Every finding on record at Crystal Oaks

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care for one resident (Resident #27) and urinary catheter (a flexible tube that is placed to drain urine from bladder) care for one resident (Resident #44) out of three sampled residents. The facility census was 120.Review of the facility's Handwashing/Hand Hygiene policy, revised October 2023, showed:- The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections;- Hand hygiene is indicated immediately before touching a resident, before performing an aseptic (to keep free from germs) task, such as handling an invasive medical device, after contact with blood, body fluids or contaminated surface;- Hand hygiene is indicated after touching a resident, a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal;- Use an alcohol-based hand rub containing at least 60 percent alcohol for most clinical situations;- Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea;- Single-use disposable gloves should be used before an aseptic procedure, when anticipating contact with blood or body fluids, and when in contact with a resident or equipment or environment of a resident on contact precautions;- The use of gloves does not replace hand washing/hygiene. 1. Observation of wound care for Resident #27 on 12/04/25 at 10:10 A.M., showed:- Licensed Practical Nurse (LPN) A washed hands, placed a towel barrier on the bedside table, and donned a gown and gloves;- LPN A obtained a plain packing strip (type of dressing) container, alginate (highly absorbent wound dressing), small amount of gentamicin (antibiotic ointment) and barrier cream in separate cups, and scissors from the treatment cart, then placed the supplies on the covered bedside table;- LPN A placed a clean towel under the resident and positioned on his/her side;- LPN removed gloves, sanitized hands and donned clean gloves;- LPN A obtained cleanser from the table, sprayed onto the wound, set back on the table, cleaned the wound with a gauze pad and removed gloves;- Without sanitizing, LPN A donned clean gloves, placed barrier cream around the wound with a cotton swab and removed gloves; - Without sanitizing, LPN A donned clean gloves and placed gentamicin in the wound with a cotton swab;- With the same gloves, LPN A removed packing from the container and placed into the wound with a cotton swab;- LPN A removed gloves, sanitized hands, and donned clean gloves;- LPN A placed alginate with a gloved finger onto the wound and applied dressing;- With the same gloves, LPN A removed the towel from under the resident, assisted the resident with his/her pants, and repositioned;- LPN A removed gloves, carried supplies inside of the towel to the treatment cart, removed gown, and washed hands;- LPN A, without cleaning the shared containers, placed the alginate container and the wound cleanser in the cart. During an interview at 10:30 A.M., LPN A said the containers should have been cleaned before placing back into the cart. 2. Observation of urinary catheter (a flexible tube inserted into the bladder to drain urine) care for Resident #44 on 12/04/25 at 10:35 A.M., showed:- Certified Nurse Aide (CNA) B and CNA C washed hands and donned gowns and gloves;- CNA B placed a towel on the bed as a barrier, then placed the washcloths and new bags on the barrier;- CNA B and CNA C pulled the bed away from the wall and pulled the cover from the resident;- CNA B lowered the bed and removed the resident's brief; - CNA B cleaned both sides of the groin area with a clean wipe each time, provided by CNA C; - With the same gloves, CNA B cleaned around the urinary catheter insertion site and down the catheter several inches with a clean cloth;- With the same gloves, CNA B removed the resident's protective boots, placed the urinary bag onto the bed, and assisted the resident to his/her left side;- With the same gloves, CNA B cleaned the buttock area with a clean washcloth and rolled the resident to his/her right side;- CNA C placed a clean brief under the resident, rolled the resident onto his/her back, attached the brief, and placed the protective boots back on the resident;- CNA C removed gloves, sanitized hands, donned clean gloves, placed the bed against the wall, locked the wheels in place, and placed the call light near the resident;- CNA B removed gloves, sanitized hands, donned clean gloves, drained the urine from the urinary collection bag into a graduated cylinder (a container with a scale used to measure liquid), and emptied in the bathroom;- With the same gloves, CNA B adjusted the resident's pillow and blanket and moved the bedside table closer to the resident;- CNA B and CNA C removed gowns, gloves, and sanitized hands before leaving the room. During an interview on 12/04/25 at 10:54 A.M., CNA B said gloves should have been removed and hands sanitized after moving the bed, touching the blanket, and prior to beginning catheter care. Hands should have been sanitized and new gloves placed after the catheter bag was emptied and before touching the resident's pillow and blanket. During an interview on 12/04/25 at 2:30 P.M., the Administrator and Director of Nursing said they would expect staff to use proper hand hygiene when performing wound and urinary catheter care and items/containers should be cleaned after being handled with dirty gloves prior to placing back into the treatment cart.

Based on interview and record review, the facility failed to provide a bed hold policy upon transfer to the hospital for two residents (Residents #7 and #79) out of five sampled residents and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital for one resident (Resident #79) out of five sampled residents. The facility also failed to complete a discharge summary that included a recapitulation of stay, describing the resident's course of treatment while residing in the facility, for one resident (Resident #136) out of two closed records reviewed. The facility's census was 120. The facility did not provide a policy. 1. Review of Resident #7's medical record showed: - admitted on [DATE]; - Transferred to the hospital on [DATE] and returned to the facility on [DATE]; - Transferred to the hospital on [DATE] and returned to the facility on [DATE]; - Transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that a copy of the bed hold policy was provided to the resident and/or the resident's representative. 2. Review of Resident #79's medical record showed: - admitted on [DATE]; - Transferred to the hospital on [DATE] and returned to the facility on [DATE]; - Transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification was provided to the resident and/or the resident's representative of the transfer. 3. Review of Resident #136's medical record showed: - admitted on [DATE]; - discharged on 09/08/25; - An order to discharge to another facility with hospice evaluation, dated 09/08/25; - A Summary of Episode with no assessment, no encounters, no goals, no functional status, no health concerns, no medical equipment, no medications, no plan of treatment, no procedures, no reasons for referral, and no diagnostic results documented; - No discharge summary or progress note regarding the resident's discharge; - No recapitulation of stay. During an interview on 12/04/25 at 1:30 P.M., the Director of Nursing (DON) said when they discharge a resident, they send a face sheet and a medication list to the facility they're transferring to. This resident discharged to another facility per the resident's choice. She believes they can pull the information from different sources, but they don't have it all together in one place, as is being requested. She is not familiar with the recapitulation of stay, but she is able to provide a Summary of Episode. She would expect there to be a progress note in the chart when a resident discharges. During an interview on 12/04/25 at 2:30 P.M., the Administrator and DON said they would expect a recapitulation of stay to be completed when a resident is discharged and a written notification of transfer and a copy of the bed hold policy to be provided to the resident and/or the resident's representative when transferred out of the facility.

Based on observations, interviews and policy review, the facility failed to ensure food was served under sanitary conditions and failed to ensure kitchen equipment were cleaned and stored in a manner to prevent contamination from foreign substances and the potential for development of foodborne illness. Specifically, the facility did not ensure staff used and maintained proper hand hygiene during food service and distribution, as well as failing to clean and maintain ice/water machine and steam table. This deficient practice has the potential to affect 117 of 117 residents who receive meals and beverages prepared in and served from the facility's kitchen. Findings include: On 08/19/24 at 11:38 AM, [NAME] 1 was observed checking the temperature of the food on the steam table prior to lunch service. [NAME] 1 removed the thermometer from her scrubs top and removed the thermometer from its sleeve cover. Without cleaning the thermometer, Cook1 placed the thermometer in the pureed meatloaf. After confirming the meatloaf was at the appropriate temperature, Cook1 removed the thermometer and was provided alcohol wipes by the Dietary Manager (DM). Cook1 was having a difficult time getting an appropriate reading of the pureed bread and asked Dietary Aid (DA1) to assist. DA1 took the thermometer and with her fingers touched the under portion of the head of the thermometer. DA1 pushed the thermometer in the dish until the bottom of the head of the thermometer touched the food. DA1 removed the thermometer and cleaned the thermometer. DA1 approached the steam table, the thermometer slipped from her hand, and she caught it against her right side, with the thermometer resting between her hand and scrubs. DA1 did not clean the thermometer and placed the thermometer into the meatloaf. During the lunch meal service on 08/19/24 at 12:00 PM, DA2 was observed providing drinks to residents in the main dining room. DA2 was utilizing a beverage cart that contained multiple beverage types and an ice chest with a scoop. DA2 offered beverages to residents at 11 tables. During this observation DA2 did not sanitize her hands. DA was observed touching handles of wheelchairs, tables, the beverage cart, and her own scrubs, as she took residents' their drink orders. After touching those items, DA2 was observed grabbing either coffee cups or cold beverage cups from the bottom of the beverage cart, and if the resident requested ice, DA2 would grab the ice scoop that was located inside of the ice chest, place ice in the cold beverage cup and place the ice scoop back inside the ice chest. Residents that requested coffee with cream, DA2 opened each individual creamer and or sugar packet. Observation at 12:29 PM, DA2 without wearing gloves, was observed assisting a resident with a straw. DA2 removed the paper sleeve of the straw and placed the straw in the resident's beverage. During a second dining observation on 8/20/24 at 11:43 AM, [NAME] 2 was observed plating the meal service. [NAME] 2 placed the hamburger on the bun, then the top bun on the burger with her hands, without the use of gloves. The DM, who was present during the meal service, was asked what her expectation was regarding hand hygiene during meal service. The DM stated that staff should sanitize their hands in between residents and to not touch food directly without wearing gloves. Review of the facility policy titled Food Preparation and Service dated November 2022, revealed, Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness Distribution Service .Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. During an observation of the common areas on 08/21/24 of the 400/500 hallway at 8:43 AM and the 100/200 hallway dining at 8:59 AM, revealed ice/water machines that were used to provide residents ice and water on the unit. The ice/water machine on the 400/500 hallways had crystallized whitish-gray and brown debris located on the ice and waterspouts. The chute cover for the waterspout was missing and located on the top of the machine, which was covered in a layer of dust and other debris. The reservoir grate also contained crystallized whitish-gray and brown debris along with dust and other unknown particles. The ice/water machine in the 100/200 hallway dining room revealed the same crystallized whitish-gray and brown debris on the water and ice spouts and chute covers. On the reservoir grate was an uncovered ice scoop that was covered in a yellowish flaky substance. Interview on 08/21/24 at 9:00 AM with Housekeeper (HK)1, he confirmed that housekeeping was responsible for cleaning and maintaining the outside of the ice/water machine daily. He added that the maintenance department was responsible for deep cleaning and maintaining the internal portion of the machine. Interview with the Maintenance Director (MD) on 08/21/24 at 9:11 AM, was asked if he maintained and cleaned the ice/water machines and he stated that he was not sure. In a subsequent interview with the MD, on 08/22/24 at 9:33 AM, he provided a book labeled Ice Machine Maintenance Monthly Log Sheet. Inside the book was a single sheet of paper that contained columns, which were each headed with a hallway followed by a month and year. Besides each date was a staff's initial. During an interview with the Director of Housekeeping and Laundry Services (DHLA) on 08/21/24 at 10:13 AM, she confirmed housekeeping staff is responsible for wiping down the ice/ water machine each evening. She was asked if there was documentation to show that this is done daily, and she stated that she does not have any documentation. Observation on 08/22/24 at 5:49 AM of the ice/water machine in the 400/500 common area revealed crystallized whitish-gray and brown debris located on the ice and waterspouts. The water chute cover was missing and was located on the top of the machine. Interview on 08/22/24 at 6:15 AM, HK2 stated that she is only responsible for wiping the ice machine down and that it is done each morning. Interview on 08/22/24 at 6:22 AM, the Director of Nursing (DON) confirmed that the ice machine in the common area of the 400/500 did not appear as if it had been cleaned weekly. Review of the facility policy titled Ice Machines and Ice Storage Chests dated January 2012 provided by the DON revealed, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. The policy also revealed that the facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. During an observation on of the steam table area on 08/22/24 at 5:51 AM revealed two meal trays on the bar above the steam table. The two meal trays contained soiled plates, cups, silverware, and uneaten food. The counter below the bar top includes cabinets and three sinks. The middle sink contained soiled silverware and the sink to the right contained a large pot. The countertop surrounding the sinks was stained with a whitish substance which could also be seen on and around the faucet. There were also food particles on the counter, on the floor, underneath the steam table and on the steam table. The lids of the steam table along with the compartments were soiled. The water in the five compartments steam table was cloudy and there were visible food particles floating within the water. The base and the side of the compartments were also stained with a whitish substance. During an interview on 08/22/24 at 6:02 AM, [NAME] 2 stated that the nursing staff leaves trays overnight on the bar top, adding that there are usually a lot more items left overnight, and this has led to an issue with pests, specifically ants. When asked what her responsibility was in that area, she stated she is only responsible for the steam table itself. Cook2 advised that she wipes it down daily and adds water to the steam compartments. She stated that the water is usually brown and the area around the steam table was not appropriate for food service. During an interview on 08/22/24 at 7:25 AM, the DM stated that the steam table was cleaned regularly. She added that some of the stains are persistent due to the hard water, but stated the compartments were de-limed weekly. The DM also provided a cleaning schedule that indicated which staff was responsible for a specific item and it indicated the cooks were responsible for the steam table, maintenance is responsible for the ice machines, and all dietary staff are responsible for cleaning sinks, counters, and mopping and sweeping floors.

Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan that addressed activities for six of 28 sampled residents (Resident (R) 33, R59, R67, R85, R89, and R102). This failure had the potential to result in activities not provided for the residents. Facility census was 117. Findings include: 1. Review of R33's undated Admission Record located in the electronic medical record (EMR) in the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease without dyskinesia. Review of R33's Annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/11/23, revealed a Brief Interview for Mental Status (BIMS), score of nine out of 15 indicating R33 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R33 to keep up with the news, to listen to music he likes, to do favorite activities, to do things with groups of people, to go outside, and participate in religious activities. Review of R33's quarterly MDS with an ARD of 06/08/24 revealed a BIMS score of 12 out of 15 which indicated that R33 was moderately cognitively impaired. Review of R33's comprehensive Care Plan, dated 02/08/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory, but am able to answer most questions . with an intervention of encourage me to attend acts of my current or past interest . However, the care plan did not address activities for R33. 2. Review of R59's undated Admission Record located in the EMR under the Profile tab, revealed he was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury. R59 was readmitted on [DATE] with a diagnoses of noninfective gastroenteritis and colitis. Review of R59's Annual MDS under the MDS tab of the EMR, with an ARD of 11/28/23, revealed a BIMS, score of 15 out of 15 indicating R59 was cognitively intact. Further review of the MDS revealed it was very important for R59 to listen to music he likes, to keep up with the news, to do things with groups of people, and to go outside. Review of R59's quarterly MDS with an ARD of 05/24/24 revealed a BIMS score of 15 out of 15 which indicated R59 was cognitively intact. Review of R59's comprehensive Care Plan, dated 10/25/21, located in the EMR under the Care Plan tab, revealed there was no focus area for activities on the care plan. 3. Review of R67's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of other schizophrenia. Review of R67's Annual MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS, score of 15 out of 15 indicating R67 was cognitively intact. Further review of the MDS revealed it was very important for R67 to keep up with the news, to do your favorite activities, to go outside, and participate in religious activities. Review of R67's comprehensive Care Plan, dated 06/09/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory but am able to make simple choices between items or tasks . with an intervention to encourage me to attend acts of my current or past interest . The care plan did not address activities for R67. 4. Review of R85's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of intestinal adhesions with complete obstruction. R85 was readmitted to the facility on [DATE] with a diagnosis of gastrointestinal hemorrhage. Review of R85's Annual MDS under the MDS tab of the EMR, with an ARD of 07/13/24, revealed a BIMS, score of 15 out of 15 indicating R85 was cognitively intact. Further review of the :MDS revealed it was very important for R85 to have things to read, to do things with groups of people, to go outside and participate in religious activities. Review of R85's comprehensive Care Plan, dated 10/10/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory from time to time . with an intervention to encourage me to attend acts of my current or past interest . The care plan did not address activities for R85. 5. Review of R89's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of paroxysmal atrial fibrillation. Review of R89's Annual MDS under the MDS tab of the EMR, with an ARD of 01/17/24, revealed a BIMS, score of 12 out of 15 indicating R89 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R89 to have things to read, to listen to music she likes, to do favorite activities, to go outside, and participate in religious activities. Review of R89's quarterly MDS with an ARD of 07/16/24 revealed a BIMS score of 13 out of 15 which indicated R89 was cognitively intact. Review of R89's comprehensive Care Plan, dated 03/15/23, located in the EMR under the Care Plan tab, revealed there was no focus area for activities on the care plan. 6. Review of R102's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R102's Admission MDS under the MDS tab of the EMR, with an ARD of 12/04/23, revealed a BIMS, score of 14 out of 15 indicating R102 was cognitively intact. Further review of the MDS revealed it was very important for R102 to have things to read, to listen to music she likes, to keep up with the news, to do favorite activities, to go outside, and participate in religious activities. Review of R102's quarterly MDS with an ARD of 06/02/24 indicated a BIMS score of 15 out of 15 which indicated that R102 was cognitively intact. Review of R102's comprehensive Care Plan, dated 12/27/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory from time to time . with an intervention to encourage me to attend acts of my current or past interest . The care plan did not address activities for R102. During an interview on 08/21/24 at 2:16 PM, the Minimum Data Set Coordinator (MDSC) confirmed she does not write care plans for activities, but the former Activities Director used to write them for the residents. The MDSC stated she did not know who was to review and complete the resident's activity care plan. During an interview on 08/22/24 at 10:04 AM, the Activity Coordinator acknowledged that she was not aware that a care plan had to be completed for activities. During an interview on 08/22/24 at 6:33 AM, the Director of Nursing (DON) stated she did not know that care plans for activities were not being completed for the residents. During an interview on 08/22/24 at 10:53 AM, the Administrator stated activities should be care planned and resident centered. Review of the facility-provided policy titled Care Plans, Comprehensive Person-Centered, revised March 2022 revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including .

Based on interview, record review, document review and facility policy review, the facility failed to provide a program of activities to support residents in their choice of activities on the weekends for six of six residents (Resident (R) 33, R59, R67, R85, R89, and R102) that attended the group meeting. This failure had the potential to negatively impact the quality of life for the affected residents. The facility census was 117. Findings include: 1. Review of R33's undated Admission Record located in the electronic medical record (EMR) in the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R33's Annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/11/23, revealed a Brief Interview for Mental Status (BIMS), score of nine out of 15 indicating R33 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R33 to keep up with the news, to listen to music he likes, to do favorite activities, to do things with groups of people, to go outside, and participate in religious activities. Review of R33's quarterly MDS with an ARD of 06/08/24 revealed a BIMS score of 12 out of 15 which indicated that R33 was moderately cognitively impaired. 2. Review of R59's undated Admission Record located in the EMR under the Profile tab, revealed he was admitted to the facility on [DATE]. Review of R59's Annual MDS under the MDS tab of the EMR, with an ARD of 11/28/23, revealed a BIMS, score of 15 out of 15 indicating R59 was cognitively intact. Further review of the MDS revealed it was very important for R59 to listen to music he likes, to keep up with the news, to do things with groups of people, and to go outside. Review of R59's quarterly MDS with an ARD of 05/24/24 revealed a BIMS score of 15 out of 15 which indicated R59 was cognitively intact. 3. Review of R67's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R67's Annual MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS, score of 15 out of 15 indicating R67 was cognitively intact. Further review of the MDS revealed it was very important for R67 to keep up with the news, to do your favorite activities, to go outside, and participate in religious activities. 4. Review of R85's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R85's Annual MDS under the MDS tab of the EMR, with an ARD of 07/13/24, revealed a BIMS, score of 15 out of 15 indicating R85 was cognitively intact. Further review of the MDS revealed it was very important for R85 to have things to read, to do things with groups of people, to go outside and participate in religious activities. 5. Review of R89's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R89's Annual MDS under the MDS tab of the EMR, with an ARD of 01/17/24, revealed a BIMS, score of 12 out of 15 indicating R89 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R89 to have things to read, to listen to music she likes, to do favorite activities, to go outside, and participate in religious activities. Review of R89's quarterly MDS with an ARD of 07/16/24 revealed a BIMS score of 13 out of 15 which indicated R89 was cognitively intact. 6. Review of R102's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R102's Admission MDS under the MDS tab of the EMR, with an ARD of 12/04/23, revealed a BIMS, score of 14 out of 15 indicating R102 was cognitively intact. Further review of the MDS revealed it was very important for R102 to have things to read, to listen to music she likes, to keep up with the news, to do favorite activities, to go outside, and participate in religious activities. Review of R102's quarterly MDS with an ARD of 06/02/24 indicated a BIMS score of 15 out of 15 which indicated that R102 was cognitively intact. During an interview on 08/20/24 at 10:15 AM, the Activity Coordinator stated the Activity Director resigned and there were only two staff members in the department. The Activity Coordinator confirmed the activity coordinators no longer work on the weekends. The Activity Coordinator stated she left activity packets on the weekends for residents at the nurses' stations which included coloring sheets, puzzles and things to read. During the Group interview on 08/21/24 at 10:35 AM, six residents (R33, R59, R67, R85, R89, and R102) confirmed there were no activities provided on the weekends and they would like evening activities because the evenings were long. The residents stated they have never used the packets that are left for them on the weekends because coloring is not something that stimulated them. The residents also stated a church group came to provide services every other Sunday, but they were not allowed to receive communion because there was no staff at the church service to ensure residents did not choke on the bread, or any diabetics did not drink the juice. During an interview on 08/22/24 at 6:33 AM, the Director of Nursing (DON) stated she was not aware that the activity coordinators did not work on the weekends. The DON also stated she thought communion was being done. During an interview on 08/22/24 at 10:53 AM, the Administrator acknowledged she was aware that the activity coordinators did not work on the weekends, and they alternate schedules for weekends and evenings. Review of the facility-provided documents titled Activity Calendar, dated August 2024, revealed on the 100, 200, 300, 400, and 500 halls activity packets were listed as an activity on 08/03/24, 08/10/24, 08/17/24, 08/24/24, and 08/31/24; Color Away Sunday was listed as an activity on 08/04/24, 08/11/24, 08/18/24 and 08/25/24; and Chapel Service was listed as an activity on 08/11/24 and 08/25/24 at 10:00 AM. Review of the facility-provided policy titled Activity Programs, revised June 2018, revealed Policy statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation . 12. Individualized and group activities are provided that: . b. are offered at hours convenient to the residents, including evenings, holidays, and weekends; .

