was 65 residents. Review of the facility's policy titled, Dietary Department - General, revised on 10/24/22, found: -The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: --Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. --Provision of effective supervision and training of food service personnel. --The Administrator is responsible for the overall operation of the Facility. The Dietary Manager reports to the Administrator. --The Dietary Manager is responsible for the oversight of the dietary department. In the Dietary Manager's absence, the cook on duty assumes oversight responsibility for the dietary department. --Cooks and dietary aides report to the Dietary Manager. Dietary aides are held accountable by the cooks for the implementation of meals. 1. Review of the facility's Grievance Logs for the preceding six months found multiple complaints regarding foods being cold and/or not palatable at the point of service as follows: - On 9/25/24 9:30 A.M. - Breakfast - no menu - checked nurse's station. Don't believe the tray had ever been in the heated cart. Plate was cold scrambled eggs & bacon & toast. The 'toast' was a heel, the consistency of [NAME] toast. Note two of my dislikes are scrambled eggs & white bread. I ate the cold oatmeal with a fork. Glazed ham, scraps served in a pool of glaze (sugar) ice cream scoop of broccoli mush (maybe left over from lunch yesterday & reheated?). -On 9/25/24 at 7:15 P.M. Called nurse's station. My roommate & I have not received supper trays. --At 7:20 P.M. a nurse brought vegetable soup & salad. No coffee left so made my own instant. - On 9/28/24 Hall tray brought at 9:45 A.M. Ticket for breakfast lost. Received scrambled eggs & oatmeal on plate. Scrambled eggs is on dislikes. -On 9/30/24 Supper there was no protein served, misrepresented fruit, egg & cheese casserole, mostly bread, couldn't really find egg & cheese. Fresh fruit cup was canned. -On 12/15/24 Was told by the Dietary Manager at the Culinary Meeting when we have fried chicken we can put down what meat that we request. I put down breast meat but they sent me dark meat, so the only thing I ate was the mashed potatoes. On 1/4/25 Lunch Cheesy brown potatoes' was actually instant mashed potatoes with a little cheese mixed in. Spinach not on my plate. Supper was so bad I took a picture. Garden vegetable soup 1 tablespoon (scant) of chopped bell pepper in taupe colored broth. A brownie sundae always sounds good. All it was, was a brownie, I even requested vanilla ice cream but of course didn't get it. -On 2/21/25 Our breakfast was bad. I didn't have all the items I was suppose to get. What I did get was barely warm & most of it was cold. Another unknown resident only got one thing that he/she had ordered. Most of his/her breakfast was missing. I rarely get food that is warm. This happens most of the time. Don't understand why food has to come cold. Our lunch came later & was completely cold. -On 3/4/25 Supper Patty melt, meat was half raw. French fries were cold/hard under cooked. Observation on 3/14/25 of test trays for the lunch meal showed: -The meal was to include the entree and the vegetable in both regular and pureed textures. -The temperatures for food items on the test trays were obtained by [NAME] I in the presence of the Dietary Manager and the surveyor. -Prior to leaving the kitchen, [NAME] I measured the temperatures of all items plated on the test trays. --Regular textured foods were measured beginning at 1:29 P.M. with the following results: ---Turkey a la King over [NAME] - 148 F (degrees Fahrenheit (F)). ---Mixed Vegetables - 143 F. --Pureed textured foods were measured beginning at 1:32 P.M. with the following results: ---Turkey ala King over [NAME] - 154 F; ---Green Beans - 153 F. --Also served on each tray was bread in the form of a dinner roll on the regular tray and a pureed dinner roll on the pureed tray. --After the temperatures were measured and recorded, the test trays were loaded on the bottom of a heated cart set to 140 F. -The Dietary Manager and the surveyor accompanied the heated cart as it left the kitchen. -The heated cart arrived on the 100 Hall at 1:35 P.M. and was plugged in. -The first tray was not removed for delivery until 1:38 P.M. -Initially only two nursing staff members removed the meal trays from the heated cart, poured beverages, and delivered trays to the residents' rooms. -At 1:45 P.M. a nurse pulled one of the staff members off the floor, and another staff member came out of a room and assisted in passing trays. -Two staff members arrived at 1:49 P.M. to assist in meal distribution. --Each time a new staff member arrived to assist, they opened the door to the cart and started shuffling through the trays. -At 1:53 P.M., the heated cart was moved to the 200 Hall and was plugged in and trays were delivered. -At 1:57 P.M., the heated cart was moved to the 300 Hall and was plugged in and trays were delivered. -At 2:04 P.M., the heated cart was moved to the 400 Hall and was plugged in and trays were delivered. -The last resident meal tray was delivered at 2:09 P.M. -The Dietary Manager and the surveyor removed the test trays from the heated cart, and the Dietary Manager measured the temperatures as follows: --Pureed Turkey a la King - 115 F at 2:10 P.M. --Pureed [NAME] Beans - 117 F at 2:11 P.M. --Regular Turkey a la King - 117 F at 2:11 P.M. --Regular Mixed Vegetables - 116 F at 2:12 P.M. During an interview on 3/14/25 at 2:12 P.M. the Dietary Manager said: -All hot foods should have been at 135 F or higher at the point of service to the residents. -All the items on the test trays were well below the acceptable hot holding temperature of 135 F. Observation on 3/14/25 at 2:15 P.M. the test trays were taste tested and showed: -Regular Mixed Vegetables lacked color, flavor, and seasoning. -Regular Dinner Roll was doughy and undercooked. During an interview on 3/14/25 at 2:20 P.M. the Dietary Manager said: -The Regular Mixed Vegetables lacked seasoning. -The Regular Dinner Roll looked undercooked. MO00249108

