Every finding on record at Crowley Ridge Care Center

Based on interview and record review, the facility failed to ensure one resident (Resident #1) out of four sampled residents was free of misappropriation of his/her property when Social Services Director (SSD) utilized the resident's banking information for his/her own personal use. The facility census was 50. The administration was notified on 06/10/25 of the Past Non-Compliance which occurred between 06/03/25 through 06/09/25. On 06/03/25, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 06/09/25, as the facility terminated employment of SSD, in-serviced all staff on the facility's policy and procedures on misappropriation and Resident #1 is to be refunded for the amount misappropriated. Review of the facility's policy titled, Abuse Prohibition Protocol Manual, dated May 2006, showed: -Misappropriation of resident property defined as deliberate hiding, using or taking anything that belongs to a resident; -Employees are educated on the Abuse Prevention Program upon hire and annually. Review of the police report, dated 06/12/2025, showed: -During an interview on 06/11/25, SSD said Resident #1 came to his/her office for assistance with their insurance cards and Resident #1 also had his/her debit card that he/she laid on the SSD's desk. SSD wrote the debit card numbers down to use the information at a later date; -On 06/03/25, SSD transferred $500 in two separate transactions from Resident #1's account into SSD's Cash App; -SSD in an attempt to make it appear he/she was not involved in the misappropriation of Resident #1's funds made a claim to Cash App reporting fraud on his/her account. 1. Review of Resident #1's face sheet showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disease (lung disease that blocks air flow and makes breathing difficult), history of transient ischemic attack with cerebral infarction (stroke), depression, anxiety disorder, atrial fibrillation (irregular often rapid heart rate), hypertension (high blood pressure) and type 2 diabetes mellitus (uncontrolled blood sugar). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 03/27/25, showed the resident's cognition to be severely impaired. Review of the facility's investigation dated, 06/09/25, showed: -On 06/03/25, Resident #1's family member notified the facility he/she believed SSD stole money from the resident's bank account and put it on her Cash App with two separate $500 transactions. Resident #1's family along with Resident #1 went to the bank to withdraw funds from the resident's checking account and the money was not in the account. Bank investigation showed the check was deposited and then transferred into SSD's Cash App account. Resident #1's family immediately notified the facility and an investigation was started. SSD was suspended pending investigation and claimed her Cash App had been hacked and he/she would provide verification of that. The facility notified the police department to assist in the investigation. On 06/09/25, SSD admitted to the Police Department she added Resident #1's information to his/her Cash App. SSD filed a dispute of the funds taken with Cash App and Cash App will mail a check for $1000 to the SSD. The SSD will return the $1000 it to Resident #1 at the police department on Friday, 06/13/25. SSD's employment with the facility was terminated. If the SSD does not return the money as scheduled on Friday, the facility will reimburse Resident #1 for the misappropriated funds. Review of the information obtained from the resident's bank statement dated, 05/02/25-06/03/25, showed: -On 05/07/25, a transfer of $10 to an account belonging to SSD; -On 05/07/25, a transfer of $25 to an account belonging to SSD; -On 06/03/25, a two separate transfers of $500 each to an account belonging to SSD. Review of SSD's personnel file showed signed attendance for in-service regarding Abuse and Neglect on 02/28/2025. During an interview on 06/10/25 at 11:22 A.M., Law Enforcement said he/she spoke with SSD on 06/09/25 and SSD admitted to writing Resident #1's debit card information down and adding it to his/her Cash App. Family of Resident #1 agreed to not press charges against SSD if he/she would return the funds. During an interview on 06/10/25 at 11:25 A.M., SSD said he/she never took any money from Resident #1. SSD said his/her Cash App account was hacked. SSD denied admitting to the police detective she added Resident #1's banking information to his/her Cash App account and took funds from Resident #1's account. SSD said she does not know how Resident #1's information could have gotten on his/her Cash App. SSD said she disputed the two transactions through Cash App for $500 each and those funds will be returned to Resident #1. During an interview on 06/10/25 at 11:47 A.M., Resident #1 said he/she never gave SSD access or permission to use his/her bank card to transfer funds to SSD's account. During an interview on 06/10/25 at 12:17 P.M., the Administrator said he/she would expect facility staff to follow the Abuse Prevention Program policy, which they are trained on upon hire and annually. Administrator said facility staff should not add resident bank card information to their own accounts. Complaint #MO2255231

Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #47) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled residents The facility's census was 48. The facility did not provide a policy regarding trauma informed care. 1. Review of Resident #47's medical record showed: - admitted [DATE]; - Diagnoses of PTSD, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), panic disorder (a long-term anxiety disorder that involved repeated and unexpected panic attacks), generalized anxiety disorder (persistent feeling of worry), unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and delusional disorder (a serious mental illness that causes people to have unshakable false beliefs for at least a month). Review of the resident's Physician Order Sheet (POS), dated March 2025, showed: - An order for Invega Sustenna (an antipsychotic (medication used to manage psychosis (a mental health condition characterized by a severe loss of touch with reality) medication) 0.75 milliliters (ml) intramuscular (injected into the muscle) injection once a day on the 28th of each month for delusional disorder, dated 02/28/25; - An order for Seroquel (an antipsychotic medication) 200 milligrams (mg) by mouth at bedtime for panic disorder, dated 02/25/25; - An order for Xanax (an antianxiety medication) 1 mg by mouth three times a day for generalized anxiety disorder, dated 03/07/25. Review of the resident's Preadmission Screening and Resident Review (PASARR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 11/07/24, showed: - Resident with psychotic disorder, major depressive disorder, anxiety disorder, personality disorder, delusional disorder and PTSD; - The following behavior was documented: adaptation to change; - Experienced one psychiatric treatment episode that was more intensive than routine follow-up care, had attended partial care/hospitalization , or had received Program of Assertive Community Treatment or Integrated Case Management Services. Review of the resident's Care Plan, revised 02/05/25, showed: - Did not identify PTSD as a problem; - Did not address personalized triggers or interventions associated to the resident or triggers. During an interview on 03/20/25 at 9:33 A.M., Resident #47 said he/she didn't like loud noises. Lots of noise agitated him/her and made him/her anxious. He/She kept a fan on in the room with the door closed to help block out the noise from the facility. During an interview on 03/20/25 at 10:00 A.M., the Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) Coordinator said he/she would expect a resident's care plan to include a diagnosis of PTSD with triggers and the care plan should reflect the resident's current condition. During an interview on 03/20/25 at 12:00 P.M., the Administrator said she would expect the care plan to reflect the resident's current condition.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission of hospice services for one resident (Resident #50) out of three sampled residents. The facility census was 48. The facility did not provide a policy regarding the completion of significant change MDS assessments. 1. Review of Resident #50's medical record showed: - admitted to hospice services on 02/26/25; - No significant change MDS dated on or after 02/26/25; - The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice. During an interview on 03/20/25 at 10:00 A.M., the MDS Coordinator said he/she would expect a significant change MDS to be completed if a resident was admitted to hospice. He/She would expect the MDS to reflect the resident's current condition. During an interview on 03/20/25 at 12:00 P.M., the Administrator said she would expect the MDS to reflect the resident's current condition.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 38 opportunities with three errors made, for an error rate of 7.89%, which affected three residents (Residents #37, #38, and #39) out of seven sampled residents. The facility census was 48. The facility did not have a policy for insulin administration. Review of the insulin aspart (medication to lower blood sugar), Novolog (medication to lower blood sugar) insulin, and insulin lispro (medication to lower blood sugar) Pen's Manufacture Guidelines for Priming Before Each Injection and Administration, revised 02/2023, showed: - Turn the dose selector to select two units; - Hold the pen with the needle pointing up; - Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; - Keep the needle pointing upwards, press the push-button all the way in; - The dose selector returns to zero; - A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times; - Select your dose you want to give. 1. Review of Resident #37's Physician Order Sheet (POS), dated March 2025, showed an order for insulin lispro per sliding scale subcutaneous (an injection under the skin) at 7:00 A.M., 12:00 P.M., and 5:00 P.M., with meals every day for a blood sugar (BS) 70 - 130 = zero units; BS 131 - 180 = one unit; BS 181 - 240 = two units; BS 241 - 300 = three units; BS 301 - 350 = four units; BS 351 - 400 = five units; BS greater than 400, call physician, dated 06/03/24. Observation on 03/18/25 at 11:11 A.M., of the resident's insulin lispro administration showed: - Licensed Practical Nurse (LPN) A did not prime the insulin lispro pen; - LPN A administered two units of insulin lispro per the resident's pen for a blood sugar 229. 2. Review of Resident #38's POS, dated March 2025, showed: - An order for Novolog FlexPen three units subcutaneous at 7:00 A.M., 12:00 P.M., and 5:00 P.M., with meals every day, dated 09/28/24; - An order for Novolog FlexPen per sliding scale subcutaneous three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M., for a BS 70 - 130 = zero units; BS 131 - 180 = two units; BS 181 - 240 = four units; BS 241 - 300 = six units; BS 301 - 350 = eight units; BS 351 - 400 = 10 units; if BS greater than 400 = 12 units and call the physician, dated 09/28/24. Observation on 03/18/25 at 11:05 A.M., of the resident's insulin administration showed: - Licensed Practical Nurse (LPN) A did not prime the insulin Novolog pen; - LPN A administered the nine units of insulin Novolog per the resident's pen for a blood sugar 254. 3. Review of Resident #39's POS, dated March 2025, showed: - An order for insulin aspart pen give five units subcutaneous once a day at 12:00 P.M., dated 03/04/25; - An order for insulin aspart pen per sliding scale subcutaneous with meals and at bedtime at 5:00 A.M., 11:00 A.M., 4:00 P.M., and at 8:00 P.M. If BS less than 60, call the physician, BS 150 - 200 = two units, BS 201 - 250 = three units, BS 251 - 300 = six units, BS 301 - 350 = nine units, BS 351 - 400, 12 units, BS 401 - 450 = 18 units, if BS greater than 450, call the physician, dated 03/04/25. Observation on 03/18/25 at 11:21 A.M., of the resident's administration showed: - Licensed Practical Nurse (LPN) A did not prime the insulin aspart pen; - LPN A administered the 11 units of insulin aspart per the resident's pen for a blood sugar 279. During an interview on 03/18/25 at 4:15 P.M., LPN A said he/she primed the insulin pens when they were first opened and used. During an interview on 03/20/25 at 12:10 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to administer medications according to the manufacturer's guidelines.