Based on observation, interview, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure one of one clean laundry cart was covered to prevent potential contamination of all residents' in the facility personal items. The facility census was 117. Findings include: Review of the CDC guidance titled Healthcare-Associated Infections (HAI) dated 03/19/24 https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html#:~:text=Each%20floor%2Fward%20should%20have,detergent%20and%20warm%20water%20solution indicated, . Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Observation on 08/19/24 at 10:52 AM, the uncovered clean laundry cart came through the dining room. The laundry cart contained personal items During an interview on 08/19/24 at 11:43 AM, the Housekeeping/Laundry Aide 1 stated she delivered resident laundry to all rooms and has never been told to cover the clean laundry on the cart. During this observation, the cart contained residents' personal items. During an interview on 08/21/24 at 10:25AM, the Director of Housekeeping/Laundry stated she was told not to cover personal laundry only linens. The Director of Housekeeping/Laundry stated the facility outsourced all linens and the facility was only responsible for washing personal laundry. During an interview on 08/22/24 at 11:03 AM, the Administrator stated it was his expectation that residents' personal laundry was covered during transportation from the laundry to the residents' rooms.

Based on observation and interview, the facility failed to provide one of five shower rooms (300 unit shower room) that was functional and had a sanitary environment for residents in the facility. Specifically, the facility failed to ensure that the 300 unit shower room was clean and free of mold and feces on the floor, the shower curtain was free of brown stains, the shower cord did not spray water and the toilet was clean and in good repair. These failures had the potential to affect all residents on the 300 hallway who used the 300 shower room. The facility census was 117. Findings include: Observation on 08/20/24 at 9:53 AM of the shower room at the end of the 300-hall revealed a strong unrecognizable odor. The toilet in the shower room was dirty with stains and was loose from the floor. The shower curtain was heavily soiled. The shower walls had a pinkish/orange and black substance on them. There was a dead bug on the shower room floor. Registered Nurse (RN) 2, Nurse Manager for the 300, 400, and 500 halls, was present during this observation and confirmed the observations. During the Group interview on 08/21/24 at 10:35 AM, six residents (R)33, R59, R67, R85, R89, and R102) stated the shower rooms were nasty especially the 300-hall shower room. The six residents stated there was a pinhole leak in the shower cord and that they would get sprayed in the face during a shower. The six residents stated the shower curtain was dirty with brown stains; the floors were dirty and there were times there was feces on the floor. The six residents stated the inside of the shower has mold and shower floor was not clean. During an interview on 08/22/24 at 6:26 AM, the Director of Nursing (DON) stated she was aware of the 300-hall shower room condition. The DON stated she was unaware of the hole in the shower line spraying the residents. During an interview on 08/21/24 at 2:03 PM, the Director of Housekeeping/Laundry confirmed the 300-hall shower room needed to be scrubbed. The Director of Housekeeping/Laundry stated that the housekeeping staff clean the showers daily. The Director of Housekeeping/Laundry stated she did see black mold. During an interview on 08/22/24 at 11:11 AM, the Administrator stated that the shower rooms should be cleaned prior to each resident use.

Based on observation, interview and record review, the facility failed to ensure a resident's sense of well-being was promoted due to enhanced barrier precautions (EBP). Specifically, a sign was posted on the door for one of 28 sampled residents (Resident (R) 30), which caused a negative effect on R30's sense of well-being. The facility census was 117. Findings include: Review of R30's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab, showed she was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (ESRD). Review of R30's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, located in the EMR under the MDS tab, revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Observation on 08/20/24 at 8:32 AM revealed there was an enhanced barrier precautions (EBP) sign posted on the outside of R30's door. During an interview at this time, R30 stated she feels that the EBP sign posted on her door was an invasion of her privacy and does not like that residents and family members were asking if she had COVID [coronavirus disease] all the time. Continued interview with R30 on 08/20/24 at 9:42 AM, R30 told the Assistant Administrator that she did not want the EBP sign placed on the outside of her door and the Assistant Administrator replied, I do not like it either, but this is what we have to do. During an interview on 08/22/24 at 6:46 AM, the Director of Nursing (DON) stated she was not aware the EBP sign on the door was a concern for R30. The DON also stated she understood how the sign posted on the door was a dignity issue. During an interview on 08/22/24 at 7:31 AM, the Assistant Director of Nursing (ADON) stated R30 never mentioned the EBP signage on the door was a dignity issue and she was not aware that the signage did not have to be placed on the door. Review of the facility-provided policy titled Dignity, revised February 2021 revealed, Policy Statement Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times . Review of the facility-provided policy titled Enhanced Barrier Precautions, revised March 2024 revealed, Policy Statement Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents . Policy Interpretation and Implementation . 11. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE [personal protective equipment] required .

Based on record review and interviews, the facility failed to ensure that mail was delivered on Saturdays to the residents of the facility. This deficient practice has the potential to affect all of the residents in the facility. The failure to not receive mail on Saturday could cause residents to not receive important business documents timely and family communications. The facility census was 117. Findings include: 1. Review of R59's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R59's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. 2. Review R102' EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R102's EMR titled quarterly MDS with an ARD of 06/02/24 indicated the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 3. Review of R89's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R89's EMR titled quarterly MDS with an ARD of 07/16/24 indicated the resident had a BIMS score of 13 out of 15 which revealed the resident was cognitively intact. 4. Review of R67's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R67's EMR titled quarterly MDS with an ARD of 07/30/24 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. During the Group interview on 08/21/24 at 3:59 PM, four of the six residents (R )59, R102, R89, and R67) stated that they do not receive mail or package delivery on Saturdays. The residents stated that the activity staff deliver mail Monday through Fridays but do not work on the weekend so there was no mail delivery. During an interview on 08/22/24 at 11:13 AM, the Assistant Administrator stated she was unaware that mail had to be delivered on Saturdays to the residents of the facility. The Assistant Administrator stated that the facility uses PO box at the post office and either the Administrator, Assistant Administrator or Human Resources goes Monday through Friday to pick up the facility's mail from the PO box. Since they don't work on Saturdays, there is no one to go to the post office to pick up the mail.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) of three sampled residents was free from significant medication error when staff failed to verify the medication administered correlated to the physician's orders for 16 doses of a high alert (medication that bears a heightened risk of causing significant patient harm when they are used in error) chemotherapy medication (treatment that uses powerful chemicals to kill fast-growing cells in your body) which resulted in increased pain and multiple infections due to the properties of the medication and toxicity. The resident died as a result. The facility census was 118. The administrator was notified on [DATE] at 3:30 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Record review of the facility's Administering Medications Policy dated [DATE] showed: - Medications are administered in accordance with the prescriber orders, including any time frame; - If a dosage is considered to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected with being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician of the facility's medical director to discuss the concerns; - The individual administering the medications will verify the resident's identity before giving the resident his/her medications by: a) checking arm, band, b) checking photograph in the medical record, and c) if necessary, verify resident identification with other facility personnel; - The individual administering the medication will check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. The facility did not provide a policy regarding the process for accepting medications in from the pharmacy or for reconciling medications received to physician's orders. 1. Review of Resident #1's Physician Order Sheet (POS) dated [DATE] showed: - An admitted [DATE]; - Diagnosis included Congestive Heart Failure (CHF) (a chronic condition in which the heart does not pump properly); - An order for Metolazone (a blood pressure medication) 2.5 milligram (mg) for treatment of CHF; - No diagnosis for cancer or treatment of cancer. Record review of the resident's facility progress notes showed: - On [DATE], the resident admitted to the facility alert, oriented, continent and ambulatory; - On [DATE], the resident found to be cognitively impaired; - On [DATE], the resident appeared to have no interest or pleasure in doing anything; - On [DATE], the resident developed an abdominal rash. Staff notified the physician who ordered an antibiotic and skin cream; - On [DATE], the resident exhibited shortness of breath and swelling in lower extremities; - On [DATE], the resident developed wounds to the tongue, chest, right lateral thigh, groin, left foot, right foot, and back; - On [DATE], an X-ray was done and showed lungs to be clear; - On [DATE], lesions had developed and the physician ordered the resident be sent to the emergency room . On the same date, the pharmacy contacted the facility to alert them to a medication error. The pharmacy had sent Methotrexate (a high alert chemotherapy drug) instead of the resident's prescribed Metolazone (blood pressure pill). Review of Resident #1's Medication Administration Record (MAR) dated February 2024 and [DATE] showed: - Metolazone 2.5 mg administered on [DATE], [DATE], [DATE], and [DATE] through [DATE]; - Metolazone 2.5 mg administered a total of 16 times for February and [DATE]. Record review of the facility's investigation dated [DATE] showed: - On [DATE], the facility received a call from the pharmacy alerting staff they had sent the wrong medication for Resident #1; - The facility started an investigation and documented the resident had an order for Metolazone and the medication card provided by the pharmacy was Methotrexate; - The card showed 16 doses of Methotrexate had been administered by multiple facility staff members beginning [DATE]; - On [DATE], the facility notified the hospital, family and physician of the medication error; - The physician suspected the skin issue was due to the medication error as a result of Methotrexate toxicity; - The resident passed away in the hospital on [DATE]. Record review of the hospital records showed: - The resident was admitted on [DATE] with open wounds and bruises all over the body; - On [DATE], the resident had further decline with blood coming from the mouth, fallen platelets and a diagnosis of coagulopathy (a disorder of the blood preventing clotting); - On [DATE] the resident passed away. Observation on [DATE] at 10:30 A.M., showed a medication card for Resident #1, labeled Methotrexate with 16 doses missing. During an interview on [DATE] at 10:30 A.M., the Director of Nurses (DON) said the facility has a policy regarding the administration of medications. She said when medications are delivered from the pharmacy, the staff on the floor will check them in using the receipt provided by the pharmacy and the actual medication card provided by the pharmacy. They are only verifying the cards are all accounted for. The staff member is not aware of what has been ordered at this point, so would not have known that Methotrexate was wrong. She said when the medications are checked into the cart, the staff member should have caught the error. She said they do not sign off as they check in the medication, so the facility did not know who checked in the medication. The DON said nursing staff are trained and aware of the proper way to administer medications. Staff are expected to verify the medications and the orders by looking at MAR, POS, and medication card to verify the right medication and right dosage. Four Certified Medication Technicians (CMTs) administered the methotrexate to Resident #1 over the course of 16 days. No one caught the error. She said she can't imagine how they missed it and did not see the wrong medication name on the card. During an interview on [DATE] at 11:40 A.M. CMT A said he/she has been a CMT for several years and was trained in the proper way to administer medications. CMT A said this had never happened before. The name of the medication on the card and the accurate medication are close in spelling. He/she said it was a mis-read card. He/she had no explanation as to why the error was not caught prior to administering 16 doses. During an interview on [DATE] at 1:00 P.M., CMT B said he/she has no idea what happened. He/she tries to be diligent and verify medications are correct prior to administration. He/she is aware of policy, but did not read the card accurately prior to administering the medication. He/she had no explanation as to why the error was not caught prior to administering 16 doses. During an interview on [DATE] at 1:30 P.M., CMT C said the facility had recently changed pharmacies and the incident was just an oversight. The medication name on the card and on the POS were close in spelling. He/she said they may have just glanced rather than read the card. He/she had no explanation as to why the error was not caught prior to administering 16 doses. During an interview on [DATE] at 1:35 P.M., CMT D said he/she only works as needed and had no idea how the error was not caught sooner. He/she is aware of the facility policy. CMT D said it was just mis-read. He/she had no explanation as to why the error was not caught prior to administering 16 doses. During an interview on [DATE] at 2:45 P.M., the pharmacy representative said they caught the error in the medication and told the facility on [DATE]. The error was caught on the pharmacy side while preparing the order for the next month for Resident #1. The representative had no explanation as to why the error was not caught sooner. During an interview on [DATE] at 11:25 A.M., the facility physician said Methotrexate is a chemotherapy type drug used only under strict physician monitoring. She said it is usually given weekly and the facility gave it to Resident #1 daily for over two weeks. The side effects the resident experienced are consistent with the toxicity level high doses of this medication would cause. The resident would have experienced pain and the breakdown of skin cells from the inside out. This caused the resident's death. The physician said Resident #1 was alert and oriented and had a good quality of life when he/she entered the facility. The physician said she expected staff to follow prescription order and to follow standards of practice when administering medications. She said there is no excuse or explanation for administering the wrong medication 16 times. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint #MO233181 and 233193