Based on observation, interview, and record review, the facility failed to ensure staff working in the kitchen effectively restrained their hair, including facial hair, to prevent contamination of food during food preparation and service; failed to ensure staff performed hand hygiene and used single-use gloves appropriately for food safety; failed to prepare and serve foods under sanitary conditions; failed to store Time and Temperature Control for Safety (TCS) foods in refrigerators within the appropriate temperature range to promote safety; failed to routinely monitor and record food temperatures when held on the steam table prior to service; and failed to routinely monitor and record the concentration of the sanitizing solutions used in the low temperature dish machine and in the three-compartment pots and pans sink. The facility census was 65 residents. Review of the facility policy titled, Dietary Department - General, revised on 10/24/22, showed: -The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: --Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. --Maintenance of standards for sanitation and safety. --Maintenance of standards for quality of food. --Provision of effective supervision and training of food service personnel. -The Administrator is responsible for the overall operation of the Facility. The Dietary Manager reports to the Administrator. -The Dietary Manager is responsible for the oversight of the dietary department. In the Dietary manager's absence, the cook on duty assumes oversight responsibility for the dietary department. -Cooks and dietary aides report to the Dietary Manager. Dietary aides are held accountable by the cooks for the implementation of meals. -Concerns with other departments should be addressed to the appropriate department manager. -The Dietitian assumes the professional and ethical responsibility of the overall nutritional care of the residents. The Dietitian may make recommendations for departmental organization, but does not have the authority to implement such recommendations. -Employee Hygiene During Food Preparation and Service. --Employees should never use bare hand contact with any foods, ready to eat or otherwise. --Food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. However, staff do not need to wear hairnets when distributing foods to residents at the dining table(s) or when assisting residents to dine. --Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. Gloves are necessary when directly touching ready-to eat food and when serving residents who are on transmission-based precautions. staff do not need to wear gloves when distributing foods to residents at the dining table(s) or when assisting residents to dine, unless touching ready-to-eat food. Disposable gloves are a single use items and should be discarded between and after each use. Review of the facility policy titled, Hand Hygiene, revised on 10/24/22, showed: -The Facility considers hand hygiene the primary means to prevent the spread of infections. -Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -Facility Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy. -Facility Staff, visitors, and volunteers must perform hand hygiene procedures in the following circumstances: --Wash hands with soap and water: Before and after food preparation; In between glove changes. -The use of gloves does not replace hand hygiene procedures. -Washing Hands: --The following equipment and supplies are necessary when performing this procedure: Running water Soap (anti-microbial or non-antimicrobial) Paper towels Trash can. --Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. --Discard towels into trash. Review of the facility policy titled, Cleaning Schedule, revised 10/24/22, showed: -The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager. --The Dietary Manager will develop a cleaning schedule that includes the frequency of which equipment and areas are to be cleaned. --The cleaning schedule is posted weekly. --The cleaning schedule includes tasks assigned to specific positions with the dietary department. --Dietary staff will initial next to the assigned task once it is completed. -The Dietary Manager monitors the cleaning schedule to ensure compliance. Review of the facility policy titled Refrigerator/Freezer Temperature Records, revised on 10/24/22, showed: -The Dietary Manager or designee is to record daily all refrigerator and freezer temperatures on DS - 53 - Form A - Refrigerator/Freezer Temperature Log during A.M. and P.M. shifts. -The freezer temperature must be 0 F [degrees Fahrenheit] or below. -The refrigerator temperature must be 41 F or below. -Temperatures above these areas are to be reported to the Dietary Manager immediately. -Note on the temperature forms the plan of action taken when temperatures are not in acceptable range. -Corrective action should be taken to correct the temperature or the items should be moved to another storage area to maintain acceptable temperature. Review of the facility policy titled Food Temperatures, revised on 10/24/22, showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. -Measuring Food Temperature: --It is recommended to use a thermometer with a practical range of 0 F to 220 F. --Insert the thermometer into the center of the product. --Allow time for stabilization. Wait until there is no movement for 15 seconds. Several readings may be required to determine hot and cold spots. --Record the reading on DS - 16 - Form A - Food Temperature Log at the beginning of the tray line. --Take the temperature of each pan of product before serving. --Re-sanitize the thermometer after each use. Review of the facility policy titled Dish Machine Operation and Cleaning, revised 10/24/22, showed: -The dietary staff will use the dish machine according to the manufacturer's guidelines. The dish machine will be sanitized between uses. -Routinely monitor soap, sanitizer and rinse agent to ensure adequate supply throughout operation of the dish machine. 1. Observation on 3/11/25 at 10:03 A.M. during the initial tour of the kitchen with Assistant Administrator T showed: -Dietary staff used a heavily soiled white garbage barrel with a lid that had to be lifted by hand to discard paper towels after washing their hands. -No trash receptacle was readily available near the handwashing sink that did not require manually lifting the lid with their hands before use. -Dietary Aide K, had with facial hair that appeared to be longer than 0.25 inch, was wearing a hairnet but not a beard guard. -The walls and floors of the kitchen, both behind and under wheeled/movable equipment, as under and behind stationary storage racks and appliances, were heavily soiled with dirt. -The removable grease filters in the range hood were heavily soiled, with thick build-ups of grease running down from the bottoms of the grease filters. -The top of the Vulcan convection oven, on which were stored an open box of paper sheet pan liners and several oven mitts, was visibly soiled with a coating of debris that, when tested with a fingertip, was greasy and easily removed. The box of pan liners was visibly soiled with grease/oil stains all over the box. -Two wire utility carts in the dishwashing area, which were used to hold clean dishes after they were washed, were rusted and soiled with a sticky, greasy substance on the supports; this substance was easily removed by rubbing with a fingertip. -A 3-shelf pink hard plastic cart, on which were stored hot beverage dispensers for coffee and hot chocolate, trays of clean coffee mugs, and a gray multi-section storage bin containing individually packaged items such as sugar packets, tea bags, etc., had multiple broken sections of plastic with jagged edges exposed, and all shelves were heavily soiled and stained with what appeared to be dried coffee spills. -Plastic carts parked just outside the kitchen and in the dining room, which were used to stage food trays prior to being delivered to the residents in the dining room, were heavily soiled, as was the wall behind the carts. -The walk-in refrigerator unit was not working. The walk-in refrigerator unit needed a new fan, even though it had just recently been repaired, and the facility was storing refrigerated food items in residential refrigerators in an unoccupied resident room on the 600 Hall (Assisted Living). --The walk-in freezer had food on the floor under the wire storage racks (e.g., loose frozen yellow vegetables (squash slices), bags of frozen Brussel sprouts, etc.). --Also on the floor in the walk-in freezer was a large puddle of frozen liquid, loose cardboard scraps, a single-serve cup of yogurt, and several pink and blue plastic reusable ice cubes. --On the wire storage racks were meats that were not in their original packaging, which included pieces of poultry (which were later identified as being turkey) in a large resealable baggy, two partial rolls of ground meat wrapped in plastic wrap, and a large rectangular package of beef; none of these items was labeled or dated. --One of the small rolls of meat, which was wrapped in green paper inside the plastic wrap appeared to be sausage. The other small roll of meat appeared to be ground beef, and the end of the roll was notably [NAME] in appearance than the rest of the roll. Observation on 3/11/25 of the refrigerators in the unoccupied room on 600 hall (room [ROOM NUMBER]) with Assistant Administrator T showed: -At 10:14 A.M. Refrigerator #1 had an internal thermometer that read 54 F (verified by Assistant Administrator T). The contents of the refrigerator included: --Eight bags of shelled hard-boiled eggs which were stored in the door's shelves (each contained a dozen eggs). An opened box containing trays of raw eggs, bulk containers of salad dressing, a bulk container of pimento cheese salad, and one-gallon jugs of milk. ---There was no refrigerator temperature log on or near the refrigerator. -At 10:16 A.M. Refrigerator #2 had an internal thermometer that read 44 F (verified by Assistant Administrator T). The contents of the refrigerator included: --A large package of sliced American cheese; a bag of hotdogs; loose single-serve containers of yogurt; bulk containers of pimento cheese salad, sour cream, parmesan cheese; a bulk container of orange sections; and a large piece of cardboard that was wet and had ice formed on it. ---Assistant Administrator T removed the cardboard and said that ham had been on top of the cardboard thawing. ----There was no refrigerator temperature log on or near the refrigerator. At 10:18 A.M. Refrigerator #3 had an internal thermometer that read 46 F (verified by Assistant Administrator T). The contents of the refrigerator included: --Meat slices (identified by Assistant Administrator T as being bologna) that were ineffectively wrapped with aluminum foil and not labeled or dated; American cheese slices in a small plastic container that was covered with foil and not labeled or dated; a carton of liquid eggs; a bulk container of salad dressing; and multiple one-gallon jugs of milk. --On the top shelf of the refrigerator was a tray of shell eggs with loose debris which appeared to be particles of food on the tops of the eggs; on the bottom shelf of the refrigerator were an open bag of chopped iceberg lettuce and a bag of shredded cheese, as well as an open carton of liquid eggs with the contents dripped down the front of the carton. ---There was no refrigerator temperature log on or near the refrigerator. During an interview on 3/11/25 at 10:20 A.M. Assistant Administrator T said he/she did not know if there were any temperature logs for the three different refrigerators. Observation on 3/11/25 at 11:44 A.M. showed: -The Dietary Manager had facial hair that was longer than 0.25 inches and was not wearing a beard guard with her/his hairnet. -The Dietary Manager washed her/his hands at the handwashing sink. He/She turned the faucets off with her/his bare hands, obtained a paper towel to dry their hands, then lifted the lid of the white garbage barrel to discard the paper towel. Observation and interview on 3/11/25 showed: -At 11:48 A.M. a bath blanket was on the floor under a preparation sink equipped with a garbage grinder. --At 11:48 A.M. the Dietary Manager said Maintenance was working on a leak. -At 11:49 A.M. Dietary Aide J, who had long black hair and trimmed facial hair did not have her/his hairnet on to effectively restrain all his/her hair in the back; this person was also not wearing a beard guard. -At 11:53 A.M. [NAME] I washed her/his hands and put on a pair of single-use gloves, after which he/she obtained a food thermometer and began measuring hot food holding temperatures with the following results: --Rice - 177 F (degrees Fahrenheit); Broccoli - 191 F; Teriyaki Beef - 193 F ; Egg Roll - 143 F; [NAME] Gravy - 191 F. [NAME] I did not write down any of these holding temperatures at the time he/she took them. -At 11:56 A.M. after taking the holding temperatures, [NAME] I removed the single-use glove from her/his right hand, threw the glove into the trash, applied a new glove to the right hand without performing handwashing or hand hygiene, and started plating the first plate of food. After plating a scoop of rice, [NAME] I left the trayline, used her/his gloved hand to pull open the utensil drawer, obtained a slotted spoodle, pushed the drawer closed, returned to the trayline to dip up, and plated a spoodle full of Teriyaki Beef. [NAME] I left the trayline again to obtain a solid spoodle for the beef and left the trayline again to obtain a pair of tongs to plate an eggroll, again opening and closing drawers, all while in the process of plating the first tray. -After [NAME] I plated the food, he/she passed the plate to Dietary Aide J, who placed the plate on a cafeteria tray on which he/she had already placed a red cloth napkin and a plastic spoon and plastic fork. Dietary Aide J then carried the tray to an open cart just inside the dining room for service to the resident by nursing personnel. [NAME] I and Dietary Aide J prepared three more meal trays in the same manner. -At 12:01 P.M. Dietary Aide J exited the kitchen into the dining room and returned with a heater cart, which he/she plugged in. He/She did not change her/his gloves or wash her/his hands after handling the heated cart and the power cord. Dietary Aide J then walked over to a box of plastic eating utensils, obtained a handful of eating utensils, and carried them over to her/his workstation and placed them in a storage bin. -At 12:09 P.M. the trays were wet as [NAME] I placed the paper tray tickets on the trays. --Cook I said staff sometimes allowed the trays to air dry after washing them. --The Dietary Manager said with the time we have allotted, staff put the trays together while they're still wet. -At 12:09 P.M. Dietary Aide J carried a large container of cottage cheese into the kitchen, opened it, and attempted to scoop a portion out of the container without success because the contents were frozen. --Dietary Aide J said the cottage cheese had come from the back of one of the refrigerators in room [ROOM NUMBER]. -At 12:10 P.M. the surveyor showed the Dietary Manager that the thermometer in Refrigerator #1 in room [ROOM NUMBER] was reading in the 50's while still storing raw and shelled hard-boiled eggs. --The Dietary Manager said that's running hot. I'll need to get maintenance to look at it. -At 12:13 P.M. the Dietary Manager washed her/his hands at the handwashing sink, turned off the spigots with her/his bare hands, obtain a paper towel to dry her/his hands, and lifted the lid of the white garbage barrel with her/his bare hand to throw away the paper towel. -At 12:15 P.M. the Dietary Manager was asked about the log for hot food holding temperatures. --The log dated March 2025 was on a clipboard near the steam table. and had multiple days where the food temperatures were not recorded. -At 12:16 P.M. [NAME] I, while wearing single-use gloves, touched environmental surfaces before he/she placed an egg roll on a resident's plate with tongs. With the same gloved hands, he/she held the egg roll down with her/his left hand while cutting the egg roll into smaller pieces with her/his right hand. After doing this, [NAME] I did not remove her/his gloves, wash their hands, or put on a new pair of single use gloves. -At 12:18 P.M. continuous observation of the trayline found [NAME] I obtained a baked potato from the steam table. while wearing the same single-use gloves, [NAME] I pushed down on the baked potato to spread the potato where the skin had been scored. -At 12:21 P.M. [NAME] I handled egg rolls for two more plates, holding each down with one hand while cutting the egg roll with the other hand. No glove changes or handwashing occurred. -At 12:24 P.M. [NAME] I patted down the rice and broccoli with her/his gloved hand after plating the items on a resident's plate. --At 12:26 P.M. the Dietary Manager said the noon meal food hot holding temperature had not been recorded. -At 12:28 P.M. [NAME] I said he/she had measured the temperatures but had been too busy to write them down. -At 12:30 P.M. the Dietary Manager recorded the holding temperatures using the information the surveyor had recorded while [NAME] I took the temperatures before the start of the meal service. --The Dietary Manager said the March 2025 food temperature log had gotten wet and was shredded, he/she was backfilling the information into the March log. -At 12:32 P.M. the Dietary Manager said he/she could order beard guards, he/she didn't know he/she needed them. He/She had always worked in settings that did not require them. During an interview on 3/13/25 at 1:28 P.M. [NAME] I said during the lunch service on 3/11/25, he/she should have changed gloves and washed his/her hands each time he/she contaminated the gloves. 2. Observation and interview on 3/12/25 of the kitchen with the Dietary Manager showed: -At 12:26 p.m. the Dietary Manager was still not wearing a beard guard when in the kitchen while passing by food preparation, dish washing, and food service areas of the kitchen. -At 12:27 P.M. the Dietary Manager said he/she could not locate the low temperature sanitizing solution log for the dishmachine. He/She tested the concentration of the chorine-based sanitizing solution in the dish machine, by dipping a test strip in the standing water inside the machine which resulted in 100 parts per million (ppm). -At 12:29 P.M. the Dietary Manager dipped a test strip in the sanitizer reservoir during the rinse cycle which resulted in 200 ppm. -At 12:31 p.m., the Dietary Manager tested the concentration of the quaternary ammonium sanitizing solution in the third compartment of the 3-compartment sink where pots and pans were cleaned and sanitized - which resulted in 200 ppm. Review of the Pot and Pan Sanitizer Logs dated 1/1/25 through 3/12/25 showed: -Entries recorded three times a day with entries ranging from 150 ppm to 250 ppm, and with 250 ppm being recorded 15 times in January, 33 times in February, and 16 times in March. -The log did not define what the appropriate range should be, nor what actions were to be taken if the sanitizer's concentration was not at the correct level. Observation on 3/13/25 at 3:20 P.M. of the placard on the dish machine showed: -NSF Machine Operational Requirements as manufactured by American Dish Service. --Wash Temperature: 120 F minimum. --Rinse Temperature: 120 F minimum. --Required: 50 parts per million (ppm) available chlorine rinse. Observation on 3/13/25 at 1:51 P.M. of the test strips used for measuring the concentration of the quaternary ammonium sanitizing solution in the Pot and Pan sinks showed: -The facility used Hydrion (R) QT-44 Quaternary Test Paper manufactured by Micro Essential Laboratory. --Review of the Hydrion (R) QT-44 specification sheet found the following directions for use: Dip a strip of paper into the solution to be test. Hold in still solution for 10-seconds; do not agitate. Remove and immediately compare to color chart. The sanitizer concentration will be associated with the closest matching color. The specification sheet further identified that Color Match Points were available for 0 ppm, 150 ppm, 200 ppm, 300 ppm, and 400 ppm. There was no Color Match Point for 250 ppm. 3. Observation on 3/12/25 at 2:49 P.M. of the walk-in freezer with the Dietary Manager and the Regional Dietary Manager showed: -New boxes of stock received on 3/11/25 had been placed directly on the floor of the freezer. -Loose yellow vegetables (yellow squash slices) and bags of Brussel sprouts were still seen under the racks on the floor in the freezer. -The repackaged meat items observed on 3/11/25 were still present in the freezer without labels or dates. -A cardboard box of hamburger patties was open on a shelf with the inner plastic liner also open, exposing patties to the air. -A cardboard box of frozen vegetables was seen open on a shelf with the inner plastic liner also open, exposing vegetables to the air. -The large puddle of frozen liquid remained on the floor of the walk-in freezer. 4. Review of the hot food holding temperature logs dated January 2025, February 2025 and March 2025 showed: -The January 2025 log had blanks spots for temperatures that should have been recorded for evening meals. -The log for February 2025 was illegible in places and the first few days of March 2025 were recorded on the February 2025 log. -There were blanks on the March 2025 log. --In total, between 1/1/25 and the noon meal on 3/12/25, there were 34 meals for which no food temperatures were recorded and one meal where food temperatures were not recorded for all diet textures served. During an interview on 3/12/25 at 12:41 P.M. the Dietary Manager said: -The food temperature logs for January 2025 and March 2025 were incomplete. -He/She could not recall a specific date but believed the walk-in refrigerator was out of service on the first of March 2025. -A new residential refrigerator had been purchased the previous evening and the repairs needed to the walk-in refrigerator had been completed. -The contents of the defective refrigerator (with temperature reading of 54 F on 3/11/25) had been moved into the new refrigerator. The Regional Dietary Manager directed the Dietary Manager to discard the eggs. 5. During an interview on 3/12/25 at 12:55 P.M. the Regional Dietary Manager said beard guards should be worn by dietary staff with facial hair. 6. During a telephone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian said: -He/she had assumed responsibility for this facility in January 2025 and that he/she had been watching meal service with respect to timeliness of the meals. -He/She had been informed but he/she was not aware how long the walk-in had been out of service. -He/She hoped the food that was in the residential refrigerator that had an internal temperature in the 50 F range had been discarded. MO00249108

Based on interview, and record review, the facility failed to have a Registered Nurse (RN) at least eight consecutive hours a day for seven days a week. This was evidenced by the facility's documentation indicating RNs were not working in the facility for 11 out of 30 days, from 2/11/25 through 3/11/25. The facility census was 65 residents. 1. Review of the staffing sheet dated 2/12/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/13/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/14/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/16/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/17/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/20/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/26/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/28/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 3/4/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 3/6/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 3/11/25 showed there was no RN coverage all day. During an interview on 3/14/25 at 11:45 A.M. the Staff Development Manager said: -The facility needed a RN for at least eight consecutive hours a day for seven days a week. -The expectation was that the facility had a RN for eight hours a day, every day. During an interview on 3/14/25 at 12:28 P.M. the Administrator said: -It was the expectation of the facility to have a RN on the schedule daily for eight hours a day.