Based on interview and record review, the facility failed to prevent the misappropriation of four resident's (Residents #1, #2, #3, and #4) narcotic medication. The facility census was 46. The administrator was notified on 02/03/25 of the Past Non-Compliance which occurred on 01/28/25. On 01/28/25, facility staff started an investigation, completed disciplinary action and began in-servicing all involved licensed nurses on the narcotic count and documentation policies and procedures. Facility staff also notified Department of Health and Senior Services on 01/28/25 and local law enforcement on 01/28/25. The noncompliance was corrected 01/31/25. Review of the facility's Medication Administration Guidelines, undated, showed: - Residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; - The complete act of administration entails removing an individual dose from a previously dispensed properly labeled container, verifying with the physicians orders, giving the individual dose to the proper resident and promptly recording the information. Review of the facility Abuse and Neglect Reporting manual dated 11/28/2016, showed: - Misappropriation of resident property as defined the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residents belongings or money without the residents' consent; - The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation; - The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment. Thoroughly investigate the alleged violation, prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress and take appropriate corrective actions as a results of the investigation finding. 1. Review of Resident #1's medical record showed: - Admission to the facility on [DATE] with diagnoses of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), pain of left ankle and left joints of left foot, pain in joints of right hand, long term use of opiate analgesics (pain medication); - Cognition severely impaired. Review of the Physician's Order Sheet (POS), dated January 2025, showed an order dated 10/12/2023, for hydrocodone-acetaminophen (APAP) (an opioid used to treat pain) 5- 325 milligrams (mg) every six hours as needed (prn) for pain. Review of the Medication Administration Record (MAR) dated January 2025, showed on 01/28/2025 there was no record of the opioid medication being administered by Certified Medication Technician (CMT) A. Review of Resident #1's Controlled Drug Receipt/Record/Disposition form (the form the facility uses to log the receipt and administration of controlled drugs), showed a quantity of 30 Hydrocodone/APAP 5/325 mg tablets were received on 01/16/25, with the most recent being administered on the morning of 01/28/2025 by CMT A, leaving 11 tablets remaining. 2. Review of Resident #2's medical record showed: - Admission to the facility on [DATE] with diagnoses of dementia, low back pain, pain in right knee, pain in right shoulder and other chronic pain; - Cognition severely impaired. Review of the POS, dated January 2025, showed an order dated 02/03/25, for hydrocodone/APAP 5/325 mg every six hours prn for pain. Review of the MAR dated January 2025 showed on 01/28/25 no record of the hydrocodone/APAP 5/325 mg being administered by CMT A. Review of Resident #2's Controlled Drug Receipt/Record/Disposition form, showed a quantity of 30 Hydrocodone/APAP 5/325 mg tablets were received on 01/20/25, with the most recent being administered on the morning of 01/28/25 by CMT A, leaving 20 tablets remaining. 3. Review of Resident #3's medical record showed: - Admission to the facility on [DATE] with diagnoses of dementia, chronic pain, low back pain, pain right shoulder and knee; - Cognition severely impaired. Review of the POS dated January 2025 showed: - An order dated 10/27/2023 admit to Hospice care; - An order dated 03/26/24 for oxycodone (an opioid used to treat pain) 5 mg every six hours prn for pain. Review of the MAR dated, January 2025, showed on 01/28/25 no record of oxycodone medication being administered by CMT A. Review of Resident #3's Controlled Drug Receipt/Record/Disposition form, showed a quantity of 30 oxycodone 5 mg tablets were received on 01/21/25, with the most recent being administered on the morning of 01/28/25 by CMT A, leaving 23 tablets remaining. 4. Review of Resident #4's medical record showed: - Admission to the facility on [DATE] with diagnoses of dementia and pain to the left shoulder; - Cognition impaired; Review of the POS dated January 2025 showed an order dated 10/12/23, for hydrocodone-APAP 10- 325 mg one tablet three times a day prn for pain. Review of the MAR dated January 2025 showed on 01/28/25 no record of the medication being administered by CMT A. Review of Resident #4's Controlled Drug Receipt/Record/Disposition form, showed a quantity of 30 hydrocodone-APAP 10-325 mg tablets were received on 01/21/25, with the most recent being administered on the morning of 01/28/25 by CMT A, leaving 22 tablets remaining. 5. Review of the facility's investigation, dated 01/28/25, showed CMT B reported to the Director of Nursing (DON) concerns regarding CMT A's narcotic record keeping and destruction of narcotics. On 01/28/25 at approximately 10:30 A.M., the DON and the Assistant Director of Nursing (ADON) conducted an audit of the medication cart CMT A had been assigned. During the audit of the narcotic box it was identified that four residents, Residents #1, #2, #3, and #4 were all missing one tablet of narcotic medications. The DON and ADON gathered the following information: - Resident #1's Controlled Drug Receipt/Record/Disposition form for Hydrocodone/APAP showed 11 tablets available, the card of Hydrocodone/APAP contained 10 tablets, one tablet could not be accounted for; - Resident #2's Controlled Drug Receipt/Record/Disposition form for Hydrocodone/APAP showed 20 tablets available, the card of Hydrocodone/APAP contained 19 tablets, one tablet could not be accounted for; - Resident #3's Controlled Drug Receipt/Record/Disposition form for Oxycodone showed 23 tablets available, the card of Oxycodone contained 22 tablet, one tablet could not be accounted for; - Resident #4's Controlled Drug Receipt/Record/Disposition form for Hydrocodone/APAP showed 22 tablets available, the card of Hydrocodone/APAP contained 21 tablets, one tablet could not be accounted for. During an interview on 02/10/25 at 12:00 P.M., CMT B said about three weeks ago he/she noticed CMT A had documented he/she (CMT A) had documented dropping pills and destroying them. CMT B said there should always be a witness to destruction of medications. CMT B said he/she had worked with CMT A for several years and knew of his/her history with drug addiction. CMT B said that was when he/she reported the information to the DON. During an interview on 02/10/25 at 1:15 P.M., the DON said on 01/28/25 CMT B reported to her that something seemed off with CMT A and he/she was not destroying narcotics with a witness. The DON said she decided to audit and reconcile all of the controlled medications and the logs. There were no discrepancies with the shift change narcotic counts but when auditing CMT A's medication cart there were narcotics missing from 4 residents. CMT A could not say what happened or where the pills were. Later that same morning, CMT A recanted her story and said he/she had taken the pills but refused to state if she actually ingested the tablets or where they were at the time. The medication cart and keys were taken from CMT A and he/she was written up and signed the termination paper showing she had misappropriated the medication and was terminated. Complaint #MO 248707