Based on observation, interview, and record review, 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 94. Record review of the facility's policy titled, Operational Manual, dated [DATE], showed: - It is policy that the dietary department participates in a strict environmental sanitation program; - Staff is trained to properly clean and sanitize all food service equipment in the food service department; - Steam tables, ovens, carts, racks, tables and all other equipment is cleaned and sanitized by Dietary daily; - Cracked China and glassware will be discarded; - Dishwashing procedures and techniques will be carried out as specified by State and local health codes; - Walls, pipes, sinks and fixtures are cleaned routinely with sanitizing compounds by Housekeeping; - Floors are swept by Dietary and mopped by Housekeeping nightly. Floors are also deep scrubbed with scrubber on Mondays and Thursdays; - Ceilings, vents, walk-in cooler and freezer fans, motors on top of fridges and freezers, electrical cords, electric boxes and hood filters are cleaned by Maintenance; - Garbage shall be removed from work stations by Housekeeping after each meal; clean up and more frequently as needed. Record review of the facility's policy titled, Operational Manual, dated [DATE], showed it is the policy of the facility that: - Any food brought into the facility must be in an airtight disposable container (zipper bags, plastic ware type sealed container); - Food must be marked with resident name, room number, labeled, and dated; - Food needing refrigeration must be stored in refrigeration units on hall; - Food that is in resident room is controlled by the resident; - Food must be reheated to 165 for 15 seconds by a Dietary staff member to assure proper temperature; - Food will only be reheated once then discarded; - Food not reheated and used within three (3) days will be discarded from the refrigerator by the dietary department; - Food found not to be in airtight disposable containers or labeled and dated will be disposed of immediately by food service personnel. Record review of an untitled facility policy showed: - Sundays clean all shelves and tables top and bottom; - Wipe down pot holder rack over counter; - Wipe down little table with toaster top, bottom and sides; - Wipe table that holds trays; - Wipe down rack that holds tops and bottoms; - Clean glass rack holders and coffee pot table; - Clean and wipe any food splatters you see on walls; - Mondays clean all fridges and freezers in the kitchen outside and on top edges; - Clean behind stove; - Clean ice machine on top and outside filter, raise lid and clean with bleach water; - Tuesday clean stove, take top off and clean really good; - Pull out shelves, clean and replace foil; - Clean knobs, front and sides of oven; - Pull down shelf over stove and clean; - Wednesdays clean both fast ovens in, out, top and sides; - Tilt skillet top legs and sides; - Thursdays clean cold bar in and out clean over by electric boxes, it likes to gather dust in that corner where the lines go up, make sure it is all dusted on top of electric boxes; - Clean trash cans and any other things you see that needs cleaning because I am sure I have missed things; - Also deep fryer will need pulled out once a month; - Sides and front cleaned but we will have to schedule that; - We will schedule steam tables, fridges etc.; - Clean under stoves, tables, fridges etc.; - If any extra time just clean what you feel needs cleaned and clean all your areas. 1. Observations of the walk in refrigerator on [DATE] at 11:08 A.M. showed: - A brown liquid on the floor under the right side food rack. 2. Observations of the dry food storage area on [DATE] at 11:10 A.M. showed: - One dented 6 lb. (pound) 10 oz. (ounce) can of pumpkin; - One dented 6 lb. 9 oz. can of sliced beets. 3. Observations of the kitchen on [DATE] at 11:15 A.M. showed: - Suspended ceiling (a type of ceiling paneling that hangs below the main structural ceiling) with eleven 2 ft. (foot) x 4 ft. plastic light fixture covers with dust and bug debris inside; - One in. (inch) PVC (Polyvinyl chloride) drain pipe covered with brown and black grime below ice machine; - Floor area beneath commercial gas range covered with food debris and brown grime; - Two, 18 in. frying pans with black grime build-up inside and outside, hung from a rack over a food prep area; - Fourteen assorted spice bottles with gray dust and oily film covered tops sat on shelves above food prep area; - Twenty-six 16 in. x 24 in. x 1 in. deep baking pans with black grime build-up inside the corners, on the cooking surface and outer surfaces; - Commercial dishwasher with white flake build-up outside of door and below dish removal area. 4. Observations of the dining room serving area on [DATE] at 3:23 P.M. showed: - The suspended ceiling over dining room steam table with one 2 ft. x 4 ft. panel with a thin layer of gray dust build-up hanging loosely from the edge; - The suspended ceiling over dining room steam table with two 2 ft. x 4 ft. non intact panels. 5. Observations of the kitchen on [DATE] at 3:33 P.M. showed: - Floor area beneath commercial gas range was covered with food debris, brown grime, and a chicken strip. During an interview on [DATE] at 3:31 P.M., the Dietary Manager (DM) said he/she had attempted to clean under the commercial gas range, but was unable to remove most of the food debris. 6. Observations of the walk in refrigerator on [DATE] at 3:36 P.M. showed: - One non intact 1 ft. x 1 ft. CVT (Composite vinyl tile) floor section in front of the door, outside of refrigerator; - Four non intact 1 ft. x 1 ft. CVT floor sections in front of the door, outside of the walk in freezer; - Floor covered in brown grime in front of the door, outside the refrigerator; - Two 1 ft. x 1 ft. plastic ventilation louvers inside the refrigerator with dust between the grids; - Two yogurt cups, one chocolate shake, a large onion peeling and food debris on the floor below food shelving. 7. Observations of the 200 hallway refrigerator on [DATE] at 3:55 P.M. showed: - The lower shelf with pink grime build-up; - One cardboard one half pt. (pint) milk container dated [DATE]; - Three cheese sandwiches dated [DATE] on a plate with an opened clear plastic wrapper; - Two bologna sandwiches wrapped in clear plastic dated [DATE]. 8. Observations of the 200 hallway ice and water dispenser on [DATE] at 3:57 P.M. showed: - The machine's outer surfaces with a white grime build-up; - The floor below the ice and water dispenser with white grime build-up. 9. Observations of the 300 hallway refrigerator on [DATE] at 9:22 A.M. showed: - A lower shelf with brown grime build-up; - An enclosed butter storage area with three bologna and cheese sandwiches wrapped in clear plastic dated [DATE]. 10. Observations of the 300 hallway ice and water dispenser on [DATE] at 9:24 A.M. showed: - Dispenser cup holder with white and brown grime build-up in the drain area; - The machine's outer surfaces with a white grime build-up. 11. Observations of the kitchen on [DATE] at 4:03 P.M. showed: - Conveyor toaster with black grime build-up along the edge of bread rack; - Thirteen, twelve cup muffin baking pans with brown grime build on the cooking surface; - One 8 ft. x 30 in. section of wooden butcher block food prep counter with deep knife scrapes filled with black grime; - Eight small stainless steel drawers with greasy film on outer surface above butcher block food prep counter. 12. Observations of the dry food storage area on [DATE] at 9:40 A.M. showed: - Five individual jelly packs, one raw onion and one snack sized container of cheese puffs on the floor below food racks. 13. Observations of the 300 hallway refrigerator on [DATE] at 9:25 A.M. showed: - An enclosed butter storage area with two bologna and cheese sandwiches wrapped in clear plastic dated [DATE]. During an interview on [DATE] at 9:42 A.M., the (DM) said the facility has a three day limit on leftover food items placed in refrigerators. He/she said all dietary staff should follow facility policies. He/she said that other staff should be throwing away food that is left in the snack refrigerators. He/she said that ceiling areas should be clean and intact above any food service areas including the dining room. He/she said that kitchen appliances and machines should be clean. He/she said that gas range has a grease trap that should have been emptied. He/she said the grease trap overfilled and spilled into the floor below the gas range, creating a grease problem that is difficult to clean. He/she said there should be no food debris on the floor below food storage racks in the dry food storage area or walk in refrigerator. He/she said that light fixture covers should be clean. He/she said that all cookware should look clean and not have dark colored build up. He/she said baking pans will be thrown out if they can't be cleaned. During an interview on [DATE] at 9:51 A.M., Dietary Aide A said that some leftover foods are kept for seven days except egg salad or anything with mayonnaise. He/she said there should be no dented cans in the dry food storage area and all floors should be clean. He/she said refrigerators should be clean and no expired foods should be inside. He/she said the dry food storage area should be cleaned weekly and trash should be picked up if there are spills in between scheduled cleanings. He/she said ceilings should be clean in the kitchen and food service areas. He/she said that appliances should be clean on all surfaces and the floor should be clean below the gas range and under shelves. He/she said that pans and cookware should be clean. During an interview on [DATE] at 11:38 A.M., the Administrator said he/she expects staff to follow policy and keep the kitchen clean. He/she said the dry food storage area should be clean and no dented cans should be on the shelf. He/she said that all refrigerators should be clean and no expired foods should be left inside. He/she said the ice and water dispensers should be clean. He/she said the facility has a hard water problem. He/she would expect left over food to be thrown out after three days. He/she said light fixture covers and ceiling tiles should be clean and intact over food service areas. He/she said that baking sheets and other cookware should be clean with no build up. He/she said that the kitchen counter tops should be clean and intact.