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity during dining observations, call bell response, and during the provision of care and treatment for six sampled residents (Resident #263, #50, # 264, #12, #30, and #43) out of 29 sampled residents reviewed for dignity and respect. The facility census was 65 residents. Review of the facility's policy titled, Privacy and Dignity, dated October 24, 2022, showed: Purpose: To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity, and overall quality of life. Policy: The facility promotes resident care in manner and an environment that maintains or enhances dignity and respect, full recognition of each resident's individuality. Procedure: I. Staff assists the resident in maintaining self-esteem and self-worth. II. Residents are groomed as they wish to be groomed. III. Residents are dressed appropriate to the time of day and season as well as well as individual preferences. IV. Resident clothing is labeled in a way that respect their dignity. V. The Facility promotes independence and dignity in dining. VI. The Facility respects the resident's private space and property. VII. Staff treats residents with respect including respecting their social status, speaking respectfully listening carefully. VIII. Staff focuses on residents as individual when they speak to them and address resident as individual when providing care and services.1. Review of Resident # 263's face sheet showed he/she was admitted to the facility on [DATE] and identified herself as being her own responsible party Resident #263 had diagnoses which included Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Anemia, Type 2 Diabetes Mellitus without Complications, Anemia, unspecified, Obstructive Sleep Apnea (adult)(pediatric), Paraplegia, Unspecified, Essential (primary) Hypertension, Unspecified Atrial Fibrillation, Chronic Diastolic (congestive) Heart Failure, Unspecified Urinary Incontinence, Weakness. 1. Review of Resident #263's Admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 3/8/25 showed: -There was no assessment completed at the time of review or at the time of exit from the survey process. --The completion date of the MDS was 3/18/25. Review of the resident's undated Care Plan Report, showed: -He/She had an Activities of Daily Living (ADL) Self Care Performance Deficit related to limited range of motion (ROM) to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) secondary to Rheumatoid Arthritis (RA). -He/She required two staff for assistance with transfers using the Hoyer lift. -Staff documented that the resident required one person assistance with transfer and all weight bearing ADL's, and set up assist with eating and personal hygiene. During an interview on 3/11/25 at 11:30 A.M., the resident said: -He/She put the call bell on last night at 2:00 A.M. -Staff came into the room and indicated that he/she would be back. However, around 2:28 A.M., he/she put the call bell on again and no one answered the call light until 6:40 A.M. -He/She was soiled for all that time, and no one came to help him/her. -He/She began to cry during this interview. -Being left soiled for so long made him/her feel really horrible, bad, and sad. -He/She would be looking for another facility. -His/Her bottom was burning. -This happened a lot during the night shift. -He/She felt that staff did not like him/her because sometimes it took two staff members to change him/her. -The surveyor could talk with Certified Nursing Assistant (CNA) D, this person was great and changed him/her that morning around 6:45 a.m. -He/She told CNA D that the staff during the evening shift did not like to help him/her at all. -He/She continued to cry. During an interview on 3/14/25 at 5:41 P.M. the Administrator said: -He/She expected all staff to answer call lights in a timely manner. -It was the facility's expectation that all residents were treated with respect and dignity. 2. Review of Resident #50's Face Sheet revealed he/she was initially admitted to the facility on [DATE] with diagnoses including Quadriplegia, unspecified, Muscle Weakness (generalized) their reduced mobility, Need for assistance with personal care, Adjustment Disorder, unspecified, Hypomagnesemia, Shortness of Breath, Type 2 Diabetes Mellitus without complication , Chronic Pulmonary Edema , Morbid (severe) Obesity due to excess calories, Fracture of orbital floor, right side, subsequent encounter for fracture ,Other muscle spasm ,Personal history of other venous thrombosis and embolism, Hereditary and Idiopathic Neuropathy, unspecified, Chronic Pain Syndrome, Vitamin B12 Deficiency Anemia, unspecified, Gastro-Esophageal Reflux Disease without Esophagitis, and Vitamin D Deficiency, unspecified. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was able to make his/her needs known to staff. -Was dependent on staff for all their activities of daily living. Review of resident's undated Care Plan showed the resident: -Was dependent on staff for assistance with all meals. -Would have his/her needs met with assistance of staff thru next review period as evidenced by (AEB): being clean, dry, dressed appropriately and well groomed. -Had a flat touch call light. Position it by his/her head so he/she could turn his head to turn on the call light. -Refused to sleep in bed. Slept in recliner/broda. -BED MOBILITY: Resident was dependent on staff participation to reposition and turn in recliner -BATHING: Resident was dependent on staff participation with bathing. -PERSONAL HYGIENE/ORAL CARE: Resident was dependent on staff participation with personal hygiene and oral care. -DRESSING: Resident was totally dependent on staff for dressing. -EATING: Resident required total assistance to eat. -TRANSFER: Resident required total assistance with Hoyer for transfers. During an interview on 3/12/25 at 11:31 A.M., the resident said: -He/She did not have choices of his/her care and treatment with meals. -He/She was always fed in the main dining room. -The only reason he/she was told that he/she could not eat or be fed in his/her room was because the facility did not have enough staff on the unit. -He/She was transported by staff to the dining room around 5:15 P.M. daily and had to wait to be assisted with the meal. -Nine times out of 10, he/she was the last one to be assisted with his/her meals. -He/She waited over one hour to be assisted with his/her meals, and sometimes this caused him/her to experience muscle spasms and made him/her upset. Observation on 3/12/25 in the main dining room, showed: -At 5:41 P.M., the resident was waiting to be for assisted with his/her meal. -At 6:21 P.M., staff were assisting the resident with his/her meal. During an interview on 3/12/25 at 6:30 P.M. Certified Nursing Aide (CNA) M, who was assisting the resident said: -The staff were aware of the resident's concerns of wanting to eat in his/her room, but the facility did not have enough staff for him/her to be fed in his/her room. -Due to the loud noises and other interaction with residents, this could be very upsetting to the resident and sometimes this caused him/her to have behaviors. Observation on 3/13/25 in the main dining room showed: -At 5:25 P.M., the resident was waiting to be assisted with his/her meal. During an interview on 3/14/25 at 2:14 P.M. the Administrator said: -It was the facility's expectation that residents' choices be honored. -All residents needed to be treated with respect and dignity. Observation on 3/14/25 in the main dining room showed: -At 5:46 P.M. the resident was waiting to be assisted with his/her meal. During an interview on 3/14/25 at 5:46 P.M. the resident said: -Having to wait to be fed made him/her sad and upset. -Because the facility did not have enough staff he/she had to go in the dining room every day. During an interview on 3/14/25 at 5:50 P.M. the Staff Development Manager (SDM) said: -The reason the resident could not eat or be assisted with their meals during meal time was because the facility did not have enough staff to have some residents eat in their room. -The resident was not the only resident that did not want to eat in the dining room. -He/She was aware the resident did not like to eat in the dining room all the time. During an interview on 3/14/25 at 5:51 P.M. the Infection Control Nurse said: -The resident was not able to eat his/her meals in his/her room because the facility did not have enough staff. 3. Review of Resident #264's face sheet showed he/she was admitted with diagnoses that included Postprocedural Intestinal Obstruction, unspecified as to Partial Versus Complete, Chronic Respiratory Failure with Hypoxia, unspecified Severe Protein-Calorie Malnutrition, Chronic Obstructive Disease, unspecified, need for assistance with personal care, Unsteadiness on Feet, Muscle Weakness (generalized), Influenza a Virus with other Respiratory Manifestations, Pressure Ulcer of Sacral Region, Stage 2, Chronic Kidney Disease, Stage 3B, Sarcoma of Dendritic Cells (accessory cells) Anemia, unspecified Chronic Diastolic (congestive) Heart Failure, and Weakness. Review of the resident's Admission Minimum Data Set, dated dated dated [DATE] showed staff documented: -The resident was able to communicate he/she needs to the facility staff. -The resident needed moderate to maximal assistance with care and treatment. Review of the resident's undated care plan showed: -The resident was at risk Activities of Daily Living (ADL) resident required assistance with transfers. -The resident required staff assistance to turn and reposition in bed. -The resident required staff assistance for toileting. -The resident needed to be encouraged to sit on the toilet to evacuate bowels if possible. -The resident had an actual witnessed non-injury fall on 3/1/2025. During an interview on 3/11/25 at 3:09 P.M. the resident said: -He/She had been placed on the toilet and left for a long period of time without assistance from staff. -He/She would get staff to help him/her to the bathroom, and staff would leave him/her in the bathroom for long periods of time. -Staff left him/her in the bathroom this weekend. -Last night, staff would not answer his/her call light. -He/She felt bad, helpless, and sad. -He/She wished that he/she could do better for himself/herself, but the reason he/she waited was because of being afraid of falling. -He/She did not want to do something wrong and fall. -If he/she were to fall, it would be bad and horrible. During an interview on 3/13/25 at 3:15 P.M. the resident's family said: -He/She received calls weekly from the resident. -The resident told him/her that he/she had waited long times for staff to assist him/her to the bathroom, and sometimes he/she needed things during the evening that he/she was unable to reach. -The resident felt that the facility did not have enough staff to help them at night. During an interview on 3/13/2025 at 5:41 P.M. the Administrator said: -It was the expectation of the facility that all staff answered call lights in a timely manner and treated residents with respect and dignity. 4. Observation on 3/11/25 at 2:14 P.M. showed: -Resident #30 was served her/his lunch tray in her/his room. -On the tray was a red cloth napkin and a black plastic fork and spoon. 5. Observation on 3/12/25 at 5:54 P.M. showed: -Resident #43 had been served a meal tray in her/his room. -On the tray was a white paper napkin, a black plastic spoon, and a white plastic knife. -In a Styrofoam bowl containing sections of pears, was a black plastic fork. During an interview on 3/12/25 at 5:54 P.M. the resident said: -He/She sometimes received regular silverware. 6. Observation on 3/12/25 at 5:50 P.M. on the 100 hall showed: -Five trays that had a black plastic spoon and white plastic fork for the residents. The desserts, salads, and drink were in Styrofoam containers. 7. Observation on 3/12/25 at 6:10 P.M., on the 200 hall showed: -Four trays that had black plastic spoons and white plastic forks for the residents. The residents' desserts, salads, and drinks were in Styrofoam containers. 8. Observation on 3/12/25 at 6:16 P.M., on the 300 hall showed: -Seven trays, that had black plastic spoons and white plastic forks for the residents. The residents' desserts, salads, and drinks were in Styrofoam containers. 9. Observation on 3/12/25 at 6:23 P.M., on the 400 hall showed: -Five trays that had black plastic spoons and white plastic forks for the residents. The residents' desserts, salads, and drinks were in Styrofoam containers. 10. During a telephone interview, on 3/13/25 at 2:16 P.M. the Registered Dietitian (RD) said: -It was his/her expectation that residents have regular silverware except when disposable utensils would be required during an emergency/disaster. -It was a dignity issue to not be given regular silverware.