Based on observation, record review and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 43. Review of the facility's policy titled, Storage of Dry Food and Supplies, dated April 2011, showed: - The Dietary Department will store dry food and supplies according to facility guidelines and state regulations; - The storeroom must be neat and orderly; - Open boxes are to be effectively resealed. Bulk crackers, cereal, cookies, pasta, are to be stored and properly labeled in sealed containers; - Severely dented, rusted, leaking, and bulging cans must be placed in a separate, labeled holding area for return to the distributor. Observation on 04/03/24 at 10:34 A.M., of the dry food storage room showed: - Three 12 quart (qt.) plastic containers containing dry cereals without an item label or date; - One 12 qt. plastic container containing salt without a date; - One 5 gallon plastic container containing sugar without a date; - One 6 pound (lb.) 5 ounce (oz.) dented can of sliced apples, one 6 lb. 8 oz. dented can of sauerkraut, and one 6 lb. 8 oz. dented can of great northern beans on the canned food storage rack; - A 30 milliliter (ml) plastic medication cup containing a white cream substance on a food storage shelf; - A sweatshirt wadded up on a food storage shelf. During an interview on 04/03/24 at 10:50 A.M., the Dietary Manager said dented cans should be separated or returned to the distributor, the medication cup contained Silvadene (a topical antibiotic used to treat burns) for a burn on one of the cooks, containers should be labeled with the item and date, and personal items had to be kept in the food storage room because there was no other place to put them. During an interview on 04/04/24 at 10:12 A.M., the Administrator said she expects staff to not use dkeep dented food cans with the other food items and to return them to the vendor, label containers with the item name and date, and personal items should probably not be kept in the food storage room.

Based on observation, interview, and record review the facility failed to follow standard precautions to prevent the spread of infection. This had the potential to affect all residents. The facility census was 43. Review of facility policy titled, Medications, Storage of from the Nursing Guidelines Manual states: - Drugs must be stored in an orderly manner in cabinets, drawers, or carts. - Each resident must have a space assigned to them that prevents the possibility of a drug for one resident being administered to another. Review of facility policy titles, Infection Prevention and Control Program dated 10/13/22 states: - Medical staff supports the infection prevention/control program by adhering to all policies and procedures related to infection prevention. - Employees support resident safety by adhering to all guidelines related to infection prevention. Observation on 04/05/24 at 9:00 A.M., showed Certified Medication Technician (CMT) A's personal travel cup with clear lid and straw full of cream-colored liquid sitting in drawer of the medication cart along with stock medications being administered to residents. Observation on 04/05/24 at 9:00 A.M., showed CMT A pulled Polyethylene Glycol 3350 (used to treat constipation) from the same drawer of CMT A's cup to administer to Resident #37. During an interview on 04/05/24 at 9:00 A.M., CMT A stated he/she forgot to put his/her cup in the breakroom. Observation on 04/05/24 at 10:16 A.M., showed LPN B took Resident #37's Humalog Kwik Pen (an insulin injection used to lower blood sugar) opened on 04/02/24 from basket with three other residents' insulin pens. During an interview on 04/05/24 at 10:16 A.M., Licensed Practical Nurse (LPN) B stated opened insulin pens are kept in the same basket in the medication cart. During an interview on 04/05/24 at 2:00 P.M., the Administrator said he/she would expect insulin pens to be separated by resident to prevent cross contamination. 49999

Based on interview and record review, the facility failed to ensure two residents (Resident #8, and #16) received a Level II Preadmission Screening and Record Review (a comprehensive evaluation required as a result of a positive Level I screening and to determine whether placement or continued stay in a nursing facility to be appropriate) (PASARR) out of four sampled residents. The facility census was 43. The facility did not provide a policy. 1. Record review of Resident #8's significant change Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff), dated 01/22/24, showed: - admitted to the facility on [DATE]; - Diagnoses of neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), cerebral vascular accident (CVA, an interruption in the flow of blood to the brain), paraplegia (paralysis of the legs and lower body), anxiety disorder (disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a chronic and severe mental disorder which affects how a person thinks, feels and behaves); - Level I PASARR completed on 11/05/12 indicated the need for a level II PASARR to be completed; - No documentation of a Level II PASARR. During an interview on 04/04/24 at 10:30 A.M., the Social Services Director (SSD) said Resident #8 was transferred from another facility and did not have a level II PASARR completed upon admission to this facility. 2. Review of Resident # 16's medical record showed: - admitted to the facility on [DATE]; - Diagnosis of Huntington's disease (an inherited disorder that causes nerve cells in part of the brain to gradually break down and die), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder( a mental health condition that causes extreme mood swings that include emotional highs and lows) , with psychotic features, anxiety disorder (a mental health disorder characterized by feelings of worry,anxiety, or fear, that are strong enough to interfere with one's daily activities); - Level I PASARR completed on 10/20/12 indicated the need for a level II PASARR to be completed. - No documentation of a Level II PASARR. During an interview on 04/02/24 at 3:30 P.M., the Social Services Director (SSD) said that resident #16 was transferred from another facility and did not have a level II PASARR completed upon admission to this facility. During an interview on 04/05/24 at 2:00 P.M., the Administrator said that she would expect a resident who triggers a Level II PASARR to have that screening completed. 49879

Based on interview and record review, the facility failed to provide the required annual competencies of Abuse Prevention and Dementia Care for two out of two nurse aides sampled. The facility census was 43. The facility did not provide a policy regarding Abuse Prevention and Dementia Care training. 1. Review of the facility's April 2023 through March 2024 in-service records showed: - Certified Nursing Assistant (CNA) C with a hire date of 04/26/14; - CNA C attended a total of 16.5 hours of in-services; - CNA C did not attend an annual competency in-service on Abuse Prevention; - CNA C did not attend an annual competency in-service on Dementia Care. 2. Review of the facility's April 2023 through March 2024 in-service records showed: - CNA D with a hire date of 01/20/22; - CNA D attended a total of 12 hours of in-services; - CNA D did not attend an annual competency in-service on Abuse Prevention; - CNA D did not attend an annual competency in-service on Dementia Care. During an interview on 04/05/24 at 2:00 P.M., the Administrator said that annual nurse aide training should include Abuse Prevention and Dementia Care.

