Every finding on record at Elsberry Missouri Health Care Center

Based on observation, interview and record review, the facility failed to ensure one resident, (Resident #49), with diagnosis of dementia, in a review of 17 sampled residents, received appropriate care to ensure his/her individualized dementia care needs were met. Resident #49 wandered in and out of other residents' rooms uninvited and went through other residents' belongings upsetting other residents. In response, the facility frequently moved the resident to different rooms. On 7/28/24, Resident #49 was looking through his/her roommate's (Resident #46) belongings. Resident #49 became verbally agitated with Resident #46 and in response Resident #46 punched Resident #49 in the arm multiple times resulting in a large bruise to the resident's arm and reinjury to an existing skin tear on the resident's hand. Further review showed Resident #49's care plan did not address dementia or interventions to address the resident's behaviors. The facility census was 54. During an interview on 07/31/25 at 12:04 P.M., the Director of Nursing (DON) said the facility did not have a policy for dementia care. The facility followed standards of practice. 1. Review of Resident #49's undated face sheet showed diagnoses of dementia (a condition characterized by a progressive decline in cognitive functions, such as memory, thinking, language, judgment, and behavior) and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life.) Review of the resident's nurse's notes showed staff documented the following: -On 04/21/25 at 4:20 P.M., the resident came running out of his/her room shaking and yelling, I can't even go out of my room, I can't even touch my things, it's not supposed to be like this, this is supposed to be my room and it's not. I can't do nothing. I just wanted my clothes. This is supposed to be my room, too!. The resident was pointing to the curtain which separated the resident from his/her roommate. The resident said, He/She yells at me all the time, I can't do nothing. The resident was shaky and visibly upset. The nurse called the Director of Nursing (DON) and got permission to move the resident to another room for the night; -On 04/23/25 at 10:35 A.M., staff moved the resident to another room on 04/22/25 at 2:30 P.M. (the third room change since the resident's admission);-07/18/25 (a late entry) at 10:04 A.M., staff moved the resident to another room on 07/16/25 at 9:00 A.M. (a fourth room change since the resident's admission). Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/24/25, showed the following:-Severely impaired cognition;-No physical behavioral symptoms directed toward others;-No verbal behavioral symptoms directed toward others;-He/She was independent with walking;-He/She was independent with transfers. Review of the resident's nurse's notes showed staff documented on 07/28/25 at 9:51 P.M., the Certified Nurse Assistant (CNA) entered the resident's room, and the resident had his/her hand in his/her roommate's (Resident #46) face. Resident #49 said, you better watch yourself and the roommate grabbed the resident's left arm and started hitting Resident #49. Staff removed Resident #49 from the room and took him/her to the day room near the nurse's station. Review of Resident #49's care plan, revised 07/29/25, showed the following:-The resident can get confused on where to go and needs to be redirected on where to go when he/she was out of his/her room; -Independent with ambulation, but may need directions on where to go;-The resident had an altercation with his/her roommate on 07/28/25;-The care plan did not address the resident's diagnoses of dementia, behaviors of going through others' belongings or provide interventions for staff specific to the resident's individualized needs due to dementia. Observation on 07/29/25 at 12:40 P.M., showed the resident sat at the dining table with a foam dressing covering the top of his/her left hand, dated 07/29/25, and a large bruise on his/her left forearm near his/her left elbow. During an interview on 07/30/25 at 11:56 A.M. the resident's responsible party said the following:-The resident has anxiety and dementia;-On admission, the resident's first roommate screamed at the resident for getting into his/her belongings. Staff moved the resident to a room by himself/herself and the resident did well;-The resident then had a roommate again and this roommate watched TV a lot. If the resident walked in front of his/her roommate's TV, it irritated his/her roommate, and the roommate would yell or get upset at Resident #49; -The resident got in a fight the other night with his/her new roommate;-He/She was concerned about the most recent incident because it wasn't just verbal it was physical;-The resident gets confused because staff keep moving him/her. 2. Review of Resident #46's quarterly MDS, dated [DATE], showed the following:- Cognitively intact;- He/She had no behaviors. During an interview on 07/30/25 at 10:19 A.M. and 10:29 A.M., the resident said the following:- His/Her roommate (Resident #49) was getting into his/her closet (on 07/28/25) and he/she said something to Resident #49r about those not being his/her belongings. Resident #49 came up to him/her, so he/she punched Resident #49 because the resident raised his/her hand and made a fist like he/she was going to hit him/her; -He/She punched Resident #49 on the arm a few times; -Two (unnamed) nurses were in the room with him/her and his/her roommate when this happened;-Resident #49 gets into his/her drawers and closet frequently and had even got into bed with him/her once; -He/She reported to staff before the incident occurred that he/she didn't think they would get along and he/she thought it was a bad fit because he/she didn't like someone getting into his/her things and Resident #49 didn't like people getting on to him/her for doing those things;-He/She only hit his/her roommate because he/she made a fist and threatened him/her;-He/She thinks his/her roommate was too confused and it was not fair to the other residents to put up with Resident #49 going through their belongings. 