Based on observation and interview, the facility failed to close and lock the shower doors on the 200, 300 and 400 Halls to prevent high risk wandering residents from hazardous accidents for 13 wandering residents. The facility census was 65 residents. A request was made of the facility for policies and procedures addressing the storage of chemicals. No such policies or procedures were provided prior to the exit. 1. Observation on 3/12/25 at 10:00 A.M. showed: -The door to the shower room on the 200 Hall unit was opened and exposed multiple areas within the shower room. -Multiple body washes, shampoos and conditioners, anti-perspirants/deodorant, and a bottle of hair spray. -There was a four door storage cabinet. Each door was equipped with a key-lock cabinet for staff to lock all items in the shower room. Observation on 3/12/25 at 10:15 A.M. showed: -The door to the shower room on the 300 Hall unit was opened and exposed multiple areas within the shower room where hallway residents and guest walked by. -The shower room had a Betco PH7Q Disinfectant Germicidal Spray bottle on the counter which was half full of liquid. The spray bottle had a label that stated, Hazard to Humans Harmful if inhaled. -There was a four door storage cabinet. Each door was equipped with a key-lock cabinet for staff to lock all items in the shower room to keep hazardous materials from the wandering residents on this unit. Observation on 3/12/25 at 10:35 A.M. showed: -The door to the shower room on the 400 Hall was open. -Hanging from one of the safety bars in the shower stall was a spray bottle of LNZ Liquid Enzyme Deodorizer Digester Spotter. On the label of this spray bottle was CAUTION: MAY BE HARMFUL IF SWALLOWED - KEEP OUT OF REACH OF CHILDREN. -Hanging on the same safety bar was a spray bottle of BETCO pH7Q READY-TO-USE One Step Disinfectant - Germicidal - Detergent - Deodorizer. On the label of this spray bottle were warnings to KEEP OUT OF REACH OF CHILDREN and PRECAUTIONARY STATEMENTS HAZARDS TO HUMANS AND DOMESTIC ANIMALS: Harmful if inhaled. Remove contaminated clothing and wash clothing before reuse. -Standing along on the top of the safety bar were multiple bottles of personal body wash, shampoo, hair spray, conditioner, and combs for residents. Observation on 3/12/25 at 6:05 P.M. showed: -The door to the shower room on the 300 Hall unit was opened and exposed multiple areas within the shower room and the hallway where residents and guests walked by. -The shower room had a Betco PH7Q Disinfectant Germicidal Spray bottle on the counter which was half full of liquid. The spray bottle had a label that stated, Hazards to Humans .Harmful if inhaled. Observation on 3/13/25 at 5:43 P.M. showed: -The door to the shower room on 400 Hall was opened/ajar and did not have a locking mechanism on the door lever. -Hanging from one of the safety bars in the shower stall was a spray bottle of LNZ Liquid Enzyme Deodorizer Digester Spotter. On the label of this spray bottle was CAUTION: MAY BE HARMFUL IF SWALLOWED - KEEP OUT OF REACH OF CHILDREN. -Hanging the same safety bar was a spray bottle of BETCO pH7Q READY-TO-USE One Step Disinfectant - Germicidal - Detergent - Deodorizer. On the label of this spray bottle were warnings to KEEP OUT OF REACH OF CHILDREN and PRECAUTIONARY STATEMENTS HAZARDS TO HUMANS AND DOMESTIC ANIMALS: Harmful if inhaled. Remove contaminated clothing and wash clothing before reuse. -Standing along the top of the safety bar were multiple bottles of personal body wash, shampoo, conditioner. -Outside of the shower stall was a four door storage cabinet. Each door was equipped with a key lock. Three of the cabinet doors were slightly ajar. -The toilet stall adjacent to the shower stall had an access panel removed, which exposed a hole in the drywall above the safety bar next to the toilet. The hole measured approximately 16 inches square and allowed access to the plumbing serving the shower. The access panel itself was on the floor propped against the wall. During an interview on 3/13/25 at 6:05 P.M. the Director of Nursing (DON) said: -The chemicals should be behind a locked door at all times. -The chemicals should have been locked in the four door cabinet next to the shower stall. During an interview on 3/14/25 at 2:14 P.M. the Administrator said: -It was his/her expectation that all shower doors be closed and all hazardous materials be locked up.

Based on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) Plan was in place to ensure the facility's care delivery system was consistent and accurate and did not identify concerns within the facility system and ensure a plan was in place to ensure improvement. This affected all residents. The facility census was 65 residents. A review of the facility's policy and procedure titled, QAPI Program, dated 10/24/22, showed: -Purpose: To ensure that all services provided by the facility to resident meet quality standards. -The Facility implements and maintains an ongoing, Facility-wide Quality Assurance and Performance Improvement (QAA) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. -Procedure: 1. Goals: A. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. B. To reinforce and build upon effective systems of services and positive care measures; C. To provide a structure and process to correct identified quality deficiencies; D. To establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcomes; E. To help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability; and F. To establish a system and process to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program .V. Feedback: A. The Facility obtains feedback from direct care staff, other staff, residents and resident representatives, as well as other sources, to identify problems that are high-risk, high-volume, and/or problem-prone, as well as opportunities for improvement. B. Systems for obtaining feedback include but are not limited to: i. Satisfaction surveys. ii. Care Planning meetings. iii. Resident Council and Family Council meetings. iv. Safety Committee meetings. v. Suggestion box. vi. Compliance Hotline. 1. Review of the facility QAPI Agendas showed: -The facility failed to ensure that all residents were treated with dignity during mealtimes. -The facility failed to ensure that all residents were provided with choices during mealtimes and were provided assistance with meals. -The facility failed to ensure that all residents, who were at risk for alterations in skin, were changed and repositioned every two hours and did not ensure that an alteration in skin occurred. -The facility failed to ensure there was a sufficient number of staff to assist residents who were at risk for alteration in skin and required to be repositioned every two hours to prevent damage to skin. -The facility failed to ensure that the kitchen was clean and sanitary, food handling practices were in place to prevent an outbreak of foodborne illness, and did not ensure that food safety was maintained to store, prepare and distribute food safely to all residents. During an interview on 3/14/25 at 12:09 P.M. the Administrator said: -A representative from the Corporate Office came into the facility in December of 2024 to conduct a mock survey of all departments within the facility. -He/She did not receive a report from the mock survey but that there were concerns identified. -The facilities QAPI program met every three months and sometimes monthly if warranted. -Not all managers within the facility provided him/her with concerns that may be within the facility. -The management team did not share everything with him/her related to problems on the floor or in the kitchen, which made it difficult for him/her to identify breaks within the system. During an interview on 3/14/25 at 2:45 P.M the Administrator said: -The Ombudsman State Representative would enter the facility monthly to talk to the residents and reported all concerns to the Social Worker, who no longer worked there. -The Social Worker had never discussed any resident concerns with him/her. -It was his/her expectation that the facility management team discuss all concerns with him/her. -The facility's management team did not effectively communicate with him/her all concerns within the facility. During an interview on 3/14/25 at 3:59 P.M. the Medical Director said: -He/She was aware of the facility having staffing shortages recently. -It was his/her expectation that residents be repositioned every two hours. -It was his/her expectation that the facility provided appropriate nursing staff to ensure all residents received appropriate care. -He/She did attend the facility's QAPI meetings monthly and also entered the facility every Thursday to review medical records.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections by not ensuring staff transported residents food down each hall in a manner to prevent cross-contamination; failed to ensure supplements and disposable equipment used during the administration of enteral nutrition were labeled, dated, and/or discarded when indicated and stored in a safe and sanitary manner between uses for two sampled residents (Resident #43 and #6); out of two sampled residents who received enteral nutrition; failed ensure personal hygiene products and care equipment (e.g., roll-on deodorant, combs, etc.) stored in the 400 Hall shower room were not available for common use to the 17 residents residing on this hall. The facility census was 65 residents. A request was made for all policies and/or procedures related to the administration of enteral nutrition via gastrostomy tube. No such policies and/or procedures were provided prior to the time of exit. A request was made for any policies and/or procedures addressing the storage of personal hygiene items. No such policies or procedures were provided prior to the time of exit. Review of the facility policy titled Infection Prevention and Control Program, revised 10/24/22, showed: -Purpose: To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements -Infection Control Policies and Procedures --The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. --Objectives Maintain a safe, sanitary, comfortable environment for personnel, residents, visitors, and the public. --Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. 1. Observation on 3/12/25 showed: -At 5:41 P.M. Both Certified Nursing Assistant (CNA) D and CNA M passing and picking up trays on halls 100, 200, 300 and 400. -At 5:50 P.M.,on the 100 hall, five five trays with the residents' desserts, salads and drink were not covered. -At 6:10 P.M. on the 200 hall, four trays with the residents' desserts, salads and drink were not covered. -At 6:16 P.M. on the 300 hall, seven trays with the residents' desserts, salads and drink were not covered. -At 6:23 P.M. on the 400 hall, five trays with the residents' desserts, salads and drink were not covered. During an interview on 3/12/25 at 6:35 P.M. CNA M and CNA E said: -The deserts, salads and drinks for the residents on the halls came out uncovered from the kitchen daily. -Resident desserts, salads and drinks were served in plastic bowls and coffee cups. During a phone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian (RD)said he/she expected all food items to be covered while being transported down hallways to the residents in their rooms. 2. Observation on 3/11/25 at 10:42 A.M. showed: -Resident #43 was in bed with the head of the bed elevated. -Located at the head of the resident's bed was an intravenous (IV) pole on which were hanging a full 1500 milliliter (ml) bottle of Jevity 1.2 nutritional supplement and a refillable kangaroo bag filled with water; neither the bottle nor the bag was labeled or dated. -The tubing, which was connected to both the bottle and the bag and were threaded through the feeding pump, was primed with the enteral supplement but was not labeled or dated. -The end of tubing was uncapped and draped freely over the top of the pump. -The IV pole and its wheeled base were heavily soiled with an accumulation of a dried, tan-colored substance similar in color to the Jevity 1.2. -On the counter next to the sink were three piston syringes. --One purple 60 ml ENFit syringe, which was not dated, was laying directly on the counter with the plunger stored in the barrel of the syringe (not separated to air dry). ---Clear liquid was observed collected at the end of the barrel near the tip where the plunger rested. --A second undated 60 ml piston syringe, which had a legacy tip, a circular thumb control ring, and a blue Luer tip adapter stored inside the barrel, was observed stored with the plunger inside the barrel. ---The tip of this second syringe had several drops of pink-colored liquid on it and had not been effectively rinsed after use. --A third 60 ml piston syringe with a legacy tip and thumb control ring was stored tip-down in a 500 ml graduated container; the graduated container was dated 3-8-25. Observation on 3/11/25 at 2:12 P.M. showed: -Resident #43 was in bed. -The feeding pump was programmed and running at 75 ml per hour with 100 ml water flushes to be administered every six hours. -The bottle of Jevity 1.2 and the kangaroo bag for water flushes remained unlabeled with no date. -The tubing also remained undated. 3. Observation on 3/11/25 at 10:57 A.M. showed: -Resident #6 was lying in bed by the door. -A feeding pump was observed on an IV pole located at the head of the resident's bed. -Hanging from the IV pole was a bag of IsoSource enteral supplement and a refillable kangaroo bag filled with water. -Neither of the bags was labeled nor dated. -The administration tubing threaded from the bags through the feeding pump was also not labeled or dated. -The feeding pump was programmed and running at 40 ml per hour. -The wheeled base of the IV was heavily soiled with an accumulation of a dried, tan-colored substance similar in color to the IsoSource. -A 60 ml ENFit piston syringe stored in direct contact with the overbed table with no clean barrier present. --The syringe was not dated, the syringe components were not separated to air dry, and moisture was observed on the tabletop directly below the tip of the syringe. --There was a graduated collection container on the sink counter dated 3-8-25. -A second ENFit piston syringe was seen on the floor under the resident's bed. 4. During an interview on 3/12/25 at 6:12 P.M. the Director of Nursing (DON) said: -The IV poles were dirty and should have been cleaned more frequently. -The piston syringes were supposed to be changed every night. -They were supposed to be dated when changed. -They were to be rinsed after each use and allowed to air-dry before being reassembled. -They were not be stored in direct contact with the counter or assembled while wet. 5. Observation on 3/12/25 at 5:43 P.M. showed: -The counter by the sink on the 400 hall shower room had a pile of hair combs, including nit combs [fine-toothed combs used to remove lice eggs]. --The combs had hair and dander on them. -Next to the pile of combs was one bottle of Medline Shampoo and Body Wash and two bottles of roll-on deodorant. -The bottles of deodorant were not labeled with an individual resident's name and were available for common use. During an interview on 3/12/25 at 6: 05 P.M. the DON said: -The combs should not be on the counter. -They should be sanitized after every use. -Everyone should have their own combs.