Based on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP), a professional who assures healthcare workers and residents are doing everything possible to prevent infection, position. This had the potential to affect all residents in the facility. The facility census was 41. The facility did not provide records indicating any staff member had been enrolled in the specialized training for the IP position. During an interview at 11/03/22 at 1:21 P.M., the Director of Nursing (DON) said she had been keeping track of the antibiotic stewardship and would be signing up for the IP class that day. During an interview on 11/04/22 at 12:52 P.M., the Administrator said the DON and Registered Nurse (RN) D both shared the responsibility of the IP. They were both in the process of signing up for the training and she would expect the IP(s) to have had the training required. Record review of the facility's policy for the Infection Prevention and Control Program, updated 10/13/2022, showed: - The IP is qualified to conduct infection prevention and control activities as a result of education, training and experience (he/she will complete the Center for Disease Control (CDC) Long Term Care Infection Preventionist module).

Based on observation, interview and record review, the facility failed to obtain a physician's order for oxygen (O2) use for one resident (Resident #138 ) out of 12 sampled residents. The facility census was 41. Record review of the facility's Physician's Orders policy, dated April 2006, showed: - Oxygen orders must specify the rate of flow, route and rationale. 1. Record review of Resident #138's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's November 2022 Physician's Order Sheet (POS) showed: - No order for oxygen use. Observations of the resident showed: - On 11/1/22 at 12:31 P.M., the resident sat in a recliner in his/her room with oxygen on at 3 Liters (L) per nasal cannula (NC) (a device used to deliver supplemental oxygen to an individual in need of respiratory help); - On 11/2/22 at 9:01 A.M., the resident sat in a recliner in his/her room with oxygen on at 3 L per NC. During an interview on 11/2/22 at 9:01 A.M., the resident said he/she used the oxygen and setting should be at 3 L. During an interview on 6/10/22 at 10:40 A.M., the Director of Nursing (DON) said there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/02/22 at 12:19 P.M., Licensed Practical Nurse (LPN) A said the resident should be on O2 at 3 L per NC. At this time, LPN A reviewed the physician's orders and said the order is not there, I guess it never got written. During an interview on 11/03/22 at 12:23 P.M., the Administrator said she would expect an order to be in place for a resident with oxygen.

Based on observation, interview, and record review, the facility failed to provide care and services for activities of daily living (such as bathing) for three residents (Resident #1, #2 and #3) out three sampled residents. The facility census was 41. The facility did not provide an Activities of Daily Living policy. Record review of the residents' scheduled shower sheets showed the residents would be bathed two times per week. Record review of Resident #1's February 10, 2022 through March 10, 2022, shower sheets showed: - The resident received two bed baths out of nine opportunities; - The facility failed to bathe the resident two times a week. Record review of Resident #2 's February 10, 2022 through March 10, 2022, shower sheets showed: - The resident received one shower out of nine opportunities; - The facility failed to bathe the resident two times a week. During an interview with a family member on 3/10/22 at 11:10 A.M., the resident had not been bathed appropriately, the family member stated he/she bathed the resident during visits. Record review of Resident #3's February 10, 2022 through March 10, 2022, shower sheets showed: - The resident received three showers out of nine opportunities; - The facility failed to bathe the resident two times a week. During an interview with a family member on 3/10/22 at 11:35 A.M., the resident had not had a shower in at least a week. He/she said a bed bath was given by him/her during a visit the other day. During an interview on 3/10/22 at 2:05 P.M., Nurse Aide (NA) A said staff had been really short-staffed and were doing what they could, but the showers had not been getting completed. NA A said the showers were scheduled two times a week. During an interview on 3/10/22 at 2:15 P.M., Certified Nurse Aide (CNA) B said showers were completed as assigned to him/her. He/she said, We had been working short-staffed. During an interview on 3/10/22 at 2:17 P.M., Licensed Practical Nurse (LPN) C said he/she was aware staff had not completed the residents' showers. The CNA's had not been turning their shower sheets in as expected. LPN C expected staff to complete the residents showers as scheduled. During an interview on 3/10/22 at 2:40 P.M., the Administrator said she would expect staff to complete the residents' showers as scheduled.

Based on interview and record review, the facility failed to implement an individualized comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for one resident (Resident #50) out of 15 sampled residents. The facility's census was 61. 1. Record review of Resident #50's medical record showed: - admitted on [DATE]; - [DIAGNOSES REDACTED].), repeated falls, history of urinary tract infections (UTI's) lack of coordination, major [MEDICAL CONDITION] (a mood disorder which interferes with daily life), and [MEDICAL CONDITION] (trouble sleeping). Record review of the resident's Physician order [REDACTED]. - [MEDICATION NAME] Sprinkles ([MEDICAL CONDITION] medication and used for behaviors) delayed release 125 milligrams (mg), one capsule by mouth two times a day, at 7:00 [NAME]M. and 12 P.M. for [MEDICAL CONDITION] with delusions, with a start date of 10/3/19; - [MEDICATION NAME] Sprinkles delayed release, 125 mg, two capsules by mouth at 8:00 P.M., with a start date of 10/3/19; - [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 75 micrograms (mcg), one tablet by mouth once a day, with a start date of 10/3/19; - [MEDICATION NAME] (an antidepressant) 10 mg, one tablet at bedtime, with a start date of 10/3/19; -[MEDICATION NAME] (a sleep aide) three mg, one tablet at bedtime, with a start date of 10/3/19; - Memantine [MEDICATION NAME] (used for [MEDICAL CONDITION]) 25 mg, one tablet two times a day, with a start date of 10/3/19; - [MEDICATION NAME] (an medication which affects the chemicals in the brain) 2.5 mg, one tablet at bedtime, with a start date of 10/3/19; - Pantoprazole (decreases the amount of acid in the stomach) 40 mg, one tablet once a day, with a start date of 10/3/19; - Donepezil (used to treat confusion) 10 mg, one tablet by mouth once a day in the evening, with a start date of 10/3/19; - [MEDICATION NAME] (a blood pressure medication) 25 mg, one tablet by mouth at bedtime, with a start date of 10/3/19. Record review of the resident's comprehensive care plan, dated 10/14/19, showed: - Did not address any of the resident's medical conditions or medications; - Did not address the resident's history of falls; - Did not address the resident's ability or lack of ability to perform activities of daily living (activities people do every day, such as eating, bathing, getting dressed, toileting, transferring and the ability to control bowel and bladder); - The resident's likes or dislikes for activities in the facility; - Any behaviors the resident may or may not have in relation to his/her [MEDICAL CONDITION] and dementia. During an interview on 12/6/19 at 12:20 P.M., the Director of Nursing (DON) said she would expect residents to have a comprehensive care plan done upon admission. The facility did not provide a policy.