Based on observation and interview, the facility failed to ensure the garbage dumpster and trash receptacles were covered for four of four days of observation. The facility census was 94. 1. Observation of the kitchen on 1/24/23 at 12:50 P.M. showed one uncovered trash receptacle partially full of refuse near the hand washing facility. 2. Observation of the dumpster area on 1/25/23 at 2:31 P.M. showed one 40 yd. (yard) compactor dumpster (a machine or mechanism used to reduce the size of material or bio mass through compaction) partially filled with trash bags that were full of refuse in the opened collection area of the dumpster. 3. Observation of the dining room serving area on 1/25/23 at 3:22 P.M. showed one uncovered, brown, 13 gal. (gallon) trash receptacle partially full of refuse beside the steam table. 4. Observation of the dumpster area on 1/26/23 at 9:34 A.M. and 1:05 P.M. showed the following: - One 40 yd. compactor dumpster with trash bags full of refuse in the opened collection area of the dumpster; - One 40 yd. compactor dumpster with trash bags full of refuse and a couch in the opened collection area of the dumpster. 5. Observation of the kitchen and dining room serving area on 1/27/23 at 9:29 A.M. showed the following: - One uncovered, brown, 13 gal. trash receptacle partially filled beside the steam table; - Three uncovered 32 gal. trash receptacles partially filled; - Two uncovered trash receptacles partially filled near the hand washing facility. 6. Observation of the dumpster area on 1/27/23 at 11:33 P.M. showed one 40 yd. compactor dumpster filled half way with trash bags that were full of refuse in the opened collection area of the dumpster. During an interview on 1/25/23 at 3:15 P.M., the Dietary Manager said facility staff are supposed to compact the trash every time it is placed in the opened area of the dumpster. He/she said trash receptacles should be covered in the kitchen and dining area near the steam table. During an interview on 1/26/23 at 1:10 P.M., the Building Operations Manager said the opened area of the trash dumpster is normally left open all day and night. He/she said this is due to most facility staff not being trained to engage the compactor ram so it may be left in a closed position to seal facility trash inside the dumpster. He/she said he/she was not aware it was a requirement to close the dumpster. During an interview on 1/27/23 at 11:38 P.M., the Administrator said that trash bags left in the opened receiving area of the dumpster hasn't caused a problem in the past. He/she said that OSHA (Occupational Safety and Health Administration) inspectors required the facility to place warning signs on the chain link fence and gate that surrounds the front entrance to the dumpster. He/she was not aware that trash cans in the kitchen near the staff hand washing stations should be covered. He/she said that trash cans in other areas of the kitchen and near food service areas should be covered. The facility failed to provide a policy.

Based on observation, interview, and record review, the facility failed to post the nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift and failed to maintain the posted daily nurse staffing data for a minimum of 18 months. The facility census was 124. Observation on 02/04/20 showed the nurse staffing data posted did not include: - The total number of Registered Nurses (RN) and Licensed Practical Nurse (LPN) for each shift; - The total number of hours worked by RN, LPN, and Certified Nurse Aides (CNA) for each shift. Record review of the facility's posted nurse staffing data for the past 30 days showed the facility did not maintain a copy of the nurse staffing data. During an interview on 02/04/20 at 2:00 P.M., the Director of Nursing said she did not know the nurse staffing data posted should include the total number of RN and LPN for each shift and the total number of worked hours by RN, LPN, and CN[NAME] She said the facility posts the nurse staffing data on a daily basis but has not kept a copy. She did not know the facility should maintain a copy of the daily nurse staffing data for 18 months. The facility did not provide a policy regarding posting of nurse staffing data.

Based on interview and record review, the facility failed to notify in writing the resident and/or family or legal representative of a facility-initiated transfer to the hospital for eight residents (Resident #26, #47, #6, #22, #40, #88, #10 and #67) of 24 sampled residents. The facility census was 121. 1. Record review of Resident #26's nurse progress notes dated 4/23/19 to 4/24/19 showed resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. 2. Record review of Resident #47's nurse progress notes dated 5/12/18 to 5/14/18 showed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. 3. Record review of Resident #6's nurse progress notes dated 2/13/19 to 2/16/19 showed resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. 4. Record review of Resident #22's nurse progress notes dated 4/5/19 to 4/24/19 showed: - Resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - Resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfers to the hospital. 5. Record review of Resident #40's nurse progress notes dated 4/22/19 showed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. 6. Record review of Resident #88's nurse progress notes dated 3/3/19 to 3/21/19 showed resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. 7. Record review of Resident #10's nurse progress notes dated 3/31/19 to 4/11/19 showed resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. 8. Record review of Resident #67's nurse progress notes dated 2/24/19 to 2/27/19 showed resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the record showed no documentation of the resident or resident's representative notified in writing of the resident's transfer to the hospital. During an interview on 05/01/19 at 10:59 AM , the Director of Nursing said the facility does not send a hospital transfer information sheet to the family. The electronic reason for transfer information document is sent to the hospital with the resident for the hospital. Record review of the facility's policy, dated August, 2013, on transfers shows a written notice of transfer or discharge shall be sent to the resident, legally authorized representative and to at least one family member. If there is no family member known to the facility, a notice shall be sent to the regional coordinator of the Missouri State Ombudsman's office.

Based on interview and record review, the facility failed to maintain infection control practices by failing to implement a water management program that identified a system for preventing, identifying, reporting, investigating, and controlling infections, for all residents, staff, volunteer, and other individuals providing services. This deficient practice had the potential to affect all residents in the facility. The facility census was 121. 1. Record review of the facility's water management plan showed the facility did not have a water management program. During an interview on 5/2/19 at 3:00 P.M., the Administrator said the facility does not have a water management plan.

Based on interview and record review, the facility failed to develop and implement a base line care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission that included the minimum healthcare information necessary to properly care for one resident (Resident #46) out of 23 sampled residents. The facility census was 115. 1. Record review of Resident #46's medical chart, showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED].); - Nursing note, dated 3/03/18, the resident receives [MEDICAL TREATMENT] on Monday, Wednesday, and Friday; shunt (used to perform [MEDICAL TREATMENT]) to right arm, port ([MEDICAL TREATMENT] catheter) to right chest for secondary site related to [MEDICAL TREATMENT]. Record review of the resident's base line care plan, dated 3/02/18, showed no documentation of: - The resident receiving [MEDICAL TREATMENT], including the days and time of [MEDICAL TREATMENT] treatments; - The presence of a shunt to the resident's right arm and a port to the resident's right chest, including any care or precautions. During an interview on 3/14/18 at 11:12 A.M., Certified Nurse Aide (CNA) B said he/she uses the base line care plan located in the resident's closet to know how to care for each resident. He/she looked at Resident #46's base line care plan and indicated it did not list the resident received [MEDICAL TREATMENT] or any special care needed. During an interview on 3/14/18 at 1:40 P.M., Licensed Practical Nurse (LPN) C said staff use the care plan located in each resident's closet to know how to care for the resident. He/she said the care plan is updated by the Minimum Data Set (MDS) Coordinator. During an interview on 3/14/18 at 2:15 P.M., the MDS Coordinator said Resident #46's base line care plan should have included information regarding [MEDICAL TREATMENT], including the days of the week and the care needed. During an interview on 3/14/18 at 3:06 P.M., the Director of Nursing (DON) said a resident's care plan should include [MEDICAL TREATMENT] and any special precautions. Record review of the facility's Approach to Care Planning policy, dated 10/97, showed: - To assure a systematic, comprehensive approach to assessing, planning for, and meeting resident needs; - To provide direction toward achieving and maintaining optimal resident medical and functional status; - To assure coordinated participation of all appropriate health care professionals.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less. There were three errors out of 41 opportunities for errors, resulting in an error rate of 7.32 percent. This practice affected two residents (Resident #8 and #280) outside of the sample. The facility census was 115. 1. Record review of Resident #280's (MONTH) (YEAR) Physician order [REDACTED]. - an order for [REDACTED].>- If blood sugar is 140-175 give 1 unit; - If blood sugar is 176-200 give 2 units; - If blood sugar is 201-250 give 3 units; - If blood sugar is 251-299 give 5 units; - an order for [REDACTED]. Observation on 3/14/18 at 11:17 A.M., showed: - Licensed Practical Nurse (LPN) A performed blood sugar monitoring for the resident with a blood sugar reading of 262; - LPN A prepared the resident's Humalog Kwikpen (an insulin injection pen) for administration; - LPN A reviewed the resident's orders and determined he/she should administer 10 units of insulin for the routine dose and 3 units for the sliding scale dose; - LPN A set the dial on the Humalog Kwikpen to 13 units; - LPN A administered 13 units of insulin subq to the resident's upper left arm. LPN A did not administer the correct dose of insulin based on the resident's blood sugar reading. The resident should have received a total of 15 units of insulin (10 units for the routine dose and 5 units for the sliding scale). During an interview on 3/14/18 at 12:03 P.M., LPN A said he/she miss read the sliding scale blood sugar orders and should have given the resident 5 units of insulin instead of 3 units per the sliding scale. 2. Record review of Resident #8's (MONTH) (YEAR) POS, showed: - an order for [REDACTED].>- an order for [REDACTED].>- If blood sugar is 150-200 give 2 units; - If blood sugar is 201-250 give 4 units; - If blood sugar is 251-300 give 6 units; - If blood sugar is 301-350 give 8 units; - If blood sugar is 351-400 give 10 units; - If blood sugar is 401-450 give 12 units. Observation on 3/14/18 at 11:34 A.M., showed: - LPN D performed blood sugar monitoring for the resident with a blood sugar reading of 251; - LPN D prepared the resident's [MEDICATION NAME] for administration; - LPN D reviewed the resident's orders and determined he/she should administer 10 units of insulin for the routine dose given at lunch and 4 units for the sliding scale dose; -LPN D set the on the [MEDICATION NAME] to 14 units and administered the insulin to the resident in the upper right abdomen. LPN D did not administer the correct dose of insulin based on the resident's blood sugar reading of 251. LPN D should have administered 21 units of insulin (15 units for routine dose with lunch and 6 units for the sliding scale). During an interview on 3/14/18 at 1:30 P.M. LPN D said he/she had read the order incorrectly and gave the wrong dose of insulin to the resident. During an interview on 3/15/18 at 9:45 A.M., the Director of Nursing (DON) said she expects staff to administer insulin according to the physician orders. Record review of the facility's Insulin Pen Administration policy, dated 6/16, showed: - Check the Medication Administration Record [REDACTED] - Check for the correct resident, correct medication, correct dosage, correct time, and correct route; - Select the dose; turn the dose selector to select the number of units; - Review the order again.