Based on observation, interview, and record review, the facility failed to ensure a wheelchair available for common use was maintained in a safe and sanitary manner. This deficient practice had the potential to affect any of the 17 residents residing on 400 hall who may have required wheelchair assistance. The facility census was 65 residents. A review of the facility policy titled Infection Prevention and Control Program, revised 10/24/22, showed: -Purpose: To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. -Infection Control Policies and Procedures --The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. --Maintain a safe, sanitary, comfortable environment for personnel, residents, visitors, and the public. --Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. 1. Observation on 3/13/25 at 5:43 P.M. of the shower room on 400 hall showed: -A wheelchair stored in an open area near the sink with other mobility devices. -The vinyl covering of one of the armrests on the wheelchair was torn. -The foam padding of the armrest was exposed. During an interview on 3/13/25 at 6:05 P.M. the Director of Nursing (DON) said: -The wheelchair was available for common use with any resident. -Because of the exposed foam padding of the armrest, the surface of the armrest could not be effectively cleaned and/or sanitized between uses by different residents.

Based on interview, and record review, the facility failed to follow physician's orders for treatments and to document the resident's pressure ulcers, for one sampled resident (Resident # 3) out of six sampled residents. The facility census was 61 residents. On 10/15/24 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 7/30/24. On 7/30/24 the facility Administrator was notified of the Wound Nurse was not signing off treatment orders and not completing documentation as expected. Wound Nurse A was assigned a floor position, and wound duties were assigned to the Assistant Director of Nursing (ADON) on 8/8/24. No nurses were allowed to provide wound care prior to reeducation completed 7/30/24. The deficiency was corrected on 7/30/24. Review of the facility Wound Management Policy dated 10/24/22 showed: -To provide a system for the treatment and management of residents with wounds including pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) and non-pressure ulcers (a chronic open wound that develops due to a primary cause other than pressure or shear). -A resident who had a wound would receive necessary treatment and services to promote healing, prevent infections and prevent new pressure ulcers from developing. -A licensed nurse would perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse would: --Measure the wound (length, width, depth) in centimeters (cm). --Initiate a Wound Monitoring Record sheet. ---A Wound Monitoring record would be completed for each wound. ---The Wound Monitoring Record was optional for recording skin tears, lacerations, cuts, and abrasions. ---If the Wound Monitoring Record was not used, documentation would be recorded within the medical record which may include nursing notes, treatment records or care plans. --Implement a wound treatment per physician's order. -Per physician's order, the nursing staff would initiate treatment and utilize interventions for pressure redistribution and wound management. -The physician and Interdisciplinary Team (IDT - A group of people from different backgrounds who work together to achieve a common goal) would be notified of: --New pressure ulcers and wounds. --Pressure ulcers or wounds that did not respond to treatment. --Pressure ulcer or wounds that worsened or increased in size. --Complaints of increased pain, discomfort or decreased mobility by a resident. --Signs of ulcer sepsis (a blood stream infection), presence of exudates (any fluid that has been forced out of the tissue or its capillaries because of inflammation (an immune response that causes redness and swelling of an area on the body or possibly tissue) within the body or injury, odors, or necrosis (relating to localized death of living cells as from interruption of blood supply or infection), if not already noted by the physician. --Resident refusing treatment. -Licensed nurse would document effectiveness of current treatment in the resident's medical record on a weekly basis. -Document notifications following a change in the resident's skin condition. -Update the resident's care plan as necessary. --NOTE: Nothing in the policy talked about documenting each treatment on the Treatment Administration Record (TAR). 1. Review of Resident #3's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/15/24 showed the resident: -Was severely cognitively impaired. -Had one Stage one (intact skin with non-blanchable (to press blood away and wait for return of blood) redness of a localized area usually over a boney prominence) pressure ulcer. -Had Coronary Artery Disease (narrowing of the coronary arteries due to buildup of plaque). -Had Peripheral Vascular Disease (inadequate flow of blood to the extremities). Review of the resident's Physician's Order sheet (POS) dated April 2024 showed: -Apply Zinc barrier cream (skin protection against urine and fecal matter, moisturizes and sooths reddened irritated skin) to his/her buttocks every shift and as needed (PRN), every morning and at bedtime for redness, started 4/7/24 and discontinued 4/17/24. -Apply Zinc barrier cream to his/her buttocks every shift and PRN, every shift for redness on buttocks, day, evening, & night, started 4/17/24 and discontinued 4/30/24. Review of the resident's TAR dated April 2024 showed: -Apply Zinc barrier cream to the resident's buttocks every shift and PRN, every morning and at bedtime for redness, started 4/7/24 and discontinued 4/17/24. --No documentation the treatment was completed by facility staff five out of 21 opportunities. -Apply Zinc barrier cream to the resident's buttocks every shift and PRN, every shift for redness on buttocks, day, evening, & night, started 4/17/24 and discontinued 4/30/24. --No documentation the treatment was completed by facility staff seven out of 36 opportunities. Review of the resident's Care Plan dated 4/5/24 showed the resident did not have a plan of care for his/her pressure ulcers. Review of the resident's Weekly Skin Observation dated 4/12/24 showed an area to his/her coccyx (tailbone), wound Stage I reddened area, treatment in place. Review of the resident's Weekly Skin Observation dated 4/16/24 showed an area to his/her coccyx wound Stage I reddened area, non-blanchable, painful. Review of the resident's Weekly Skin Observation dated 4/22/24 showed an area to his/her coccyx wound Stage I pressure ulcer, treatment in place. Review of the resident's Weekly Wound Observation Tool dated 4/29/24 showed: -His/her right buttock wound measured 2.2 centimeter (cm) x 2.3 cm x 0.2 cm, full thickness, date acquired 4/29/24, first observation, no reference, granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) tissue present, serosanguinous drainage (a thin, watery fluid that is a combination of blood and serum, the clear, straw-colored part of blood), small amount, no odor. --Treatment was to cleanse with hypochlorous acid (fights common bacterial skin problems), apply Santyl (an ointment used for debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of a pressure ulcer) nickel thick to wound bed, apply calcium alginate (a gelatinous, water-insoluble substance that is used in wound dressing to absorb exudate and promote healing) to wound base, cover with bordered gauze (an absorptive dressing that consists of three layers, soft, and flexible, easy to conform to difficult wounds). Change daily and PRN (as needed). -His/her bottom of the left foot 3 cm x 2 cm, full thickness, date acquired 4/29/24, first observation, no reference, slough (nonviable yellow, tan, gray, green or brown tissue, usually moist, can be soft, stringy, and mucinous in texture) tissue present, serosanguinous drainage, moderate amount, greenish in color, no odor. --Treatment was to cleanse with hypochlorous acid, apply Santyl nickel thick to wound bed, apply calcium alginate to wound base, cover with bordered gauze. Change daily and PRN. Review of the resident's Hospital discharge date d 5/2/24 showed: -admitted into the hospital on 4/29/24 for local infection of wound. -Would and blood cultures obtained, positive for Staph aureus (a bacterial skin or soft tissue infection). -Intravenous (IV - injected into the veins) antibiotic started as well as inpatient wound care. -Consult on left heel stage III (a full thickness tissue loss, subcutaneous fat may be visible, but bone, tendons or muscle is not exposed) wound. -Consult on right buttock stage III wound. -Consult on left buttock stage II (partial thickness, loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (nonviable yellow, tan, gray, green or brown tissue, usually moist, can be soft, stringy, and mucinous in texture) wound. -Dressing changes daily and PRN if gets soiled or falls off. -Cleanse all wounds with normal saline, place Aquacel Ag (a sterile, absorbent, and antimicrobial wound dressing), cut to wound size on wound beds, cover with bordered foam (an island dressing consisting of a highly absorbent primary hydrophilic (water-loving) foam layer with a waterproof adhesive backing). -Consult wound care. -New order for Cephalexin (antibiotic) 500 milligram (mg) capsule, oral four times a day for five days for infection. Review of the resident's significant change MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had two Stage II pressure ulcers and infections to skin. -Pressure reducing devices for the bed and chair. -Pressure ulcer care. -Had Coronary Artery Disease. -Had Peripheral Vascular Disease. Review of the resident's POS dated May 2024 showed to apply Zinc barrier cream to his/her buttocks every shift and PRN for redness, started 5/2/24 and discontinued 6/12/24. Review of the resident's TAR dated May 2024 showed: -Apply Zinc barrier cream to his/her buttocks every shift and PRN for redness, started 5/2/24 and discontinued 6/12/24. --No documentation the treatment was completed by staff eight out of 44 opportunities. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --No documentation the treatment was completed by staff seven out of 15 opportunities. ---This treatment was ordered twice. Did not say what was to be treated. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --No documentation the treatment was completed by staff seven out of 15 opportunities. ---Did not say what was to be treated. Review of the resident's Weekly Wound Observation Tool dated 5/8/24 showed: -Bottom of his/her left foot 2 cm x 1 cm x 0.2 cm, full thickness, date acquired 4/29/24, first observation, unchanged, slough tissue present serous drainage, small amount, and no odor. --Treatment to cleanse with hypochlorous acid, apply Santyl nickel thick to wound bed, apply calcium alginate to wound base, cover with bordered gauze. Change daily and PRN. Review of the resident's Weekly Skin Observation dated 5/13/24 showed: -Skin color normal. -Skin Temperature dry. -No Skin issues noted. Review of the facility Performance Improvement Plan dated July 2024 showed: -Identified Area for Assessed Improvement. --Wound Nurse A not signing off treatment orders as expected. --Wound Nurse A not completing documentation as expected. -Plan. --Current Wound Nurse A assigned a floor position, wound duties assigned to the Assistant Director of Nursing (ADON) or designee while position was being filled. --Wound Nurse position posted. --New Wound Nurse hired 9/28/24. --Regional Wound Nurse support added for enhanced oversight. -Action Steps to implement plan. --The DON or designee in-serviced licensed nurses on completion of treatments and documentation of treatments in the Medication Administration Record (MAR)/TAR. --DON or designee in-serviced ADON on position expectations and documentation expectations. --Twice weekly calls initiated with the facility nurse management and regional wound support and Regional Nurse Consultant to review wound processes for compliance. -Objective Measures to Evaluate. --Regional Wound Consultant would audit wound assessments and wound reports weekly. If concerns were identified, they would be corrected by the ADON, or designee and in-service would be provided. --DON or designee would review current wounds weekly in Risk to ensure physician notification was completed, treatment orders were in place, and treatments were completed as ordered. If any issues were identified, then education would be completed by the DON or designee. --Regional Nurse Consultant would pull weekly medication/treatment reports to send to the facility for review. -Person Responsible for Oversight. --DON or designee -To be completed in July 2024 and ongoing. During an interview on 10/8/24 at 10:47 A.M., Wound Nurse A said: -He/she completed all his/her treatments as ordered for the resident. -If busy he/she would forget to sign the TAR that the treatment was done. -He/she was educated on wound documentation and notification to family and physician if the resident refused the treatment. -He/she did not notify the physician if the resident refused a treatment occasionally. -He/she was no longer the Wound Nurse. -If the TAR was left blank it meant the treatment did not get done. During an interview on 10/8/24 at 11:01 A.M., the ADON said: -He/she had trained on wound documentation, wound reports, and wound care plans. -He/she was assisting with wound care for the residents. -He/she was auditing the MAR and TAR to make sure the nursing staff were signing when medications were given, and treatments were done. -If the MAR/TAR was not signed the process did not happen. During an interview on 10/8/24 at 2:28 P.M., the DON said: -Wound Nurse A had been educated several times about signing the TAR after a treatment was done but kept leaving blanks on the TAR. -Wound Nurse A was no longer the wound nurse. -A new wound nurse had been hired and was in training now. -He/she and the ADON were working on training the new Wound Nurse. -He/she was auditing the MARs/TARs to make sure they were being signed when medications were given, and treatments were done. This was ongoing. -Provided education to the nursing staff about documentation on wound care and notification to physician and family. -The charge nurses were completing the treatments along with him/her, the ADON and wound nurse in training, with assistance from the Regional Wound Consultant. -He/she and the ADON were doing the weekly wound assessments, measurements, and rounding with the outside wound care team. During an interview on 10/8/24 at 4:37 P.M., the Administrator said: -The facility had a new wound nurse due to Wound Nurse A no longer treating wounds and just working the floor effective 8/8/24. -The wounds were not healing like they should. -Wound Nurse A was on the floor all day doing treatments. -An audit was done in July and found that Wound Nurse A was not signing the TAR when the treatments were done. -Wound Nurse A was educated again about signing the TAR after the treatment were done and documenting if the physician had been called or if the resident refused the treatment. -In July 2024, A Performance Improvement Plan was put into place for Wound Nurse A not signing the TAR or documenting on the treatments as expected. -All nurses were educated on wounds on admission, following physician's orders, documentation on wounds, notifying the physician of refusal of treatments, ensure the MAR/TAR were signed off, wound care planning, wound reports, and wound documentation. During an interview on 10/9/24 at 10:13 A.M., the Physician said: -He/she would expect the licensed nurses to completed treatments as ordered for the residents. -He/she was not notified the resident was refusing treatments. -He/she should be notified if a resident was refusing treatments. -There was no outcome from the treatments not being done. -The resident was very sick and was on hospice (end of life care) due to a decline in health. MO00243272