Based on interview and record review, the facility failed to ensure residents diagnosed with [REDACTED]. level of functioning and psychosocial needs for one resident (Resident #50) out of one sampled resident. The facility census was 61. 1. Record review of Resident #50's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 10/14/19, showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. - Severely impaired cognitive status; - Received antipsychotic (a major tranquilizer) medication; - Received an antidepressant medication. Record review of the resident's Physician order [REDACTED]. - an order for [REDACTED]. and 12:00 P.M., dated 10/3/19; - an order for [REDACTED]., dated 10/3/19; - an order for [REDACTED]., dated 10/3/19; - an order for [REDACTED].>- an order for [REDACTED].>- Donepezil (used to treat confusion/dementia related to [MEDICAL CONDITION]) 10 mg one tablet by mouth at bedtime, with a warning not to crush, dated 10/3/19. Record review of the resident's care plan, dated 10/14/19, showed: - [DIAGNOSES REDACTED]. - A focus concern of cognitive loss and dementia due to Alzheimer's dementia; - No individualized interventions for the [MEDICAL CONDITION] care; - No individualized interventions for activities for a resident with a focus of [MEDICAL CONDITION]; - No identification of targeted behaviors with interventions; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors. During an interview on 12/6/19 at 12:45 P.M., the Director of Nursing (DON) said she would expect if a resident had a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to provide showers as scheduled for one resident (Resident #20) and to provide appropriate incontinent care for one resident (Resident #24) out of 15 sampled residents. The facility census was 61. 1. During an interview on 12/04/19 at 1:09 P.M., Resident #20's representative said he/she doesn't know if the resident always gets baths like he/she should. His/her hair gets greasy and will get dandruff. The representative has to get onto the staff and then things will get better for awhile. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/24/19, showed: - [DIAGNOSES REDACTED].); - Severely impaired cognitive status; - Total assistance of one to two staff for bathing, bed mobility, transfers, locomotion, dressing, and personal hygiene. Record review of the Shower Schedule book showed: - The resident to receive showers two times a week on Monday and Thursday evenings. Record review of the resident's shower sheets, dated 10/6/19 - 12/6/19: - For (MONTH) 2019, shower sheets completed for 10/17/19, 10/19/19, and 10/24/19; - For (MONTH) 2019, shower sheets completed for 11/11/19 and 11/18/19; - For (MONTH) 2019, shower sheets completed 12/2/19; - The facility failed to provide a shower for the resident 12 out of 18 opportunities. Record review of the facility's Bath (Shower) policy, dated 3/2015, showed: - The purpose will be to maintain skin integrity, comfort, and cleanliness; - Report any reddened areas, skin discolorations or skin breaks to the charge nurse. 2. Observation on 12/5/19 at 8:56 [NAME]M., showed: - Resident #24 lay in bed on his/her left side on an incontinent pad soiled with urine; - Certified Nurse Aide (CNA) I wiped the resident's front peri area with one wipe of the wash cloth from the back of the resident; - CNA I, with the same soiled wash cloth, wiped the resident's rectal area soiled with fecal material; - CNA I failed to use a clean wash cloth for the back peri care; - CNA I failed to wash the resident's thighs, buttocks, and hips. During an interview on 12/6/19 at 9:35 [NAME]M., CNA I said he/she wasn't prepared to provide incontinent care for the resident but he/she should have been. CNA I said he/she should have used more than one wash cloth for the front and back peri areas. He/she should have cleaned the resident's hips, buttocks, and the resident's entire front peri area. Record review of the facility's Perineal Care policy, dated 3/2015, showed: - Perform front perineal care with a wet wash cloth, make a mitt with it; - Use a new wash cloth and wash the back perineal area. During an interview on 12/06/19 at 12:48 P.M., the Director of Nursing (DON) said she would expect the staff to provide showers/baths as scheduled for Resident #20 and to document that they were completed. She would also expect staff to provide complete and appropriate incontinent care for the residents.

Based on observation, interview, and record review, the facility failed to provide professional standards of equability for one resident (Resident #17) by crushing a delayed release medication. The facility census was 61. 1. Record review of Resident #17's physician's orders [REDACTED]. - (MONTH) crush or alter medications unless otherwise indicated; - [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITIONS] disorder and irritability caused by autism) 0.5 milligram (mg) one tablet by mouth three times daily; - [MEDICATION NAME] sprinkle delayed release (medication used to treat [MEDICAL CONDITION]) 125 mg one capsule by mouth three times daily. Observation on 12/4/19 at 12:35 P.M., Certified Medication Technician (CMT) B administered the following medications to Resident #17: - [MEDICATION NAME] 0.5 mg one tablet by mouth three times daily; - [MEDICATION NAME] sprinkle delayed release 125 mg one capsule by mouth three times daily; - CMT B placed the [MEDICATION NAME] tablet in a pill crusher pouch, opened the [MEDICATION NAME] capsule and poured the sprinkles into the pill crusher pouch, crushed the medications, and added them to applesauce, and administered to the resident. Record review of the manufacturer's guidelines for [MEDICATION NAME] sprinkle on (MONTH) 2019 showed: -[MEDICATION NAME] Sprinkle Capsules may be swallowed whole or may be administered by carefully opening the capsule and sprinkling the entire contents on a small amount (teaspoonful) of soft food such as applesauce or pudding; -The drug/food mixture should be swallowed immediately (avoid chewing) and not stored for future use. During a phone interview on 12/6/19 at 10:22 [NAME]M., the Medical Director said he/she would not expect a delayed release medication to be crushed. During an interview on 12/6/19 at 1:35 PM, the Director of Nursing (DON) and the Administrator said they would expect the facility policy to be followed when crushing medications. Record review of the facility's Medication Administration policy, dated (MONTH) (YEAR), showed: - Offer resident water before/after medication administered to aid in swallowing; - Do not crush any medication if a liquid form available; - Certain medications should never be crushed; - Refer to the pharmacy manual if unsure if a medication can be crushed.

Based on interview and record review, the facility failed to electronically transmit quarterly Minimum Data Sets (MDS; a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for three residents (Resident #2, #6, and #7) out of a sample of 15 residents and five residents (#1, #3, #4, #5 and #8) outside the sample. The facility's census was 61. Record review of the MDS 3.0 Resident Assessment Instrument (RAI) for assessment transmission showed the following: - Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date; - All other MDS assessments must be submitted within 14 days of the MDS completion date. 1. Record review of the facility's Center of Medicare and Medicaid Services (CMS) submission report, with a submission date of 11/27/19, showed: - Resident #1's quarterly MDS had a target date of 10/22/19 and a submission date of 11/27/19; - Resident #2's quarterly MDS had a target date of 10/19/19 and a submission date of 11/27/19; - Resident #3's quarterly MDS had a target date of 10/20/19 and a submission date of 11/27/19; - Resident #4's quarterly MDS had a target date of 10/22/19 and a submission date of 11/27/19; - Resident #5's quarterly MDS had a target date of 10/23/19 and a submission date of 11/27/19; - Resident #6's quarterly MDS had a target date of 10/26/19 and a submission date of 11/27/19; - Resident #7's quarterly MDS had a target date of 10/27/19 and a submission date of 11/27/19; - Resident #8's quarterly MDS had a target date of 10/28/19 and a submission date of 11/27/19; - All MDS's submitted after the 14 day required timeframe. During an interview on 12/6/19 at 11:20 [NAME]M., the MDS Coordinator said he/she had just started this position this week. The previous MDS Coordinator left around the end of (MONTH) and two other people had filled in to help keep the MDS's up-to-date. The MDS Coordinator said MDS's should be completed and then transmitted by 14 days after completion. The above MDS's were all submitted to CMS late. During an interview on 12/6/19 at 12:30 P.M., the Administrator and the Director of Nursing (DON) said they would expect MDS's to be completed and submitted in the proper timeframe. Record review of the facility's policies showed the facility follows the RAI Manuel for MDS's.