Based on observation, interview, and record review, the facility failed to use proper infection control techniques for cleaning the glucometer (a machine used to measure blood sugars) for two residents (Resident #8 and #280) outside of the sample. The facility census was 115. 1. Observation on 3/14/18 at 11:17 A.M., showed: - Licensed Practical Nurse (LPN) A removed the glucometer from the medication cart; - LPN A cleaned the glucometer with a Clorox wipe for one minute; - LPN A performed blood sugar monitoring for Resident #280; - LPN A wiped the glucometer with a Clorox wipe for one minute after obtaining the blood sugar; - LPN A did not allow the glucometer to remain in contact with the wipe for four minutes; - LPN A placed the glucometer inside the medication cart. During an interview on 3/14/18 at 11:22 A.M., LPN A said he/she had been taught to disinfect a glucometer for one minute with a Clorox wipe. 2. Observation on 3/14/18 at 11:34 A.M., showed: -LPN D removed the glucometer from the medication cart; -LPN D cleaned the glucometer with a Clorox wipe for one minute; -LPN D performed a finger stick blood sugar on Resident #8; -LPN D cleaned the glucometer with a Clorox wipe for 2 1/2 minutes after obtaining the finger stick blood sugar; -LPN D did not allow the glucometer to remain in contact with the wipe for four minutes; -LPN D placed the glucometer inside the medication dart. During an interview on 3/14/18 at 11:45 A.M., LPN D said he/she was following the facility's policy in using Clorox wipes for disinfection. He/she said staff was instructed to disinfect for one minute. During an interview on 3/15/18 at 9:40 A.M., the Director of Nursing (DON) said she expects staff to clean and disinfect glucometers per the directions of the disinfectant wipe and the manufacturer's guidelines. She said the facility policy did not include the amount of time required for disinfecting with Clorox wipes. She said the facility would be changing the type of disinfectant wipes used to clean glucometers since Clorox wipes require 4 minutes to disinfect and did not cover all pathogens. Record review of the manufacturer's cleaning directions showed not to use organic solvents such as benzene, [MEDICATION NAME], or any household and industrial cleansers that may cause irreparable damage to the meter. Record review of Clorox disinfecting wipes product information sheet, dated 3/15/18, showed kill time 4 minutes. Record review of the facility's Blood Sugar Testing policy, dated 1/18, showed: - Follow the manufacturer's directions for using each individual meter; - Remove glucometer from cart and clean with Clorox wipe; - Remove glucometer from resident's room, clean glucometer with Clorox wipe, and place in cart or designated area.

Based on observation, interview and record review, the facility failed to ensure staff provided proper incontinence care for three expanded sampled residents. The sample was 21. (Residents #25, #26 and #27) The census was 116. 1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/6/17, showed the following: -Rarely/never understood/understands; -Total dependence of two (+) persons required for bed mobility, transfers and toilet use; -Total dependence of one person required for dressing and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Observation on 4/26/17 at 5:05 A.M., showed the resident lay in bed on disposable pads. Certified Nurse Aide (CNA) C and Nurse D positioned the resident onto his/her back. The CNA said the disposable pads were wet with urine. The CNA washed the resident's genitalia then positioned the resident onto his/her right side. Using a disposable wipe, the CNA started at the top of the middle of the buttocks, wiped down between the buttocks, past the anal area and ended the wipe between the resident's legs (back to front). The CNA repeated this cleaning motion three times before the resident was repositioned onto his/her left side. The CNA again wiped from back to front. During an interview at that time, the CNA said he/she had been cleaning the resident's buttocks wrong. He/she should have started around the anal area and wiped up the buttocks (front to back) to prevent a urinary tract infection. 2. Review of Resident #26's quarterly MDS, dated [DATE], showed the following: -Short term memory loss; -Required extensive staff assistance for all activities of daily living; -Incontinent of bladder. Review of the resident's care plan, dated 4/15/17, showed the following: -Problem: Required extensive assistance with toileting, personal hygiene and bathing, dribbled urine at times; -Approach: Assist with toileting and check for incontinence. Provide with appropriate perineal care as required Observation on 4/26/17 at 5:36 A.M., showed the resident lay in bed on a bed pan. After removing the bed pan, CNA A wiped each side of the perineal area with a disposable wash cloth but failed to wipe down the middle. During an interview on 4/26/17 at 5:54 A.M., CNA A said he/she should have wiped each side and down the middle when providing perineal care. 3. Review of Resident #27's quarterly MDS, dated [DATE], showed the following: -Short/long term memory problems; -Required extensive staff assistance for bed mobility, dressing, toilet use and personal hygiene; -Required total staff assistance for transfer and bathing; -Incontinent of bowel and bladder. Observation on 4/25/17 at 5:07 A.M., showed the resident lay in bed on a wet incontinence pad. After washing his/her hands and applying gloves, CNA E wiped each side of the resident's perineal area with a disposable wipe, but failed to wipe down the middle. During an interview on 4/25/17 at 5:15 A.M., CNA E said he/she should have wiped down the middle when providing perineal care. 4. During an interview on 4/28/17 at 8:00 A.M., the Director of Nurses presented the facility Perineal Skin Care for the Incontinent Resident policy and said she expected staff to follow the policy. 5. Review of the facility's Perineal Skin Care for the Incontinent Resident policy, dated 6/08 and revised on 3/14, showed the following: -It is the policy that all nursing staff will provide routine, preventative, skin and perineal care to residents after an incontinent episode; -Bowel incontinence: Remove fecal matter and clean anal area, buttocks and hips, wiping from front to back; -Urinary incontinence: Gently wash the inner legs, hips and outer perineal area along the outside of the genital area. Wash from front to back.