Based on interview, and record review, the facility failed to follow physician's orders for skin treatments and to document the treatments in the medical record for one sampled resident (Resident #3) out of six sampled residents. The facility census was 61 residents. On 10/15/24 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 7/30/24. On 7/30/24 the facility Administrator was notified the Wound Nurse was not signing off treatment orders and not completing documentation as expected. Wound Nurse A was assigned a floor position, and wound duties were assigned to the Assistant Director of Nursing (ADON) on 8/8/24. No nurses were allowed to provide wound care prior to reeducation completed 7/30/24. The deficiency was corrected on 7/30/24. Review of the facility Wound Management Policy dated 10/24/22 showed: -To provide a system for the treatment and management of residents with wounds including pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) and non-pressure ulcers (a chronic open wound that develops due to a primary cause other than pressure or shear). -A resident who had a wound would receive necessary treatment and services to promote healing, prevent infections and prevent new wounds from developing. -A licensed nurse would perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse would: --Measure the wound (length, width, depth) in centimeters (cm). --Initiate a Wound Monitoring Record sheet. ---A Wound Monitoring record would be completed for each wound. ---The Wound Monitoring Record was optional for recording skin tears, lacerations, cuts, and abrasions. ---If the Wound Monitoring Record was not used, documentation would be recorded within the medical record which may include nursing notes, treatment records or care plans. --Implement a wound treatment per physician's order. -Per physician's order, the nursing staff would initiate treatment and utilize interventions for pressure redistribution and wound management. -The physician and Interdisciplinary Team (IDT - A group of people from different backgrounds who work together to achieve a common goal) would be notified of: --Complaints of increased pain, discomfort or decreased mobility by a resident. --Signs of wound sepsis (a blood stream infection), presence of exudates (any fluid that has been forced out of the tissue or its capillaries because of inflammation (an immune response that causes redness and swelling of an area on the body or possibly tissue) within the body or injury, odors, or necrosis (relating to localized death of living cells as from interruption of blood supply or infection), if not already noted by the physician. --Resident refusing treatment. -Licensed nurse would document effectiveness of current treatment in the resident's medical record on a weekly basis. -Document notifications following a change in the resident's skin condition. -Update the resident's care plan as necessary. --NOTE: Nothing in the policy talked about documenting each treatment on the Treatment Administration Record (TAR). 1. Review of Resident #3's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/15/24 showed the resident: -Was severely cognitively impaired. -Had no wounds or infections. -Had Coronary Artery Disease (narrowing of the coronary arteries due to buildup of plaque). -Had Peripheral Vascular Disease (inadequate flow of blood to the extremities). Review of the resident's Physician's Order sheet (POS) dated April 2024 showed: -Facility nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD (abdominal thick wound dressing) pads and wrap with Kerlix (woven gauze that is non-adhesive used to wrap wounds and burns) two times a day for edema (swelling) and weeping of his/her lower extremities, started 4/7/24 and discontinued 4/26/24. -The wound nurse was to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times a day and PRN until healed, for edema and weeping, started 4/26/24 and discontinued 4/30/24. Review of the resident's TAR dated April 2024 showed: -Facility nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times a day for edema and weeping of lower extremities, started 4/7/24 and discontinued 4/26/24. --No documentation that the treatment was completed by facility staff 14 out of 38 opportunities. -The wound nurse was to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times a day and PRN until healed, for edema and weeping, started 4/26/24 and discontinued 4/30/24. --No documentation the treatment was completed by facility staff one out of six opportunities. Review of the resident's Hospital discharge date d 4/5/24 showed: -Diagnosis of COVID (a new disease caused by a Novel (New) coronavirus), edema and syncope (fainting or sudden temporary loss of consciousness). -Follow up with physician within one to two days. Resident had edema and swelling of both legs. -Please make sure to wrap his/her legs up daily and change his/her dressings daily to prevent worsening edema. -After wrapping his/her legs with Ace bandage (a type of compression bandage that is used to provide support and reduce swelling in injured areas of the body), please place a compression stocking over his/her legs to help reduce edema (swelling). Review of the resident's Care Plan dated 4/5/24 showed the resident did not have a plan of care for his/her wounds, or skin infections. Review of the resident's Nursing Note dated 4/6/24 showed: -Resident complained of pain in his/her lower legs, -Nurse went to assess resident's legs and resident had pulled down the Ace wraps which were saturated with fluid and his/her legs were weeping and bleeding. -Nurse spoke to operator at hospital who stated that there was not an on-call physician on for their practice. -The nurse attempted to administer Tylenol (pain medication) and the resident stated, that does not work. -Nurse went to get supplies to clean the resident's legs and to look at orders for treatment. -Resident walked out in the common area and demanded to go to hospital. -911 was called to transport resident to the hospital for evaluation and treatment. -Family was notified of the transfer and report was called to the hospital. Review of the resident's Hospital discharge date d 4/7/24 showed: -Diagnosis of lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph fluid (is part of the lymph system which helps the body fight infection and disease)) and cellulitis (an infection of deep skin tissue) to his/her bilateral lower legs. -New order for Cephalexin (antibiotic for infection) 500 milligrams (mg) oral capsule, one capsule oral, every six hours for 10 days for lymphedema. Review of the resident's Weekly Skin Observation dated 4/12/24 showed bilateral lower extremities with 3 to 4 plus pitting edema, weeping serosanguinous (containing blood and watery drainage) drainage, multiple areas of skin peeling and bleeding. Treatment in place. Review of the resident's Weekly Skin Observation dated 4/16/24 showed: -Bilateral lower extremities with 3 to 4 plus pitting edema, with multiple scabbed areas. -Right lower leg with partial thickness open area 2.5 centimeters (cm) x 2 cm. Edges well defined, scant amount of serous (watery, clear, or slightly yellow/tan/pink drainage) drainage noted. Review of the resident's Weekly Skin Observation dated 4/22/24 showed bilateral lower extremities with 3 to 4 plus pitting edema, weeping, peeling skin, treatment in place. Review of the resident's medical record showed he/she was sent to the hospital on 4/29/24. Review of the resident's Hospital discharge date d 5/2/24 showed: -admitted into the hospital on 4/29/24 for local infection of wound. -Would and blood cultures obtained, positive for Staph aureus (a bacterial skin or soft tissue infection). -Intravenous (IV - injected into the veins) antibiotic started as well as inpatient wound care. -Wrap lower extremities. -Consult wound care. -New order for Cephalexin (antibiotic) 500 mg capsule, oral four times a day for five days for infection. Review of the resident's significant change MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had other wounds and skin problems. -Had ointments/medications other than to feet. -Had Coronary Artery Disease. -Had Peripheral Vascular Disease. Review of the resident's POS dated May 2024 showed: -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds, started 5/3/24 and discontinued 6/12/24. --This treatment was ordered twice. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds, started 5/3/24 and discontinued 6/12/24. --This was a duplicate order. -Wound nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times daily and PRN for edema and weeping, started 5/2/24 and discontinued 6/12/24. Review of the resident's TAR dated May 2024 showed: -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --This treatment was ordered twice. Does not say what was to be treated. -No documentation the treatment was completed by staff seven out of 15 opportunities. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --Does not say what was to be treated. -No documentation that the treatment was completed by staff seven out of 15 opportunities. -Wound nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times daily and PRN for edema and weeping. -No documentation the treatment was completed by staff 13 out of 30 opportunities. Review of the resident's Weekly Skin Observation dated 5/13/24 showed: -Skin color normal. -Skin Temperature dry. -No skin issues noted. Review of the facility Performance Improvement Plan dated July 2024 showed: -Identified Area for Assessed Improvement. --Wound Nurse A not signing off treatment orders as expected. --Wound Nurse A not completing documentation as expected. -Plan. --Current Wound Nurse A assigned a floor position, wound duties assigned to the Assistant Director of Nursing (ADON) or designee while position was being filled. --Wound Nurse position posted. --New Wound Nurse hired 9/28/24. --Regional Wound Nurse support added for enhanced oversight. -Action Steps to implement plan. --The DON or designee in-serviced licensed nurses on completion of treatments and documentation of treatments in the Medication Administration Record (MAR)/TAR. --DON or designee in-serviced ADON on position expectations and documentation expectations. --Twice weekly calls initiated with the facility nurse management and regional wound support and Regional Nurse Consultant to review wound processes for compliance. -Objective Measures to Evaluate. --Regional Wound Consultant would audit wound assessments and wound reports weekly. If concerns were identified, they would be corrected by the ADON, or designee and in-service would be provided. --DON or designee would review current wounds weekly in Risk to ensure physician notification was completed, treatment orders were in place, and treatments were completed as ordered. If any issues were identified, then education would be completed by the DON or designee. --Regional Nurse Consultant would pull weekly medication/treatment reports to send to the facility for review. -Person Responsible for Oversight. --DON or designee. -To be completed in July 2024 and ongoing. During an interview on 10/8/24 at 10:47 A.M., Wound Nurse A said: -He/she completed all his/her treatments as ordered for the resident. -If busy he/she would forget to sign the TAR that the treatment was done. -He/she was educated on wound documentation and notification to family and physician if the resident refused the treatment. -He/she did not notify the physician if the resident refused a treatment occasionally. -He/she was no longer the Wound Nurse. -If the TAR was left blank it meant the treatment did not get done. During an interview on 10/8/24 at 11:01 A.M., the ADON said: -He/she had trained on wound documentation, wound reports, and wound care plans. -He/she was assisting with wound care for the residents. -He/she was auditing the MAR and TAR to make sure the nursing staff were signing when medications were given, and treatments were done. -If the MAR/TAR was not signed the process did not happen. During at interview on 10/8/24 at 2:28 P.M., the DON said: -Wound Nurse A had been educated several times about signing the TAR after a treatment was done but kept leaving blanks on the TAR. -Wound Nurse A was no longer the wound nurse. -A new wound nurse had been hired and was in training now. -He/she and the ADON were working on training the new Wound Nurse. -He/she was auditing the MARs/TARs to make sure they were being signed when medications were given, and treatments were done. This was ongoing. -Provided education to the nursing staff about documentation on wound care and notification to physician and family. -The charge nurses were completing the treatments along with him/her, the ADON and wound nurse in training, with assistance from the Regional Wound Consultant. -He/she and the ADON are doing the weekly wound assessments, measurements, and rounding with the outside wound care team. During an interview on 10/8/24 at 4:37 P.M., the Administrator said: -The facility had a new wound nurse due to Wound Nurse A no longer treating wounds and just working the floor effective 8/8/24. -The wounds were not healing like they should. -Wound Nurse A was on the floor all day doing treatments. -An audit was done in July and found that Wound Nurse A was not signing the TAR when the treatments were done. -Wound Nurse A was educated again about signing the TAR after the treatments were done and documenting if the physician had been called or if the resident refused the treatment. -In July 2024, A Performance Improvement Plan was put into place for Wound Nurse A not signing the TAR or documenting on the treatments as expected. -All nurses were educated on wounds on admission, following physician's orders, documentation on wounds, notifying the physician of refusal of treatments, ensure the MAR/TAR were signed off, wound care planning, wound reports, and wound documentation. During an interview on 10/9/24 at 10:13 A.M., the Physician said: -He/she would expect the licensed nurses to completed treatments as ordered for the residents. -He/she was not notified the resident was refusing any treatments. -He/she should be notified if a resident was refusing treatments. -There was no outcome from the treatments not being done. -The resident was very sick and was on hospice (end of life care) due to a decline in health. MO00243272