Based on record review and interview, the facility staff failed to follow their policy to check the Certified Nurse Assistant (CNA) Registry for all new hires to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect), for five of six sampled staff. The facility census was 61. Record review of the facility's Abuse Prohibition Protocol Manual, Screening components, updated 8/2017, showed: - It is the policy to screen employees and volunteers prior to working with residents; - The facility will not hire an employee or engage an individual who had a finding in the State nurse aide registry of abuse, neglect, exploitation, mistreatment of [REDACTED]. - The CNA registry must be checked for all applicants, not just CNA's. 1. Record review of new hire records showed: - Registered Nurse (RN) D had a date of hire (DOH) of 11/13/18 and did not have a CNA registry check; - Laundry Aide [NAME] had a DOH of 3/19/19 and did not have a CNA registry check; - Employee F had a DOH of 10/25/19 and did not have a CNA registry check; - Employee G had a DOH of 6/28/19 and did not have a CNA registry check; - Dietary Aide H had a DOH of 9/20/19 and did not have a CNA registry check. During an interview on 12/5/19 at 10:00 [NAME]M., the Administrator said the Business Office Manager (BOM) said he/she did a CNA registry check on everyone, but if the new employee was not a CNA, the BOM would write down the date the check had been done and did not keep the paperwork for the registry check. The Administrator said she would expect the BOM to not only check the registry for all new employees, but to keep the paperwork which proves the registry check had been done.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Resident #2, #7, and #9) out of 15 sampled residents. The facility census was 61. 1. Record review of Resident #2's medical record, showed: - The resident had been on [MEDICATION NAME] (an anti-anxiety medication); - The [MEDICATION NAME] had been discontinued on 7/31/19 as part of a gradual dose reduction of medications. Record review of the resident's quarterly MDS, dated [DATE], showed: - The resident had been on an anti-anxiety medication for the past seven day look back period. The resident had not taken an anti-anxiety medication in the seven day look back period. 2. Observations of Resident #7, showed: - On 12/3/19 at 4:00 P.M., the resident sat in his/her wheelchair, in his/her room with family and did not have a catheter (a tube which drains the bladder continuously) or a catheter bag; - On 12/4/19 at 9:53 [NAME]M., and 4:00 P.M., the resident sat in his/her wheelchair in the lobby and did not have a catheter or catheter bag; - On 12/5/19 at 10:19 [NAME]M., the resident sat in the lobby area and did not have a catheter or catheter bag on his/her wheelchair. During an interview on 12/5/19 at 3:30 P.M., the Director of Nursing (DON) said when the resident had been admitted in July, he/she had a catheter for [MEDICAL CONDITION]. It had been discontinued and they did in and out catheterizations for a while to check for residual urine in the bladder but they haven't done that in a while and so the catheter for the residual urine had also been discontinued some time ago. Record review of the resident's quarterly MDS, dated [DATE], showed: - The resident still had a catheter in the seven day look back period. 3. Record review of Resident #9's Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - An order to check the Gastrostomy tube ([DEVICE]) (a tube inserted through the belly that brings nutrition directly to the stomach) for residual (the amount of fluid/contents in the stomach) before medication administration. If the residual over 100 milliliters (ml), recheck in one hour. If normal residual, give the medications, but if over 100 ml, call the physician, dated 10/15/12; - An order to flush the [DEVICE] with 240 ml of water daily, dated 10/15/12; - An order to flush the [DEVICE] with 120 ml of water before and after medication administration two times a day, dated 8/5/13; - An order to flush the [DEVICE] with 30 ml of water before and after noon medication administration, dated 7/13/16. Observation of the resident on 12/5/19 at 11:10 [NAME]M., showed: - Licensed Practical Nurse (LPN) C checked the [DEVICE] residual with a result of zero ml; - LPN C flushed the [DEVICE] with 30 ml of water before the noon medications administered, administered the noon medications per the [DEVICE], and flushed the [DEVICE] with 30 ml of water after the noon medications administered. Record review of the resident's annual MDS, dated [DATE], showed: - No feeding tube while a resident; - No fluid intake by a feeding tube; - The facility failed to accurately complete the MDS for the [DEVICE] and the water flushes. During an interview on 12/6/19 at 12:49 P.M., the Director of Nursing (DON) said she would expect the MDS's to be completed accurately and should reflect a resident's use of a [DEVICE] and water flushes for the [DEVICE]. The DON also said she would expect if a resident no longer took a medication or did not have a catheter, it should not be coded as such on the MDS. The facility did not provide a policy.

Based on interview and record review, the facility failed to address the resident's [DIAGNOSES REDACTED].#50) out of one sampled resident. The facility census was 61. 1. Record review of Resident #50's medical record showed: - The resident admitted to the facility on [DATE]; - The resident had a [DIAGNOSES REDACTED]. Record review of the resident's baseline care plan, dated 10/3/19, showed: - [MEDICAL CONDITION] not addressed; - No resident or resident representative's signature. Record review of the resident's admission progress notes, dated 10/3/19, showed: - No indication the baseline care plan discussed with the resident or the resident's representative; - No indication the baseline care plan or a summary of the baseline care plan given to the resident or the resident's representative. During an interview on 12/5/19 at 1:30 P.M., Licensed Practical Nurse (LPN) C said the admitting nurse fills out the baseline care plan when the resident is admitted . He/she said it isn't usually documented in the notes if the resident or the resident's representative is involved in the baseline care plan or if a copy is given to the resident or the resident's representative. A copy is not usually give to the resident or their representative. During an interview on 12/6/19 at 12:20 P.M., the Director of Nursing said she would expect staff to involve the resident or their representative in the baseline care plan when it is done and she would expect staff to share or give a copy of the baseline care plan to them. The facility did not provide a policy.