3. Review of Resident #2's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 07/30/25 at 10:30 A.M., the resident said a week ago Resident #49 was his/her roommate and had tried to crawl into bed with him/her. Resident #49 touched his/her bottom and his/her feet. He/She was able to get out of bed and went to the door and yelled for security. He/She did not feel safe, like Resident #49 was trying to do something to him/her. Staff did not move Resident #49 from the room that night. He/She was nervous and didn't know if something else would happen, so he/she didn't sleep well at all. 4. During an interview on 07/30/25 at 3:15 P.M., Certified Nurse Aide (CNA) B said the following:-(On 07/28/25) Resident #46 was yelling at Resident #49 and he/she went into the room;-Resident #46 said he/she was going to beat Resident #49 up;-Resident #49 was pointing in Resident #46's face and told him/her to behave himself/herself;-Resident #46 grabbed Resident #49's arm and hit him/her with a closed fist five times near the elbow on the lower part of his/her arm;-The resident had some previous small skin tears that opened back up from the punching and Licensed Practical Nurse (LPN) C cleaned them up;-Resident #49 likes getting into other resident's things;-Resident #49 had an incident with a former resident (in April) where Resident #49 was going through his/her roommates belongings and the roommate yelled at Resident #49;-Other residents will turn their call lights on when Resident #49 comes in their rooms or when he/she begins going through their things;-Resident #49 wandered and was more confused because he/she has been moved. Staff did their best to redirect the resident, but that was usually after an incident had occurred;-He/She felt it has been confusing for Resident #49 because he/she has been in so many rooms that is why he/she is always going in other resident's rooms. During an interview on 07/30/25 at 3:15 P.M., CNA D said the following: -It was difficult to keep up with Resident #49 on evening shift because he/she wandered into other residents rooms and upset the residents;-Resident #49 wandered more at night;-Resident #49 was more confused and trying to go into other resident's rooms because he/she has been moved to at least three different rooms now. During an interview on 07/30/25 at 3:40 P.M., CNA E said the following:-Resident #49 wandered into other resident rooms;-Staff has been told in report to watch Resident #49 for wandering and to redirect the resident and monitor closely;-Something had to be triggering Resident #49 to wander. During an interview on 08/04/25 at 3:40 P.M., Licensed Practical Nurse (LPN) C said the following:-(On 07/25/25) Resident #46 was yelling and CNA B went into the room to see what was going on;-CNA B then started yelling for him/her to come in;-CNA B was taking Resident #49 to his/her recliner and said they needed to separate the residents, so they brought Resident #49 to the day room near the desk;-CNA B reported Resident #46 hit Resident #49 several times;-He/She called the on-call nurse (Assistant Director of Nursing/ADON) to report the altercation;-Resident #49 had areas with blood on his/her wrist and forearm that required wound cleanser (he/she believes it was the resident's left arm), but he/she could not see where the blood was coming from or where to even place a bandage;-Resident #46's responsible party informed him/her that Resident #49 had tried to get into Resident #46's bed previously, but he/she did not know about that at the time;-The facility tried to increase monitoring of the resident with 15 minute checks when the resident had behaviors; there were no other interventions to address the resident's behaviors. During an interview on 07/30/25 at 10:25 A.M. and 12:40 P.M. and 07/31/25 at 2:55 P.M. and 5:00 P.M., the Director of Nursing (DON) said the following:-Resident #46 said Resident #49 was in his/her closet and Resident #49 went over to him. Resident #46 hit Resident #49 on the left arm trying to get him/her away;-The nurse separated the residents and brought Resident #49 to the dayroom and called the on-call nurse, which was the ADON to report the incident;-She had heard about Resident #49 trying to get into Resident #46's bed and had told staff to increase monitoring;-Resident #49 got into Resident #46's closets and it upset Resident #46;-Resident #49 gets into other residents' closets, but she had not heard about any other resident incidents recently; -He/She believes Resident #49 does these things because he/she does not know where his/her stuff is;-Resident #49 did get into a former roommate's closet and that behavior really upset the former roommate resulting in the roommate yelling at Resident #49; -She would expect staff to redirect the resident and increase monitoring;-Resident #49 was in a room by himself/herself before he/she got his/her next roommate;- Increased monitoring and redirection were the only interventions that had been put in place to address the resident's wandering into other resident rooms;-She should redirect the resident when wandering, increase monitoring, offer an activity, anticipate the resident's needs, and determine why the resident was wandering;-Staff had not been directed specifically on these things.

Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated, and covered; failed to maintain the range hood to be free of an accumulation of grease and debris; failed to ensure staff wore beard restraints to prevent potential contamination; and failed to ensure the ice machine was free of a buildup of debris. The census was 54.Review of the undated facility policy, Food Storage-Refrigeration, showed foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with expiration dates. The manager and/or his/her designee shall check the refrigerators daily to ensure leftovers are discarded and all food is properly stored. 1. Observation on 7/28/25 at 10:51 A.M. of the reach-in refrigerator in the kitchen showed the following:-An opened five-pound bag of shredded cheddar cheese was open to air and was not sealed;-A small metal pan, labeled tomatoes, was partially covered with foil and was not dated. The pan was open to air and not sealed;-A plastic container held individually wrapped sandwiches. Neither the container nor the sandwiches were not labeled or dated;-A partial plastic bag of grated parmesan cheese was stored inside a zippered bag and was not dated. Observation on 7/28/25 at 12:25 P.M. showed a 20-ounce container of onion powder sat on a shelf over the preparation counter. The container lid was open to air and was not closed. During an interview on 7/30/25 at 10:50 A.M., the Dietary Manager said food items should be labeled, dated, and closed or sealed. The cooks checked food items when he wasn't working (on Thursdays and weekends). He checked for proper labeling, dating, etc. every other day. 2. Observation on 7/28/25 at 11:05 A.M. showed the range hood in the kitchen had a moderate buildup of dark colored debris and clear grease on the baffle filters. Yellow grease, drips and runs were visible on the interior of the range hood. During an interview on 7/29/25 at 4:20 P.M., the Maintenance Supervisor said he cleaned the range hood filters on 6/11/25. Kitchen staff wiped down the interior of the range hood, but he was unsure how often. During an interview on 7/30/25 at 10:50 A.M., the Dietary Manager said maintenance staff removed the filters from the range hood and ran them through the dish machine every other week. Dietary staff wiped down the inside of the range hood weekly. 3. Review of the facility policy, Personal Hygiene and Appearance, revised January 2016, showed hair nets or hair coverings shall be worn while in the kitchen or storage areas. Facial hair, except eyebrows, must be covered with a hair net or beard cover. Observation on 7/28/25 at 11:40 A.M. showed Dietary Aide A rolled clean silverware in napkins for the residents. Dietary Aide A had a beard and sideburns and did not wear a beard restraint. Observation on 7/28/25 at 11:58 A.M. showed Dietary Aide A filled plastic beverage glasses with a pitcher. Dietary Aide A had a beard and sideburns and did not wear a beard restraint. During an interview on 7/30/25 at 10:50 A.M., the Dietary Manager said staff should wear hair restraints when they entered the kitchen. If staff's beard hair was longer than 1/2-inch, the staff needed to wear a beard restraint. Dietary Aide A should wear a beard restraint when in the kitchen. He had trouble ordering beard restraints, but staff should use a hair restraint as a beard restraint if needed. 4. Observation on 7/29/25 at 12:55 P.M. showed the ice machine was located on the staff service hall inside the storage room labeled Compactor. [NAME] crusty debris and yellow-colored debris was visible inside the ice machine over the accumulated ice below on both sides of the unit. During an interview on 7/29/25 at 4:20 A.M., the Maintenance Supervisor said the ice machine was due to be cleaned last week. Kitchen staff empty the ice and wipe out the unit. He descaled the machine and cleaned it. He was unaware of the debris accumulation inside the ice machine. During an interview on 7/30/25 at 10:50 A.M., the Dietary Manager said dietary staff emptied the ice machine monthly into coolers and cleaned the unit inside and outside monthly. The Maintenance Supervisor descaled the unit monthly.