Based on record review and interview, the facility failed to ensure interventions were documented prior to administering as necessary (PRN) antianxiety medications. The facility identified 13 residents that received PRN antianxiety medications. Of those 13, three were sampled that had received PRN medications in March 2017 or April 2017, and problems were found with all three. The sample was 21. (Residents #11, #4 and #28) The census was 116. 1. Review of Resident #11's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/20/17, showed the following: -Understood/understands; -No behaviors; -Did not reject care; -Supervision and setup help only required for bed mobility, transfers, walking in room/corridor, dressing and eating; -Independent for personal hygiene; -[DIAGNOSES REDACTED]. -Received no antianxiety medications in the past seven days. Review of the resident's physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Review of the back of the MAR, showed no interventions attempted by staff prior to administering the medication documented. Review of the front and back of the Behavior/Intervention Monthly Flow Record (a form used to document: number of behavioral episodes, interventions, outcomes and side effects), dated 3/1/17 through 3/31/17, showed staff documented the resident had no behavioral episodes for the month. Review of the resident's MAR, dated 4/1/17 through 4/30/17, showed staff administered the resident [MEDICATION NAME] 14 times. Review of the back of the MAR, showed no interventions attempted by staff prior to administering the medication documented. Review of the front and back of the Behavior/Intervention Monthly Flow Record, dated 4/1/17 through 4/30/17, showed staff documented one behavioral episode, with interventions attempted. 2. Review of Resident #4's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/long term memory problems; -Mood problems: Feeling down, depressed or hopeless and poor appetite; -Required extensive staff assistance for bed mobility, bathing and dressing; -Required total staff assistance for transfers, toilet use and personal hygiene; -Received no antianxiety medications. Review of the resident's POS, dated 4/1/17 through 4/30/17, showed an order for [REDACTED]. Review of the resident's MAR, dated 4/1/17 through 4/30/17, showed staff administered the resident [MEDICATION NAME] 11 times. Review of the back of the MAR, showed no interventions attempted by staff prior to administering the medication documented. Review of the front and back of the Behavior/Intervention Monthly Flow Record, dated 4/1/17 through 4/30/17, showed staff one behavioral episode, with interventions attempted. 3. Review of Resident #28's annual MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/long term memory problems; -No mood or behavior problems; -Required total staff assistance for a activities of daily living; -Received no antianxiety medications in the last seven days. Review of the resident's POS, dated 4/1/17 through 4/30/17, showed an order for [REDACTED]. Review of the resident's MAR, dated 4/1/17 through 4/30/17, showed staff administered the [MEDICATION NAME] 1 time. Review of the back of the MAR, showed no interventions attempted by staff prior to administering the medication documented. Review of the front and back of the Behavior/Intervention Monthly Flow Record, dated 4/1/17 through 4/30/17, showed staff documented the resident had no behavioral episodes for the month. 4. During an interview on 4/27/17 at 3:35 P.M., the Director of Nurses said she expected staff to attempt and document at least one intervention prior to administering a PRN antianxiety medication on the Behavior/Intervention Monthly Flow Record. She did not know why staff had not been completing Behavior/Intervention Monthly Flow Record.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents from abuse by not immediately removing a female resident from the danger of abuse and not immediately assessing the resident when a licensed practical nurse (LPN) walked in on a male certified nursing assistant (CNA) in bed with an elderly contracted (chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments and tendons) female resident. This resulted in the resident being left unattended with the CNA when the LPN left the room to report what he/she saw to a supervisor (Resident #1). The census was 96. Review of the Resident #1's physician order [REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/4/15, showed: -Brief interview of mental status (BIMS) score of 0 out of a possible score of 15; -A BIMS score of 0-7 shows the resident is rarely or never understood; -Totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene; -Limitation of range of motion on one side for upper and lower extremities; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident's undated care plan, showed: -Dependent on staff for all activities of daily living (ADL) tasks. Transfer with assist of two and a Hoyer (mechanical lift). Incontinent of bowel and bladder and wore adult briefs to project skin and clothing from wetness. Maximum assist of one for bed mobility, dressing, bathing and ADL tasks. Unable to feed self and dependent on staff for eating; -Cognitive loss due to [DIAGNOSES REDACTED]. Current cognitive level is severely impaired. Problems with both long and short term memory. No longer able to make choices for self regarding care, so anticipate needs. Review of the resident's nurses notes dated 2/19/15 at 7:20 A.M., showed staff placed the resident back in bed for a full body assessment. Resident is non verbal due to end stage/advanced dementia. Review of the resident's physician progress notes [REDACTED]. -He/she was asked to see the resident that morning. A CNA was found in bed with resident. Resident has advanced dementia. Unable to obtain any history; -Resident confused. Physical examination showed: -Pelvic exam not performed due to the resident is elderly and has contractures of both hips; -No signs of trauma noted. Review of the resident's Change of Condition and Progress form, dated 2/19/15, showed: -Primary Diagnoses: [REDACTED]. -Advanced/end stage dementia; -High blood pressure; -Contractures; -Mental status change: -Cognitively impaired, alert to self only per her norm; -Functional status changes: -Totally dependent with ADL's, Hoyer lift for transfers, incontinent of bowel and bladder; -CNA was found in bed with the resident this A.M. at approximately 6:00 A.M. Employee was fully dressed. Administrator and director of nursing (DON) aware. Physician aware. Family notified. Resident fully assessed by Assistant Director of Nursing (ADON) and physician. See nurses note and physician progress notes [REDACTED].>Review of CNA A's hand written and signed statement obtained by the facility and dated 2/19/15, showed that on 2/19/15 between 5:45 - 6:00 A.M., while taking care of the resident in room [ROOM NUMBER] B, CNA A said he started to dress the resident when his left knee started hurting, so he sat on the side of bed to stretch out his knee. He ended up lying down to stretch his knee out and dozed off. Review of the facility's audio recorded interview of CNA A completed by the facility's administrator and recorded the morning of 2/19/15, showed the following: -CNA A went to the resident's room around 5:45 A.M. to 6:00 A.M. to get her dressed; -His knee began hurting, so he first sat on the resident's bed and then laid down next to her; -He then dozed off to sleep; -He and the resident were both next to each other on their backs; -The resident was awake with her eyes open; -She had a shirt and socks on, but he could not recall if she had pants on; -He was starting to sit back up when a nurse came in the room and saw him; -The administrator said laying down in bed with a resident is completely unacceptable. Review of the facility's investigation summary, provided on 2/25/15, showed: -Resident #1 listed as the resident; -Date and time of the event 2/19/15 at 6:00 A.M.; -CNA A found sleeping in resident bed (fully clothed); -Witnessed by LPN I; -Follow-up actions/interventions: -Law enforcement, Department of Health and Senior Services (DHSS), physician and family notified on 2/19/15; -Employee CNA A terminated on 2/19/15 (law enforcement removed employee from facility); -CNA A's picture placed at reception area and given to security (not permitted on premises); -ADON assessed the resident on 2/19/15; -Physician Q performed an examination on 2/19/15; -Social service visited and assessed the resident on 2/19/15; -Facility met with the resident's family 2/20/15; -No male employees to provide care to the resident; -Care plan updated on 2/20/15; -Staff to monitor the resident every hour for changes in the following areas: resistive to care, crying, change in facial expression, change in mood, combativeness, 2/20/15 and ongoing. Changes documented on resident monitor form; -Investigatory summary: -LPN R, the nurse on call, was notified by Registered Nurse (RN) K (11:00 P.M. through 7:00 A.M. shift supervisor) at around 6:00 A.M., of incident involving CNA A and the resident. RN K informed nurse on call that LPN I walked into the resident's room and found CNA A lying in bed sleeping fully clothed with the resident. RN K informed on-call nurse that CNA A was immediately removed from the hall. LPN R instructed RN K to escort CNA A to the lobby and await administration's arrival. LPN R notified ADON, DON and administrator of the incident. The administrator arrived and immediately interviewed CNA A. CNA A claimed that while dressing the resident, CNA A's left knee started hurting, so he sat on side of bed to stretch out his knee. CNA A stated he ended up lying down to stretch his knee out and dozed off. The administrator notified the local police department. Law enforcement interviewed CNA A and removed CNA A from the facility. The administrator notified DHSS of incident; -The ADON arrived to the facility and began a physical assessment. Physician Q was notified of the incident, arrived at the facility at 8:36 A.M., and performed a full examination. No injuries or abnormal findings were found by the ADON or Physician Q. Physician Q was unable to perform a pelvic exam due to the resident's age and hip contractures. The resident is alert and oriented to self only and unable to verbally communicate needs due to advanced dementia; -The ADON obtained statements from LPN I and RN K on 2/19/15. The local police department also interviewed both employees; -Interviewed employees that were on duty 2/18/15 night shift and 2/19/15 day shift that worked 300, 400 and 500 units (CNA A worked on the 300 hall that night). CNA J and LPN I stated that CNA A had gone to his car that night and slept on his lunch hour and also started to doze off when charting. CNA J reported that LPN I saw CNA A starting to doze off while charting and told CNA A he could not be doing that. All other employees reported they had not noticed any suspicious behaviors when working with CNA A; -2/20/15 at 4:00 P.M., the resident's family called the facility and reported CNA A confessed to police that he had fondled the resident above the waist for the past six months and that he found the resident attractive; -A typed statement signed by the administrator on 2/19/15, showed: -At approximately 6:30 A.M., he received a text from the on call supervisor that CNA A was caught by a nurse laying in a resident's bed sleeping and the aide was immediately pulled off the floor and was informed to wait for the ADON. The administrator arrived at the facility at 7:00 A.M. and CNA A was waiting in the lobby. The administrator asked CNA A to come to his office. The administrator asked him what happened, and he stated he was getting Resident #1 dressed and his knee started to hurt, so he laid down on her bed to stretch out his knee and fell asleep. He then heard a nurse enter the room and jump up out of the bed. He stated that her top was on, but she had no pants on. Both he and the resident were laying flat on the bed. When (CNA A) gave the administrator his written statement, he stated that he did not do anything but fall asleep in the bed. The administrator called the police. After the police conducted their interview and removed CNA A from the facility, the administrator received a call from staff at DHSS regarding another matter, while on the phone with the staff person from DHSS, he relayed what happened regarding this incident with CNA A. Review of the facility's additional investigation summary provided on 3/3/15, showed: -Resident #1 listed as the resident; -Date and time of the event 2/19/15 at 6:00 A.M.; -CNA A found sleeping in resident's bed (fully clothed); -Time line: -At approximately 5:45 A.M., Certified Medication Technician (CMT) Z reported he/she saw CNA A go into the resident's room. He/she stated that he/she knew the time because that is when he/she always passes medications on the 300 hall. CMT Z reported that he/she had stopped and asked CNA A if he needed help getting the resident up. CNA A responded no, CNA L was coming in and he/she would help him. CMT Z said he/she then passed medications to two residents on the 400 hall; -6:00 A.M., CNA A wrote on a timesheet edit sheet that he clocked out. The ADON asked CNA A to write on the edit sheet what time he/she was pulled from the floor; -6:00 A.M., LPN I found employee; -6:04 A.M., CNA L reported that he/she clocked in. When he/she walked out of the break room (after clocking in), he/she saw RN K was walking up the 300 hall toward him/her with CNA A. RN K stopped and asked that CNA A give him/her report; -6:05 A.M., RN K reports that LPN I informed him/her of incident. He/she was on the phone with the on call nurse, LPN R, when he/she was walking down the hall to obtain the employee; -6:08 A.M., LPN R, on-call nurse, reported he/she received phone call from RN K. Review of LPN R's telephone records provided by the facility, showed he/she received a call from the facility on 2/19/15 at 6:08 A.M. Further review of the facility's investigation summary of 3/3/15, showed the following: -Interviews were conducted with night and day shift nursing staff that worked on 2/19/15. The DON was unable to determine for sure if the resident was fully dressed, partially dressed or not dressed at all at the time CNA A was found in bed with the resident. All the nursing staff that worked on 2/19/15 denied dressing the resident that morning. It is highly unlikely that CNA A could have fully dressed the resident within the five to eight minute time frame between getting caught sleeping and being taken to the lobby. The resident's upper and lower extremities are severely contracted and it does take a considerable amount of time and effort to dress her; -LPN I reported that he/she found CNA A at 6:00 A.M., LPN I stated on 3/2/15 per phone interview, that he/she was sure the resident was wearing a gown. When LPN I asked CNA A what he was doing, CNA A said he was getting the resident dressed. LPN I stated that tells me the resident was not dressed at all; -The administrator reported that during the recorded interview with CNA A, that CNA A stated he started to dress the resident and had her shirt on, but no pants on when his knee was hurting and he laid down to stretch his knee out and dozed off. The administrator continued to question CNA A about how much the resident was dressed and CNA A stated she had