Based on observation, interview and record review, the facility staff failed to safely store a potentially hazardous chemical and to ensure the safety of one resident (Resident #1) of four sampled residents. The confused resident wandered into the spa (shower/bath/toilet room) and ingested a disinfectant cleaner that staff had not secured in a locked area. The facility census was 62. Record review of the facility's cleaning guidelines for tubs/whirlpools, dated March 2012, showed the guidelines directed staff to return the disinfectant to the storage area when done. Record review showed the facility did not have a policy to instruct staff to keep all chemicals in a secured locked area when not in use. 1. Review of Resident #1's face sheet showed the resident had [DIAGNOSES REDACTED]. Review of the resident's nurses note, dated 3/19/15, showed staff documented they found the resident eating foreign, non-edible, objects during the previous few days. Review of the resident's care plan, dated 3/19/15, showed staff documented the resident started eating objects such as rubber gloves and the foam pad on his/her Merry Walker. The care plan directed staff to monitor the resident closely and redirect when attempting to eat non-food items. Review of the resident's nurses notes, dated 6/9/15, showed: -At 11:45 A.M., staff found the resident at the nurses' station eating soil from a plant. Staff removed the plant and redirected the resident. -At 4:35 P.M., staff found the resident in the unlocked spa room on 300 hall drinking from a bottle of whirlpool disinfectant. The resident's eyes were red and swollen. The resident was coughing and gagging and felt clammy to the touch. Staff called 911 and poison control. The resident was transported to the hospital. Review of the resident's hospital emergency room report, dated 6/9/15 at 6:15 P.M., showed the resident had chemical induced bronchitis. Review of resident's nurses' notes, dated 6/9/15, showed: - At 8:20 P.M., staff documented the resident returned to the facility from the hospital at 7:15 P.M. The resident was pale and his/her voice was very hoarse. The resident said he/she did not feel well and needed to go to the hospital. He/she vomited large amounts of clear,mucousy phlegm and had diminished lung sounds. The physician ordered staff to transport the resident to a different hospital other than where he/she was originally sent. - At 9:00 P.M., staff received notification that the ambulance had to be diverted to the local hospital due to the resident's condition. - At 11:40 P.M., the hospital notified the facility that the resident was admitted to the hospital Intensive Care Unit with pneumonia. During interviews on 6/11/15 at 8:30 A.M. and 10:05 A.M., the Administrator said staff left a chemical (Classic Whirlpool Disinfectant Cleaner) used to clean the whirlpool jets in an unlabeled spray bottle in an unsecured spa room where they had been cleaning wheelchairs on the night shift prior to Resident #1 drinking the chemical. When staff found the resident drinking the chemical, they sent the resident to the emergency room where he/she received treatment. Upon return to the facility, the resident continued to exhibit signs of distress and was later admitted to the hospital with [REDACTED]. The resident also bit into the foam covering on his/her Merry Walker. Earlier on the day of the incident, the resident attempted to eat a plant at the nurses station and staff removed the plant. Observation on 6/11/15 at 8:45 A.M., showed the Administrator produced a gallon bottle of the chemical. The chemical was yellow and the bottle was labeled Danger and identified as Classic Whirlpool Disinfectant Cleaner. The chemical had an odor similar to window cleaner. The Administrator identified this as the chemical the resident ingested. Review of the Materials Safety Data Sheet (MSDS) showed the Classic Whirlpool Disinfectant Cleaner contained hazardous components identified as octyl decyl dimethyl ammonium chloride, alkyl dimethyl benzyl ammonium chloride, dioctyl dimethyl ammonium chloride, didecyl dimethyl ammonium chloride and ethyl alcohol. Hazardous identification (potential health effects) included possible gastrointestinal irritation, disturbance or pain if ingested. During an interview on 6/11/15 at 9:05 A.M., the Administrator, Director of Operations and Quality Assurance Nurse said staff were supposed to lock up the chemicals. During an interview on 6/11/15 at 10:30 A.M., Licensed Practical Nurse (LPN) A said that LPN B found Resident #1 in the spa room drinking a yellow chemical from an unlabeled bottle. LPN B brought the resident to the the nurses station following the incident. The resident coughed and reported a burning throat. During an interview on 6/11/15 at 10:45 A.M., the Director of Nursing (DON) said that staff used the chemical to clean wheelchairs in the spa room. Staff was supposed to lock up the chemicals but the DON thought they may just have forgotten. During an interview on 6/11/15 at 12:05 P.M., Certified Nurse Aide (CNA) C said he/she did not notice the chemical in the spa and did not use it. CNA C said he/she did not always lock up the chemicals but tried to put the chemicals in an unlocked cabinet under the sink. During an interview on 6/11/15 at 10:10 AM., CNA D said he/she did not recall seeing the chemical but that staff did not normally lock up the chemical. During an interview on 6/11/15 at 12:20 P.M., Restorative Nurse Aide (RNA) E said the resident always grabbed things and asked if they were okay to drink. RNA E said he/she recalled seeing the unlabeled bottle of yellow chemical in the spa room but it did not register to secure the chemical. During an interview on 6/11/15 at 12:35 P.M., CNA F said he/she saw the unlabeled bottle of yellow chemical in the spa room but just thought it was something from housekeeping and did not put it away. CNA F said staff stored the whirlpool disinfectant in an unlocked cabinet under the sink. During an interview on 6/11/15 at 12:40 P.M., Housekeeper G said he/she cleaned the spa earlier that day but did not notice the chemical. Housekeeper G said that, until the previous day, he/she did not have a key and could not lock the housekeeping storage closet. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility staff completed inservices with staff that included importance and requirement of storage of all chemicals and cleaning agents in a secured locked area. Licensed nurses were inserviced on monitoring that chemicals were appropriately stored in locked areas. The facility immediately examined the facility storage areas to ensure locking mechanisms were in place and in use. New locking mechanisms were placed on the whirlpool/spa areas. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations. Complaints #'s 3 & 6