Based on observation, interview and record review, the facility failed to have an Infection Preventionist, maintain proper use of Personal Protective Equipment (PPE) and adhere to isolation precautions during a COVID-19 (is an infectious disease caused by the SARS-CoV-2 virus) facility outbreak placing potentially all residents at risk for exposure. The facility census was 65 residents. Review of the facility COVID 19 Testing Infection Control Manual dated 5/16/23 showed: -Purpose: --To prevent COVID 19 from entering nursing homes, detect cases quickly, and stop transmission. -Policy: --The facility will test resident and facility staff, including individuals providing services under arrangement and volunteers for COVID 19 in accordance with the current guidelines required by state and federal oversight agencies. -An outbreak is defined as a new COVID 19 infection in any facility staff or any nursing home-onset COVID 19 infection in a resident. -Residents who were asymptomatic throughout their infection and are not moderate to severely immunocompromised should be isolated regardless of vaccination status until at least 10 days have passed since the date of their first positive viral test. -Upon identification of a resident, facility staff member, person providing services under arrangement or volunteer with symptoms consistent with COVID 19 or who test positive for COVID 19, the facility will take actions to prevent COVID 19. 1. During an interview on 4/2/24 at 10:40 A.M., the Administrator said the facility is currently experiencing a COVID outbreak. Observation and interview on 4/2/24 at 11:02 A.M. through 11:16 A.M. with Licensed Practical Nurse (LPN) A showed: -LPN A was wearing his/her mask with the top of the mask exposing his/her nose. -When asked about the position of his/her mask, he/she moved the mask over his/her nose for proper placement. Observation on 4/2/24 at 1:51 P.M., with Certified Medication Technician (CMT) A showed: -He. she was wearing an N95 with the top placed under his/her nose. -When asked about mask placement, CMT A moved the mask over his/her nose. -He/She stated the mask was then being worn correctly. Observation on 4/2/24 at 1:52 P.M. with Level 1 Medication Aide (L1MA) A showed: -He/she was sitting with a resident to his/her right on a couch in the common area and another resident to his/her left, neither resident was wearing a mask. -L1MA A was wearing his/her mask with the top of the mask positioned under his/her nose. -When asked about his/her mask placement, he/she repositioned the mask over his/her nose. Observation and interview on 4/2/24 at 2:56 P.M., with Certified Nursing Assistant (CNA) A showed: -He/she was walking through the common area with residents present and his/her mask was over not his/her nose and mouth -He/she adjusted his/her mask over his/her nose when asked about mask placement. -He/She said he/she was not wearing the mask correctly because he/she was not feeling well. During an interview on 4/2/24 at 2:00 P.M., the Administrator said the first positive COVID case was on 3/25/24. Observation and interview on 4/2/24 at 2:40 P.M., through 2:51 P.M. showed: -Multiple rooms (102, 108, 109, 207, 209, and 302) were posted for contact and droplet precautions with no PPE available at the entrance to the rooms. -At room [ROOM NUMBER] CNA A placed a personal drink with a straw with the clean PPE. -CNA A said he/she just returned from break and was carrying his/her drink when the resident in room [ROOM NUMBER] needed assistance. Observation on 4/2/24 at 2:54 P.M., showed: -CMT B was standing at the end of 300 hall with the top strap of his/her N95 mask tucked inside the mask. -He/She stated he/she was wearing the mask correctly. -When asked to verify if the top strap being tucked inside the mask was correct, he/she pulled the strap out of the mask and secured the mask correctly. During an interview on 4/2/24 at 3:09 P.M., the Director of Nurses (DON) said: -Staff was not supposed to have food or drinks in the resident areas. -The drink next to the clean PPE was potential for cross contamination. -He/She has educated staff on the increased risk for cross contamination related to personal drinks and food in resident areas. -Staff are to wear their N95 masks correctly. During an interview on 4/2/24 at 3:15 P.M., the Administrator said: -He/She expected staff to wear PPE correctly and wearing their mask under their noses was not appropriate. During an interview on 4/4/24 at 3:10 P.M., the Administrator said: -He/She had been performing the role of Infection Preventionist for about a week. -About a week ago the prior Infection Preventionist resigned the position immediately. -There was a plan to hire an Infection Preventionist within the next week. MO00234193

Based on observation and interview, the facility failed to serve the lunch meal in a timely manner, according to the facility posted schedule. This practice potentially affected all residents. The facility census was 62 residents. 1. Observation on 10/30/23 at 10:46 A.M., of the posted meal times showed the lunch meal was to be served between 11:30 A.M. and 12:30 P.M. Observation on 10/30/23 during the lunch meal preparation showed: - At 11:21 A.M., Dietary Cook (DC) A made pureed (food that was made into a paste or thick liquid suspension that was usually made from cooked food that was ground finely) rice. - At 11:30 A.M. (the time that lunch should be served), DC A washed the food processor container to puree another item (vegetables). - At 11:50 A.M., DC A checked the temperature of the roast beef tips was 146.6 F (degrees Fahrenheit) and part of that dish had to go back into the oven because the rest of the roast beef dish was not at the proper temperature. - At 11:53 A.M., DC A began to serve the meals. - At 11:54 A.M., most of the roast beef tips was still in the oven, because the temperature of the roast beef tips was still between 120 F -140 F which was not hot enough according to recipe. - At 12:21 P.M., the temperature of the stew meat, was between 174 F-183 F, -At 12:29 P.M., the temperature temp of stew meat on the steam table was 170.6 F. During an interview on 10/30/23 at 11:52 A.M., DC A said: - The temperature the roast beef tips had to attain, was 155 F (degrees Fahrenheit) . - The cooking of the roast beef was running behind because the night shift on the previous day, did not place it in the refrigerator for defrosting. Observation on 10/30/23 at 12:53 P.M., showed Nurse's Aide (NA) A delivered the first tray that was delivered any resident on the 200 Hall. Observation on 10/30/23 at 1:11 P.M. showed the first tray was delivered to a resident on the 400 Hall. Review of Resident #8's quarterly Minimum Data Set (MDS -a resident a federally mandated assessment tool completed by the facility for care planning), dated 10/4/23, showed: -The resident had moderate cognitive impairment. -A resident who was able to make himself/herself understood and understood others. -A resident who had no symptoms of swallowing disorders. Observation on 10/30/23 at 1:14 P.M., showed the last room tray was delivered to the resident. During an interview on 10/30/23 at 1:16 P.M., the resident said the following: -If he/she ate in the dining room, he/she would have already receive his/her meal, he/she gets his/her meal within 30 minutes once the dining room doors open. -If he/she received a room tray, it is at least 30-45 minutes after the dining room doors open. -On that day, he/she received his/her meal 1.5 hours after the dining room doors opened. During an interview on 10/30/23 at 1:26 P.M., Licensed Practical Nurse (LPN) A said sometimes the meals come out later than that they came out on that day (10/30/23), and how late the meals are delivered from the kitchen, depended on who cooked that day. During an interview on 10/30/23 at 1:36 P.M., DC A said the food was served late because there was only one cook and the meat for the beef stew tips was not properly defrosted. During an interview on 10/30/23 at 1:47 P.M., the Dietary Manager (DM) said there were two people who did not show up for their shift on that day (10/30/23). MO 00226545

Based on observation, interview and record review, the facility failed to follow the recipe for pureed (food that was made into a paste or thick liquid suspension that was usually made from cooked food that was ground finely) rice which resulted in a bland taste for the pureed rice and the facility failed to check the temperature of plates which contained pureed vegetables, pureed meat and pureed rice which were placed on the plates and the plates were not kept at a temperature of 120 F (degrees Fahrenheit) or greater. This practice potentially affected 4 residents who required pureed food out of 9 sampled residents. The facility census was 62 residents. 1. Review of the undated recipe for five servings of pureed rice showed: -2 1/2 cups of rice. -2 Tablespoons (Tbsp) margarine. -1 1/2 cups of water. -1 teaspoon (tsp) chicken base. Observation on 10/30/23 at 11:21 A.M., showed: -Dietary Cook (DC) A made the pureed rice with no recipe book open. -DC A poured an unmeasured amount of milk into the pureed mixture. DC A did not add margarine, or chicken bases mixed into the water to the mixture. Observation on 10/30/23 at 11:26 A.M. during a taste test showed the pureed rice tasted bland. During an interview on 10/30/23 at 11:34 A.M., after a taste test by DC A, he/she said the pureed rice did not taste good. During an interview on 10/30/23 at 1:42 P.M., DC A said: -He/she did not add chicken broth to the recipe. -He/she should have checked the menu. -He/she was used to only adding milk and margarine. -He/she would have to pay closer attention to the menu. During an interview on 10/30/23 at 1:48 P.M., the Dietary Manager (DM) said he/she absolutely expected the DCs to follow the recipe. Observation on 10/30/23 from 11:44 A.M. through 11:49 showed: - DC A placed pureed rice, pureed meat stew and pureed vegetables on divide plates for four residents. - He/she wrapped each plate with foil paper. - He/she placed the four plates in one of the wells of the steam table with two plates stacked on top of one another. Observation on 10/30/23 at 12:09 P.M. showed: -DC A was about to serve the plates of pureed food without checking the temperature. -The state surveyor asked to check the temperature of one of the pureed vegetables on one of the plates was 97 F. During an interview on 10/30/23 at 2:12 P.M., DC A said: -He/she was not able to place the plates of pureed food in the steam table well 20 minutes or more minutes ahead of time because the kitchen was understaffed during the lunch meal preparation. -The temperatures of the food items on the plates should have been checked before they were sent out to the residents. During an interview on 10/30/23 at 2:16 P.M., the DM said he/she absolutely expected dietary staff to check the temperature of pureed items. MO 00226545

Based on observation, interview and record review, the facility failed to ensure that two sampled residents (Residents #6 and #8) out of 9 sampled residents, received their preferred items during their meals. The facility census was 62 residents. 1. Review of Resident #6's quarterly Minimum Data Set (MDS -a resident a federally mandated assessment tool completed by the facility for care planning), dated 8/23/23, showed: - The resident was cognitively intact. - A resident who was able to make himself/herself understood and understood others. - A resident who had no symptoms of swallowing disorders. During an interview on 10/30/23 at 11:08 A.M., the resident said: - He/She filled out a survey and selected his/her likes and dislikes. - He/She did not always get what they order on the ticket or what he/she selected. - On a past ticket dated 10/30/23, it was indicated that he/she had white bread as a dislike, but on that day, he/she received white toast, he/she did not get the yogurt she requested. - He/She requests yogurts daily but there are about two times in a week, he/she did not receive the yogurts. - On a past ticket dayed 10/26/23, he/she received a turkey sandwich which was made with white bread. 2. Review of Resident #8's quarterly MDS dated [DATE], showed: -The resident was moderately cognitively impaired. - The resident was able to make himself/herself understood and understood others. - The resident had no swallowing disorders. Observation on 10/30/23 at 1:15 P.M., showed the resident did not receive the lemonade which was circled on his/her ticket as an item the resident requested. During an interview on 10/30/23 at 2:23 P.M., Nurse's Aide (NA) A said it was his/her responsibility to ensure the residents receive the drinks they asked for. During an interview on 10/30/23 at 2:26 P.M., Certified Medication technician (CMT) A said sometimes residents do not get the drinks they asked for. During an interview on 10/30/23 at 2:34 P.M., the Director of Nursing (DON) said he/she expected the CNAs to follow what is on the ticket for each residents as far as those residents obtaining the drinks they asked for on those tickets. MO 00226545