her shirt on, socks on and he could not remember if her pants were on yet. The administrator asked CNA A so, you had not gotten her pants on yet? CNA A responded I can't remember.; -CNA A was interviewed extensively and did not change his story relating to the resident having her shirt and socks on. LPN I was interviewed twice and did not change his/her story relating to the resident having a blue and white gown on. LPN I also said that the resident's private areas were covered. The two CNAs that assisted the resident up that morning said the resident was wearing a shirt and pants with a full body blue Hoyer pad under her. Neither CNA could remember what she was wearing. One employee thought she might had been wearing a light shirt and pink pants. Night shift CNAs regular routine is to dress the residents on the get up list that are Hoyer lifts and wait for day shift CNAs arrival to assist with getting them up. There are one to two day shift CNAs that come in early at 6:00 A.M. The rest of the CNAs arrive at 6:45 A.M. The policy is two staff assist with Hoyer lifts. Observation on 2/19/15 at 1:20 P.M., showed LPN P entered the room of Resident #1. The resident lay in the bed on her right side. Her legs were contracted. LPN P attempted to assess the resident's perianal and perivaginal area. He/she was only able to separate the resident's legs approximately 4 inches apart. The resident did not respond verbally or nonverbally to questions. During a telephone interview on 2/20/15 at 8:15 A.M., LPN I said his/her shift ended at 7:15 A.M. on 2/19/15. He/she was the nurse responsible for Resident #1 at the time of the incident. He/she walked into the resident's room at 6:00 A.M. to see the resident's roommate. He/she saw CNA A in bed. He immediately jumped up. He/she asked CNA A what are you doing? and CNA A said I am getting ready to get her dressed. My feet hurt. Both the resident and CNA A were facing the window on their right sides. CNA A was on the side closest to the door. CNA A was wearing scrubs. The blanket was at the foot of the bed. The resident was wearing a gown, open in the back and no brief. The gown was over her. He/she immediately went to tell RN K. He/she did not assess the resident at that time. The resident was still in bed the last time he/she saw the resident. He/she saw CNA A in the lobby later. He looked ashamed. At 8:51 A.M., LPN I said CNA A was still in the room when he/she walked out. He/she did not see where CNA A's hands were when he/she walked in. During an interview on 2/20/15 at 8:39 A.M., RN K said he/she was on the rehab side of the building. LPN I came and said he/she saw CNA A in bed with a resident. RN K used the portable phone to call the on-call supervisor, LPN R, as RN K walked over to the 300 hall to remove CNA A from the floor. CNA A was doing rounds. RN K told CNA A you need to come with me. He was in a room helping another female resident get up. He was getting her dressed. She was in bed. The resident only had a gown on. He was at the bedside, not holding anything. The resident was uncovered. He didn't say anything to RN K. He/she did not assess or go to check on Resident #1. During a telephone interview on 3/5/15 at 7:31 A.M., RN K said he/she cannot remember what room or what resident CNA A was with when he/she removed him from the hall. He was at the bedside of another resident, but he/she could not remember if it was Resident #1's roommate or a resident in another room. It looked like CNA A was getting ready to get this resident dressed. The bed was waste high to CNA A. He/she cannot remember if CNA A was leaned over the resident. CNA A did not say anything to him/her. During an interview on 2/19/15 at 1:39 P.M., LPN R said he/she was the nurse on-call during the time of the incident. He/she got a call at 6:08 A.M. He/she was informed that a nurse went in a resident's room and CNA A was sleeping, snuggled in with the resident and he was removed. During an interview on 2/19/15 at 12:08 P.M., the DON said CNA B and CNA L are the two staff who got the resident up that morning after the incident. During an interview on 2/19/15 at 11:24 A.M., CNA B said he/she does not get assigned a team due to being on light duty. He/she did help get Resident #1 out of bed on 2/19/15, between 6:20 A.M. and 6:30 A.M. The resident was already dressed with a sling under her. On 3/2/15 at 10:24 A.M., CNA B said when he/she entered the resident's room, she was wearing pants and a shirt and had a Hoyer lift sling under her. During an interview on 2/19/15 at 12:09 P.M., CNA L said he/she came on duty at 6:00 A.M. He/she usually comes in to help with Hoyer lifts, but today he/she took over the care for the residents on the 300 hall until the day shift CNA came in. CNA A was just leaving the floor with RN K. RN K instructed CNA A to give a brief change of shift report to CNA L. RN K was with the CNAs during this time. He/she did not know for sure what time that was. room [ROOM NUMBER] was the first room he/she went into. The resident was already dressed and the sling for the Hoyer lift under her. He/she helped to get her up. During an interview on 2/19/15 at 11:50 A.M., LPN P said he/she came on duty at 6:45 A.M. He/she is assigned to care for Resident #1 for the day shift on 2/19/15. The night shift nurse informed him/her that he/she went into the room and CNA A was lying in bed with the resident and jumped up. He/she and LPN E then got the resident into bed and assessed her. During an interview on 2/19/15 at 11:56 A.M., LPN E said he/she came on duty at 6:45 A.M. He/she is not the nurse assigned to care for Resident #1. The resident was already up. Night shift got her up. She was in the dining room. He/she and LPN P then took the resident to her room to assess her. During an interview on 2/19/15 at 1:34 P.M., the ADON said she was notified at 6:15 A.M. of the incident and she arrived a little before 7:00 A.M. She immediately assessed the resident. The administrator was in with CNA A. CNA A was in a chair with his head in his hands. She heard him say alright, alright, I will be honest. Interviews conducted with all staff working the night shift (11:00 P.M. on 2/18/15 to 7:00 A.M. on 2/19/15) and the 6:00/7:00 A.M. to 3:00 P.M. shift on 2/19/15, showed no staff reported dressing Resident #1 on 2/19/15. During a telephone interview on 2/20/15 at 1:16 P.M., the administrator said he/she does not know who got the resident dressed and put the sling under her. Regarding this incident, he would expect the nurse who found CNA A in bed with the resident to get the charge nurse or supervisor. The nurse thought the CNA was sleeping. It depends on what they thought they saw if they remove the staff person from the room. He feels LPN I acted appropriately when she left the resident in the room with CNA A and went to find the supervisor. During a telephone interview on 3/4/15 at 11:19 A.M., CNA A refused to be interviewed. Review of CNA A's employee records, showed: -Certified nurse assistant training certificate for long term care facilities, received 10/28/2004; -Date of hire 7/9/13; -Position held, CNA; -New employee orientation included the abuse policy; -No disciplinary report/actions for sleeping on the job; -A statement, signed by CNA A and dated 7/9/13 and 6/12/14, showed I (CNA A's name filled in), an employee of this facility certify that I have received a written copy of the facility's resident rights and that they have been orally reviewed with me, I certify that I understand each right and agree to promote and protect the rights of each resident. I further agree to treat each resident with kindness, dignity and respect and to report any instances of abuse, neglect and/or mistreatment of [REDACTED]. -Abuse of resident policy, last revised 3/2014; -Policy: -It is the policy of the facility that any physical striking of a resident, use of hostel, demeaning or angry language to a resident, sexual contact with and/or sexual suggestions to a resident, making fun of a resident, or intimidation, coercing, threatening or frightening of a resident will not be tolerated and will lead to termination of employment at the facility. The reporting of the offence to the Missouri Division of Aging hotline and local law enforcement; -The governing board of administrator of the facility expects all resident to be treated with dignity, respect, kindness, gentleness and courtesy at all times by all facility staff. Employees cannot, under any circumstances, physically or verbally retaliate against a resident. Employees are to seek assistance from their supervisor, charge nurse or other managers if a resident exhibits hostel or abusive behavior to the employee; -Procedure: -All facility employees are required to attend resident abuse inservices as required by state law and facility policy; -All employees are to be inserviced on this information and shall sign and date a copy of this policy to indicate his or her full understanding of, and agreement to abide by this policy; -A copy of this policy, signed and dated by the employee, shall be placed in the employee's personnel folder; -I understand and agree to abide by this policy, (signed by CNA A and dated 7/9/13 and 6/12/14). Review of the facility's Abuse Protection of Residents policy, last revised 03/2013, showed: -It is the policy of the facility to take immediate steps to protect our residents while any abuse investigation is underway; -Employees of this facility who have been accused of mistreatment will be suspended immediately until the results of the investigation have been reviewed by the administrator; -(No directions given to immediately remove the resident from danger of abuse); -(No directions to immediately assess the resident's condition after suspected abuse). Review of the facility's Abuse Identifying Events/Trends/Patterns/Occurrences of Possible Abuse policy, last revised 03/2013, showed: -It is the policy of the facility to aggressively investigate any suspicious resident event such as bruising, fracture, visible signs of unusual mental anguish or other untoward and unusual resident events; -It is important for all staff to be sensitive to any untoward or unusual visible signs of potential resident abuse; -Each suspicious incident and/or accumulation of suspicious incidents must be reported, so that a direction of investigation can be made; -All staff is to report to his/her supervisor, director of nursing or administrator any suspicious event, occurrence, pattern, trend or bruising that may be considered abuse; -All reported incidents will be investigated utilizing the following investigative protocol: -Interview resident (if applicable) and/or family (if applicable); -Identify all staff members that potentially could be involved in the established time-frame of the incident; -Obtain written statements from all staff members who would have any reason to know about the suspicious incident; -Suspend, pending investigation, any staff member who could potentially be involved in any suspicious incident; -Interview each staff member or witness, etc. who may have any pertinent information about the incident; -Report to the DHSS Hot-Line any incident that there is a reason to believe involves abuse or neglect in addition to any incident whereby remains unknown what happened, i.e. fracture that is not explained following the investigation; -Contact local law enforcement if necessary; -(No directions to immediately remove the resident from danger of abuse); -(No directions to immediately assess the resident's condition after suspected abuse). Review of Officer AA's local police department Offence/Incident Report dated 2/19/15 at 7:30 A.M., showed: -On 2/19/15 at 7:30 A.M., officers were dispatched to the facility in reference to a possible sexual misconduct report; -Upon arrival to the facility, the administrator said he received a text message at approximately 6:30 A.M., stating a CNA was found sleeping in a bed with a resident. The CNA was identified as CNA A; -The administrator reported he continued to talk with CNA A and CNA A said he was dressing Resident #1 and his knee started to hurt, so he lay down beside her to stretch out and he fell asleep. She was wearing her shirt, but no pants, nothing happened; -Officer AA interviewed CNA A and after the interviews, CNA A was taken into custody; -Officer AA interviewed LPN I and he/she reported at approximately 6:00 A.M., he/she walked into room [ROOM NUMBER] to insert a hearing aid for the resident in 312 A. He/she saw CNA A lying in a bed in a cuddling position with the resident in bed 312 B, Resident #1. As soon as CNA A saw him/her he jumped up and out of the bed. LPN I asked CNA A what he was doing and he first replied I was just getting ready to get her dressed. CNA A then stated his feet hurt, so he was resting them. LPN I stated he/she left the room and immediately notified the house supervisor, RN K; -Officer AA interviewed RN K who reported at 6:05 A.M., LPN I came to him/her and informed him/her that he/she walked into a resident's room, room [ROOM NUMBER], and found CNA A lying in bed with a resident. RN K stated he/she immediately went to the 300 hall and located CNA A in another resident's room doing his rounds. RN K stated he/she escorted CNA A to the lobby and informed him to remain there until the administration arrived. Review of Detective BB's local police department Offence/Incident Report dated 2/19/15 at 7:30 A.M., Detective BB interviewed CNA A and the following information was obtained: -CNA A said he understood why the detective was there and he wasn't going to lie and he wanted to tell the truth; -CNA A was trembling uncontrollably and kept interlocking his hands to keep them from shaking; -CNA A would not look at the detective and kept putting his head down. CNA A stated his knee was hurting from standing, so long during his shift. He was tired and laid down flat on Resident #1's bed. CNA A said he fell asleep and then heard a nurse come into the room and he got startled. CNA A stated he jumped and sat up because he knew he was not supposed to be in the bed with a resident; -As CNA A made the previous statement, he would not make any type of eye contact and kept rubbing his arms and back of his neck, showing numerous signs of stress. Detective BB told CNA A he was lying. CNA A looked at the detective, pushed his left hand away as if he was wiping something away and stated yes, that's a lie; -CNA A said his knee did not hurt and he was just tired that's why he laid down in the bed. He did not touch Resident #1 at all; -Detective BB left the room and returned several minutes later; -Detective BB told CNA A he/she watched a video and asked what CNA A thought the detective saw. CNA A said he saw him with his arm around Resident #1. The detective asked what else he/she saw. CNA A said Me, fondling her breast. The detective asked CNA A if he fondled her breast inappropriately. CNA A shook his head up and down and stated he did; -CNA A was placed under arrest; -As Detective BB was transporting CNA A to the local police department, CNA A said I guess my medical career is over. Nobody is going to hire me after I grabbed her breast. Review of the local police department Voluntary Statement, hand written and signed by CNA A, dated 2/19/15 at 8:55 A.M., showed he admitted to touching the resident's breasts 100 times over six months because she was attractive. MO 259