Based on observation, interview and record review, the facility failed to consistently implement measures to prevent weight loss and/or promote weight gain for two residents (Resident #3 and #4) of 15 sampled residents. The facility census was 68. 1. Record review of Resident #4's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 10/4/12 showed: - [DIAGNOSES REDACTED]. - Total dependence on the staff for eating and nutrition; - No prescribed weight loss plan; - Mechanical altered oral nutrition (pureed diet); - Gastrostomy ([DEVICE], a feeding tube surgically placed into the stomach for the administration of nutrition) placed on 10/5/12. Record review of the resident's Care Plan updated on 10/9/12 showed the resident required a tube feeding due to poor oral intakes and weight loss. The care plan directed staff to monitor weight as needed, notify physician of significant weight change and provide diet and [DEVICE] feeding as ordered. Record review of the resident's November 2012 physician's orders [REDACTED]. Record review of the resident's weights showed: - In March, 2012, the resident weighed 141 pounds (lbs). - In April, 2012, the resident weighed 129 lbs, experiencing a significant weight loss of 12 lbs or 8%in one month. - In May, 2012, the resident weighed 133 lbs (a 4 lbs weight gain in one month). - In June, 2012, the resident weighed 130 lbs (a 3 lbs or 2% weight loss in one month). - In July, 2012, the resident weighed 124 lbs (a 6 lbs or 4% weight loss in one month). The resident experienced a significant weight loss of 11 lbs or 7% weight loss in three months. - In August, 2012, the resident weighed 121 lbs (a 3 lbs or 2% loss in one month). - In September, 2012, the resident weighed 112 lbs, experiencing a significant weight loss of 9 lbs or 7% in one month. The resident experienced a total weight loss of 29 lbs or 20% in six months. - In October, 2012, the resident weighed 117 lbs (a 4 lbs weight gain in one month). - On 11/4/12, the resident weighed 116 lbs. The resident experienced a total of weight loss of 25 lbs or 17% in 9 months. Record review of the resident's Nutrition and Hydration Record showed: - In July, 2012, 33 times out of 93 opportunities to eat orally, the resident refused or ate less than 25% of the meal; - In August, 2012, 42 times out of 93 opportunities to eat orally, the resident refused or ate less than 25% of the meal; - In September, 2012, 54 times out of 90 opportunities to eat orally, the resident refused or ate less than 25% of the meal; - In October, 2012, 69 times out of 93 opportunities to eat orally, the resident refused or ate less than 25% of the meal; - In November, 2012, 5 times out of 9 opportunities to eat orally, the resident refused or ate less than 25% of the meal. Observation on 11/6/12 at 9:55 A.M., showed the resident lay in bed. Licensed Practical Nurse (LPN) A checked placement of the [DEVICE], checked residual and discarded a total of 65 milliliters (ml) of the residual in the trash. During an interview on 11/6/12 at 10:10 A.M., LPN A said he/she received an order to hold the tube feeding. Record review of the meal times showed the next meal served as 12:00 P.M. and the next [DEVICE] feeding as 7:00 P.M. Observation on 11/7/12 at 7:30 A.M. showed the resident sat at the nutritionally assisted table and the staff fed the resident. The resident ate 50% of the breakfast meal. Observation on 11/7/12 at 9:15 A.M., showed the resident lay in bed. LPN A checked placement of the [DEVICE], checked residual, and discarded a total of 120 ml of the residual in the trash. During an interview on 11/7/12 at 9:25 A.M., LPN A said he/she received an order to hold the tube feeding. Record review of the meal times showed the next meal served as 12:00 P.M. and the next [DEVICE] feeding as 7:00 P.M. 2. Record review of Resident #3's quarterly MDS, dated [DATE] showed: - A [DIAGNOSES REDACTED]. - Total dependence on the staff for eating and nutrition; - No prescribed weight loss plan; - Mechanical altered oral nutrition; - Gastrostomy. Record review of the resident's Care Plan updated on 10/9/12 showed the resident required a tube feeding and directed staff to check tube placement before each feeding or medication administration and to provide the tube feeding as ordered. Record review of the resident's November 2012 POS showed the physician ordered staff to administer one can of [MEDICATION NAME] 1.5 three times per day along with a pureed diet. Record review of the resident's Nutrition and Hydration Record showed: - In September, 2012, 54 times out of 90 opportunities to eat orally, the resident refused or ate less than 25% of the meal; - In October, 2012, 54 times out of 93 opportunities to eat orally, the resident refused or ate less than 25% of the meal; - In November, 2012, 2 times out of 9 opportunities to eat orally, the resident refused or ate less than 25% of the meal. Record review of the resident's weights showed: - In September, 2012, the resident weighed 103 lbs; - In October, 2012, the resident weighed 101 lbs (a 2 lbs weight loss in one month). - On 11/6/12, the resident weighed 98 lbs (a 5 lbs or 5% weight loss in two months). Observation on 11/7/12 at 9:50 A.M., showed the resident lay in bed. LPN A checked placement of the [DEVICE], checked [MEDICAL CONDITION] residual and discarded a total of 95 ml of the residual in the trash. Observation on 11/8/12 at 9:45 A.M., showed the resident lay in bed. LPN A checked placement of the [DEVICE], checked residual and discarded 60 ml of residual in the trash. During an interview on 11/9/12 at 4:25 A.M., LPN B said during his/her shift, the resident's [DEVICE] feeding was at 2:00 A.M. LPN B said he/she checked the residual and disposed of it in the sink. During an interview on 11/9/12 at 11:00 A.M., LPN A said he/she should have re-instilled the residual back into the stomach. LPN A said he/she was taught to throw the residual away. LPN A said he/she did not think about the loss of calories or that the resident had an empty stomach for a long period of time or how this would affect the resident's weight. During an interview on 11/9/12 at 9:00 A.M., Registered Dietitian (RD) H said the staff should not have thrown away the residual. She said this was a waste of calories, the resident has a weight loss and needed all of the calories he/she could get. She said the resident had an empty stomach for too long of a period of time. During an interview on 11/15/12 at 10:45 A.M., Physician K said he/she was aware the resident had been losing weight. He/she said he/she was unaware the staff had been throwing the residual away. He/she said this was a loss of calories and an unacceptable practice. Physician K said this practice of throwing the residual away could have caused the resident to have a further weight loss.

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice when monitoring [MEDICAL CONDITION] residuals (aspiration of the stomach contents) for two (Residents #3 and #4) residents who received nutrition via a gastrostomy tube ([DEVICE], a feeding tube surgically placed into the stomach for the administration of nutrition). Staff discarded the aspirated stomach contents following residual checks. A sample of 15 residents was reviewed in a facility with a census of 68. 1. Record review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 10/11/12 showed the resident had a [DIAGNOSES REDACTED]. Record review of the resident's Care Plan updated on 10/9/12 showed the resident required a tube feeding and directed staff to check tube placement before each feeding or medication administration and to provide the tube feeding as ordered. Record review of the resident's November 2012 physician's orders [REDACTED]. Record review of the resident's weight chart showed a total weight loss of 5 pounds in one month. Observation on 11/7/12 at 9:50 A.M., showed the resident lay in bed. Licensed Practical Nurse (LPN) A checked placement of the [DEVICE], checked [MEDICAL CONDITION] residual and discarded a total of 95 milliliters (ml) of the residual in the trash. Observation on 11/8/12 at 9:45 A.M., showed the resident lay in bed. LPN A checked placement of the [DEVICE], checked residual and discarded 60 ml of residual in the trash. During an interview on 11/9/12 at 4:25 A.M., LPN B said during his/her shift, the resident's [DEVICE] feeding was at 2:00 A.M. LPN B said he/she checked the residual and disposed of it in the sink. 2. Record review of Resident #4's significant change MDS, dated [DATE] showed [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. Record review of the resident's Care Plan updated on 10/9/12 showed the resident required a tube feeding and directed staff to check tube placement before each feeding or medication administration and to provide the tube feeding as ordered. Record review of the resident's November 2012 POS showed the physician ordered the staff to administer one can of [MEDICATION NAME] 1.5 three times per day along with a pureed diet for lunch and supper and mechanical soft for breakfast. Record review of the resident's weight chart showed a total weight loss of 25 pounds in nine months. Observation on 11/6/12 at 9:55 P.M., showed the resident lay in bed. LPN A checked placement of the [DEVICE], checked residual and discarded a total of 65 ml of the residual in the trash. Observation on 11/7/12 at 9:15 A.M., showed the resident lay in bed. LPN A checked placement of the [DEVICE], checked residual and discarded a total of 120 ml of the residual in the trash. During an interview on 11/9/12 at 11:00 A.M., LPN A said he/she should have re-instilled the residual back into the stomach. LPN A said he/she was taught to throw the residual away. LPN A said he/she did not think about the loss of calories or that the resident had an empty stomach for a long period of time. During an interview on 11/9/12 at 9:00 A.M., Registered Dietitian (RD) H said throwing away the residual was "absolutely not a good practice." She said the [DEVICE] feeding was figured by calories and if the staff threw away the residual, the resident just lost all of those calories. She said both of the residents had significant weight loss and needed all of the calories. She said Resident #3 had periods of not eating and the [DEVICE] feedings would have to be calculated differently. She said Resident #4 also had periods of not eating and needed the [DEVICE] feedings. During an interview on 11/9/12 at 9:35 A.M., the Quality Assurance Nurse (QA) L said the staff should have put the residual back into the stomach of the resident. During an interview on 11/15/12 at 10:45 A.M., Physician K said he/she was unaware the staff had been throwing the residual away. He/she said this was a loss of calories and an unacceptable practice. Physician K said this practice of throwing the residual away could have caused both residents to have further loss of weight. Review of Today's Dietitian's website, the June 2010 Issue, showed: - [MEDICAL CONDITION] residual refers to the volume of stomach contents or fluid remaining in the stomach at a point in time during tube feeding; - Nurses withdraw this fluid via the feeding tube by pulling back on the plunger of a large (usually 60 ml) syringe at intervals typically ranging from four to eight hours; - Most or all of the measured residual fluid should be replaced into the patient's stomach to prevent fluid, electrolyte and nutrient loss.