Based on interview and record review, the facility failed to implement the facility policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The administrator said the facility did not have a water management team, did not have a water flow map with the details of the water flow though the building and that include all of the elements the facility policy directed, and the facility had not been monitoring cold water temperatures. The Director of Nursing had not been trained to monitor residents with pneumonia for possible Legionnaire's Disease as directed by the facility policy. The facility census was 54. Review of the facility's Legionella and Water Management Policy, dated 9/26/19, showed the following:-As part of the infection prevention and control program, the facility had a water management team that includes the Administrator, Maintenance Supervisor, Director of Nursing (DON), and Medical Director;-The team is to identify areas in the water system where Legionella can grow and spread to reduce the risk of Legionnaire's disease;-A detailed description and diagram of the water system in the facility will include water intake-from the well, cold water delivery-chillers, hot water heating-boilers, hot water delivery and waste discharge;-Identification of areas in the water system that could encourage the growth and spread of Legionella include water heaters, filters, shower heads, hoses, personal humidifiers and medical machines such as Continuous Positive Airway Pressure (CPAP);-Situations that could arise and lead to Legionella include construction, water main breaks, changes in water sources, scale or sediment and stagnation, water pressure, inadequate disinfection and water temperatures;-Measures used to control the spread of Legionella include diagram of all applied control measures, monitor control limits and documentation of the program;-Review of the policy showed no direction of assessing hot and cold temperatures within the facility to ensure temperatures did not fall in the optimal growth range for Legionella and did not address how often the Water Management team was to meet. Review of the facility policy, Legionella Surveillance and Detection, dated 09/26/2019, showed the following:-The facility is committed to prevention, detection and control of water borne contaminants, including Legionella. Legionnaire's disease will be included as part of the facility infection control program;-Clinical staff will be trained on signs and symptoms associated with pneumonia and Legionnaire's and when to notify the physician in regard to testing. Symptoms can include cough, shortness of breath, fever, muscle aches, headache, diarrhea, nausea and confusion are also associated with Legionnaire's Disease;-If pneumonia or legionnaire's disease are suspected, the nurse will notify the physician immediately with an assessment of the resident's condition. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains;-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Center for Disease Control (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 1. The facility provided no documentation showing monitoring of cold water temperatures. During an interview on 08/14/25 at 3:25 P.M., the Maintenance Director said the following:-The facility had one water management team meeting since the last survey;-The water management team included himself, the Director of Nurses, administrator, and medical director;-He was not familiar with the ASHRAE standards;-He did not monitor the cold water temperatures;-He sent a monthly water sample and test for E. coli (bacteria), lead, and copper to the department of natural resources, but it does not test for legionella;-He did not know about cold and hot water ranges to prevent the growth of legionella;-He did not check for sediment, scaling, or biofilm. During an interview on 07/31/25 at 3:46 P.M., Registered Nurse (RN) M said the following:-He/She and the Administrator were both the infection preventionists in the facility;-He/She did not know what ASHRAE standards were;-He/She had not done any monitoring of any residents for legionellosis; she had not educated any staff on what to monitor for. During an interview on 07/31/25 at 3:46 P.M., the Director of Nursing (DON) said the following:-She did not know what ASHRAE standards were;-She had not attended a water management meeting;-She had not done any monitoring of any residents for legionellosis and did not have a plan to monitor future resident's with pneumonia; she had not educated any staff on what to monitor for. During an interview on 07/31/25 at 3:46 P.M., the Administrator said the following:-She and RN M were both the infection preventionists in the facility;-The facility staff do not know what ASHRAE standards are;-The facility does not have a water management team, but the Maintenance Supervisor checked temperatures on the tempering valves;-The facility had not had a water management meeting;-Staff should be monitoring residents for legionellosis per the facility policy;-The facility's water flow map had entry and exit points of water and water heaters, but no other areas in the building;-She thought the Maintenance Supervisor completed water temperature checks and thought that included cold water checks.