Based on observation, interview, and record review, the facility failed to ensure coordination of care was completed for one sampled resident (Resident #72) who missed a hemodialysis (dialysis a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment resulting in an emergency hospitalization out of 19 sampled residents. The facility census was 66 residents. Review of the facility's policy titled Dialysis Care dated 10/24/22 showed: -The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all non-dialysis needs of the resident including during the time period when the resident is receiving dialysis. -The facility will arrange dialysis care for residents as ordered by the attending physician. -The facility will arrange transportation to and from the dialysis provider and a method of communication between the dialysis provider and the facility. -The licensed nurse will monitor the integrity of the catheter dressing every shift and reinforce the dressing with tape as needed. -The nephrologist (kidney doctor)/dialysis provider and the resident's attending practitioner must be notified of a canceled or postponed dialysis treatment and responses to the change in treatment must be documented into the resident's medical record. -If dialysis is canceled or postponed, the nursing staff and dialysis provider should provide or obtain ongoing monitoring and medical management for changes such as fluid gain, respiratory issues, review of relevant lab results, and any other complications that occur until dialysis can be rescheduled based on resident assessment, stability, and need. -The Interdisciplinary Team (IDT) will ensure the resident's care plan includes documentation of the resident's renal condition and necessary precautions. -The resident's care plan will be updated as needed. 1. Review of Resident #72's face sheet showed he/she admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis) -Hemiplegia (paralysis to one side of the body) following a cerebral infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain). -Dependence on Renal (kidney) Dialysis. Review of the resident's care plan dated 7/11/23 showed: -The resident needed dialysis. -The resident went to dialysis every Monday, Wednesday, and Friday, but did not include when the resident needed to be at dialysis or what dialysis clinic the resident went to. -An intervention in place to not draw blood or take blood pressure in the arm with the graft (the access site where the resident's blood is reached). -NOTE: The resident had a left central venous catheter (CVC- a long flexible tube inserted into a vein in the neck, chest, arm, or groin that reaches the vena cava (the largest vein that empties blood into the heart) chest site. Review of the resident's Medication Administration Record (MAR) dated July 2023 showed an absence of pre (before) and post (after) dialysis vital signs on 7/14/23. Review of the resident's Electronic Medical Record (EMR) on 7/14/23 showed no documentation regarding any issues with transportation and getting the resident to dialysis. Review of a progress note dated 7/14/23 at 8:10 P.M. showed the resident's family wanted to be notified if there was no transportation available for the resident to go to dialysis because he/she would take the resident to dialysis. Review of the resident's nurse's notes dated 7/15/23 at 4:08 A.M. showed: -The resident was complaining of shortness of breath and was given a pro re nata (PRN- as needed) nebulizer (a device for producing a fine mist of liquid used for inhaling medicine) treatment. -Upon reassessment the resident could not lie flat, was audibly wheezing, and was only able to speak three to four words in between breaths. -The resident's oxygen saturation (the amount of oxygen in the blood in a percentage from 0-100% with a normal range between 95-100%) level was 82%. -The resident was transported to the hospital. Review of the resident's discharge note from the local hospital dated 7/16/23 showed: -The resident needed dialysis and stayed overnight for observation. -The resident was fluid overloaded and had been placed on oxygen for the duration of the hospital stay. -The resident had an electrolyte imbalance which was fixed by the dialysis. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/17/23 showed: -The resident had moderately impaired cognition. -The resident received dialysis treatment. Review of the resident's Physician Order Sheet (POS) dated August 2023 showed the following orders: -Pre dialysis vital signs, transcribe from dialysis communication form every day shift on Monday, Wednesday, and Friday. -Post dialysis vital signs, transcribe from dialysis communication form every day shift on Monday, Wednesday, and Friday. -Resident may receive dialysis from the local dialysis clinic every Monday, Wednesday, and Friday at 6:15 A.M. -Check the bruit (the sound of blood flowing through a narrowed portion of an artery)and thrill (a vibration felt upon palpation of a blood vessel )of the dialysis access site. -NOTE: The resident did not have a dialysis access site that could have the bruit and thrill assessed. -NOTE: There was no order for monitoring the residents CVC dialysis site in his/her chest. Review of the resident's MAR dated August 2023 showed an absence of pre and post dialysis vital signs on 8/2/23. Observation on 8/8/23 at 1:09 P.M. of the resident's dialysis access site showed he/she had a CVC line to the left chest. During an interview on 8/8/23 at 1:11 P.M. Licensed Practical Nurse (LPN) B said: -There was no folder or binder for communication with the dialysis clinic. -The residents would bring back a paper form with vital signs and the nurses were responsible for inputting the vital signs into the MAR. -Once documented in the MAR the paper would get sent to medical records and scanned into the resident's EMR. During an interview on 8/8/23 at 1:16 P.M. the Director of Nursing (DON) said: -There was no binder or folder for dialysis communication. -Residents who were on dialysis were responsible for giving the paper form to the nurses once coming back from dialysis. -The resident's communication forms would get lost sometimes. During an interview on 8/10/23 at 1:09 P.M. Registered Nurse (RN) A said: -He/She did not have any residents with dialysis on his/her floor so he/she was not sure what needed to be done. -He/She thought there was a communication form that was filled out before the residents were sent to dialysis and the dialysis clinic filled it out and sent it back with the resident after dialysis. -He/She did not think there was a communication folder or binder for residents who were on dialysis. -He/She thought it was the resident's responsibility to bring the communication form to and from dialysis. -If the communication form were to get lost he/she would call the dialysis clinic to get all pertinent information. -The resident's care plan needed to be up to date and reflect the resident's current status. -He/She would not have to work with the residents who were on dialysis because he/she was only ever on his/her assigned units. During an interview on 8/10/23 at 2:53 P.M. LPN C said: -He/she would normally get told in report if the resident went to dialysis. -He/She normally did not get to see the paper communication form from dialysis. -He/She was told the resident had missed dialysis on 7/14/23 due to a transportation issue. -The resident did not have any symptoms throughout his/her shift on 7/14/23 to indicate a decline in the resident's status. -He/She thought the hospitalization on [DATE] could have been avoided if the resident had made it to dialysis. During an interview on 8/10/23 at 2:59 P.M. Medical Records said: -The facility was responsible for the transportation of the first three dialysis appointments once admitted to the facility. -After the first three appointments then the dialysis clinic took over setting up transportation. -This was for the residents who were on Medicaid. -The resident was scheduled for dialysis on Monday, Wednesday and Friday. -He/she helped set up transportation for Wednesday 7/12/23 and the resident went to dialysis that day. -He/she did not have to set up any other transportation for the resident's dialysis. -The resident did not go to dialysis on Friday 7/14/23 because of a transportation issue. -Someone had cancelled the transportation and the facility was unable to get the resident to dialysis on 7/14/23. -The resident's dialysis appointment was rescheduled for Saturday 7/15/23. -The resident left for the hospital on Saturday 7/15/23 before the rescheduled dialysis appointment. During an interview on 8/11/23 at 8:27 A.M. the receptionist who helped set up transportation said: -He/She set up the resident's first transportation to the dialysis clinic on 7/12/23. -When a resident was on Medicaid then the dialysis clinic would take over the responsibility of getting transportation for the resident to and from dialysis. -He/She thought the dialysis clinic had set up the transportation for the resident on 7/14/23. -He/She did not have any documentation of the transportation issues on 7/14/23. During an interview on 8/11/23 at 8:43 A.M. LPN B said: -Pre and Post vital signs were completed at the dialysis clinic and none were taken at the facility. -The facility was not responsible for any documentation related to dialysis except for the vital signs. -The only thing that the nurses did when the resident came back from dialysis was collect the form from the resident and input the weight and vital signs. During an interview on 8/11/23 at 9:40 A.M. Nurse Practitioner (NP) A said: -He/She would expect the nurses to monitor the resident's access site and keep it clean. -He/She would expect the nurses to get their own set of vitals before and after dialysis. -He/She would expect there to be a communication folder or binder with the resident's vital signs, medications, and any other pertinent information related to the dialysis. -The communication folder or binder would be the nurses and/or the person who helped with transportation responsibility and not the resident's. -He/She thought the hospitalization on [DATE] could have been avoided if the resident had made it to dialysis on 7/14/23. During an interview on 8/11/23 at 11:12 A.M. the DON said: -The dialysis clinic was responsible for getting the pre and post dialysis vital signs. -The nurses were not supposed to touch the resident's dialysis access sites, but would be responsible for checking the site each shift. -There should be an order and a place to chart that the nurses were checking the dialysis access site. -The resident was scheduled for dialysis on Monday, Wednesday and Friday. -The facility was only responsible for setting up the transportation to and from dialysis for the first appointment. -Transportation was set up for Wednesday 7/12/23 and the resident went to dialysis that day. -The resident did not go to dialysis on Friday 7/14/23 because of a transportation issue. -The dialysis company transportation had cancelled the transportation to the dialysis clinic. -He/she knew there was not a note in the resident's EMR regarding the transportation issue. -He/She thought the hospitalization could have been avoided if the resident had gone to dialysis on 7/14/23. -The nurses were responsible for ensuring the dialysis orders were correct. -The care plan needed to be up to date and reflect the resident's current dialysis access site and when and where the resident had dialysis.

Based on observation and interview, the facility failed to place the date that a tray of ground meat rolls and a box of hamburger patties, were taken from the freezer for defrosting; to label two containers of liquids with the substance that was in those containers; to label three containers of a white powdery substance, with the actual substance that was in those containers; to ensure three cutting boards were maintained without numerous indentations and grooves; to ensure the floor under the dishwasher was free from grime and debris buildup; to thoroughly wash the food processor between using the food processor to grind different items of food; and to ensure one Dietary Aide (DA) A washed or sanitized his/her hands between handling soiled dishes and clean dishes. This practice potentially affected 65 residents who ate food from the kitchen. The facility census was 66 residents. 1. Observation on 8/6/23 from 2:24 P.M. to 5:48 P.M., showed: -The absence of a date on the box of ground meat and the box of all beef patties as to when those items were taken from the freezer for defrosting. -The absence of labels from three large containers of white powdery substances, which could be mistaken for another substance. -The absence of labels on two condiment bottles which contained a brown colored liquid. -The presence of numerous indentations on the yellow, green, and brown cutting boards, which rendered those cutting boards not easily cleanable. -The presence of debris including plastic glasses under the dish washer area. -The absence of labels on containers of liquid. -DA A handled soiled dishes then proceeded to stack clean dishes without changing his/her gloves or washing his/her hands. -DA A used the food processor to grind the creamed corn, then only rinsed the container before using the same container to grind potatoes. During an interview on 8/6/23 at 3:12 P.M., the Central Supply Coordinator (who helped out in the kitchen for a while on that day) said the liquids that were in the two condiment bottles, were syrup which should have been labeled during the breakfast shift because syrup was used during the breakfast shift. During an interview on 8/6/23 from 4:25 P.M. to 6:26 P.M., the Dietary Manager (DM) said: -He/she had been letting staff know what each of the containers with the powdery white substances contained. -The meat was taken out of the freezer three days prior to 8/6/23, and he/she would have to let dietary staff know about placing a date on the tray the meat was in. -The dietary staff has not gotten under the dishwasher area in a while to clean under that area. -He/she expected dietary staff to change gloves and wash hands between handling soiled dishes then handling clean dishes. During an interview on 8/6/23 at 5:13 P.M., DA A said he/she was just trying to hurry the process along by not running the food processor container through the dishwasher and there were other dietary staff who did the same thing he/she did.

Based on observation, interview, and record review, the facility failed to ensure the staffing was posted and posted correctly to include the total census of the facility. The facility census was 66 residents. Review of the facility's policy titled Nursing Department-Staffing, Scheduling, and Postings dated 10/24/22 showed: -The facility will post the following information on a daily basis: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nursing Assistants (CNA's). --Resident census. -The facility will post the nurse staffing data specified above on a daily basis at the beginning of each shift. -Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. 1. Observation on 8/6/23 at 4:55 P.M. showed no staff posting could be found anywhere in the facility. Observation on 8/7/23 at 1:44 P.M. showed no staff posting could be found anywhere in the facility. Observation on 8/8/23 at 12:15 P.M. showed no staff posting could be found anywhere in the facility. Observation on 8/9/23 at 3:03 P.M. showed: -Staffing had been posted and taped to the receptionist desk. -The staffing sheet did not include the facility census. Observation on 8/10/23 at 8:31 A.M. showed: -Staffing had been posted and taped at the receptionist desk. -The staffing sheet did not include the facility census. During an interview on 8/10/23 at 11:50 A.M. CNA J said: -He/She thought the staffing was supposed to be in a binder at the nurse's station. -He/She was unsure what needed to be included on the staffing sheet. During an interview on 8/10/23 at 11:58 A.M. Certified Medication Technician (CMT) B said: -The staffing was supposed to be posted somewhere visible. -The staffing needed to include all of the licensed staff in the building and the amount of hours they worked. During an interview on 8/10/23 at 12:59 P.M. RN A said: -The staffing was usually posted on a wall around one of the hall corners, but could not determine where it specifically was located. -He/She thought the number of residents and number of staff working needed to be included on the staffing sheet. -He/She thought the staffing sheet needed to be posted in a visible location. During an interview on 8/11/23 at 8:24 A.M. the Staffing Coordinator said: -He/She was responsible for posting the staffing sheet. -The staffing was supposed to be posted at the front of the building. -He/She knew it was not being posted prior to 8/9/23. -The staffing sheet needed to include: --The date. --The facility name. --The number of residents. --The number of licensed staff. During an interview on 8/11/23 at 11:12 A.M. the Director of Nursing (DON) said: -He/She was aware the staffing sheet was not getting posted prior to 8/9/23. -He/She thought the staffing sheet needed to be posted in a visible location. -He/She was unsure of the exact requirements for what needed to be on the staffing sheet, but thought it should include: --Licensed Staff hours. --The facility census and name. --The date.