Based on observation, interview and record review, the facility failed to make appropriate updates and revisions to develop a plan of care consistent with residents' specific conditions, needs and risks for two residents (Resident #34 and #17) in a review of 17 sampled residents. The facility failed to revise Resident #34's care plan to provide staff direction for interventions related to the resident's auditory and visual hallucinations and confusion, did not update to address the resident's mechanically altered diet/loss of liquid/solids from his/her mouth when eating or drinking, holding food in his/her mouth/cheeks or residual food in mouth after meals, and did not address pain medications for pain and/or anxiety, and failed to revise Resident #17's care plan to include the resident's current oxygen therapy order. The facility census was 54. Review of the undated facility policy, Care Plan, showed the following:-A care plan is initiated upon admission (known as the baseline care plan) and is revised quarterly, with a significant change, and as needed. The MDS coordinator is the primary person responsible for updating the care plan, however the nursing staff, dietary manager, resident service coordinator, and restorative aide are responsible for updating the care plan as needed;-The comprehensive care plan will be initiated within 14 days of admission;-The care plan will be completed no later than 7 days after the comprehensive MDS is completed;-Care plan meetings are scheduled once a week and as needed to meet family/resident needs;-The MDS Coordinator chairs the meetings with input from the other department heads. 1. Review of Resident #34's undated medical diagnoses page showed the following:-Cerebrovascular disease (a group of disorders that affect blood vessels and blood supply to the brain, potentially leading to stroke, aneurysm, or other serious conditions);-Dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, language, and judgement that interferes with daily life and independence;-Dysphagia (a medical condition characterized by difficulty swallowing);-Hallucinations (a sensory experience that seems real but is not).-No diagnoses related to pain noted. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/01/25, showed the following:-Cognitively intact;-No behaviors;-Independent for eating;-No alternative or special diet;-No swallowing concerns;-The resident had pain that rarely interfered with his/her sleep and day-to-day activities. Review of the resident's significant change MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-No behaviors;-Independent for eating;-No alternative or special diet;-No swallowing concerns;-The resident had pain that rarely interfered with his/her sleep and day-to-day activities. Review of the resident's progress notes, dated 06/29/25, showed the following:-The resident refused to get out of bed for lunch, lunch tray taken to room and 0 percent (%) eaten;-40% of dinner consumed in room, being fed by staff. Resident refused to feed self, said hands didn't work. Review of the resident's Physician Order Summary Report showed the following:-Tylenol 650 mg every four hours PRN for pain; start date of 02/01/25;-07/03/25, a physician ordered regular diet, mechanical soft texture, regular/thin consistency;-Morphine sulfate (medication for pain) 0.25 milliliters (ml) every three hours PRN (as needed) for pain; start date of 07/07/25. Review of the resident's progress notes showed staff documented the following:-On 07/03/25 at 10:33 A.M. the resident recently had a significant decline in condition, appetite was poor, but weight was stable;-On 07/03/25 at 3:34 P.M., the resident was on a mechanical soft diet with thin liquids;-On 07/07/25 at 5:16 A.M. the resident yelled out and talked in his/her sleep; -On 07/08/25 at 1:42 A.M. the resident was extremely confused Review of the resident's Physician Order Summary Report showed an order for lorazepam (medication for anxiety) 0.5 ml every four hours PRN; start date of 07/09/25. Review of the resident's progress notes showed staff documented the following:-On 07/17/25 at 2:10 P.M. behavior charting showed the resident called out from his/her room and dining room, saying help me. -On 07/18/25 at 2:29 P.M. behavior charting showed the resident was hollering out complaining of pain this shift and ate 25% to 50% of food at all meals; -On 07/19/25 at 6:11 A.M. behavior charting showed resident yelled off and on all shifts;-07/19/25 at 2:02 P.M. behavior charting showed the resident was restless and yelling out at breakfast; -07/20/25 at 2:02 P.M. behavior charting showed the resident was confused while talking throughout the day-07/24/25 at 10:22 A.M. notified resident's family of residents decline in condition, requiring total assist with eating, not eating well, ate less than 10% of breakfast, yelling out in pain, family notified and decided to proceed with hospice referral;-07/25/25 at 1:47 P.M. behavior charting showed the resident yelled out during lunch. Review of the resident's significant change MDS, dated [DATE], showed the following:-Severe cognitive impairment;-No behaviors;-Dependent for eating;-Loss of liquid/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals;-On a mechanically altered diet;-The resident had pain that frequently interfered with his/her sleep and day-to-day activities. Observation on 07/29/25 at 12:47 P.M. and 1:02 P.M. showed the resident assisted by staff to eat a mechanical soft diet. The resident did not eat any of the mechanical soft meal, ate two ice creams and drank water and juice. Review of the resident's updated care plan, dated 07/29/25, showed the following:-He/She had auditory and visual hallucinations;-He/She had periods of confusion, encourage to drink fluids throughout the day;-He/She was on a regular diet, dependent on staff to eat;-He/She had chronic knee pain, takes scheduled pain medication, if increased pain offer a hot pack or offer to reposition;-The care plan was not updated to address the resident was on a mechanically altered diet, lost liquid/solids from his/her mouth when eating or drinking or pocketing food; -The care plan did not address interventions for when the resident was having auditory and visual hallucinations or when the resident was confused;-The care plan did not address as needed pain and anxiety medications available for pain and/or anxiety. Observation on 07/30/25 at 6:47 A.M. showed the resident in his/her room, yelling out and asking for someone to come to his/her room. Observation on 07/30/25 at 7:01 A.M. showed the resident continued to yell out from his/her room, asked for someone to come to his/her room, yelled for someone to untie him/her, had other mumbled conversations. Certified Nurses Aid (CNA) J knocked on the resident's door and told the resident he/she would be right back after he/she finished helping another resident. Observation on 07/30/25 at 7:18 A.M. showed the resident continued to yell out from his/her room. CNA J knocked and entered the resident's room and asked the resident if he/she was in pain. Resident stated yes, in his/her legs. CNA J said he/she would let the nurse know about his The resident was confused, yelling out and asking where he/she was and asked where [NAME] was. Observation on 07/31/25 at 8:52 A.M. showed the resident yelling out from his/her room, someone come down here, anyone help, I found her, hey come here please, come on nurse, and other inaudible comments. Observation on 07/31/25 at 9:01 A.M. showed the resident continued to yell out from his/her room, please! Someone come down here. I need someone to come down here. Please!. An unidentified nurse aide exited the room next to the resident's, collected the dirty linen cart and walked away down the hall. During an interview on 07/31/25 at 9:36 A.M., Licensed Practical Nurse (LPN) K said the following:-The resident started declining quickly, within the last month;-The resident developed new behaviors of anxiety and yelling out during this time, and they have worsened over the last couple weeks;-The resident's diet changed from mechanical soft to pureed yesterday due to pocketing of food during meals;-Interventions for the resident's behaviors include regular checks, talking and communication, offering food and drink, adjusting temperature to ensure comfort, and asking about pain;-He/She knew the interventions from nursing report and being a smaller facility and familiar with the residents, it was not listed on the resident's care plan. 2. Review of Resident #17's care plan, dated 04/24/25, showed the resident with diagnosis of chronic obstructive pulmonary disease (COPD - disease of the lungs) and required him/her to be on oxygen at 2 liters (L) per nasal cannula (NC - flexible prongs placed in the nares that deliver oxygen) continuous. Review of the resident's physician orders, dated 05/30/25, showed an order for oxygen at 2L per NC as needed for shortness of breath. Review of the resident's care plan, on 07/30/25, showed it had not been updated to show the resident no longer required continuous oxygen therapy and only required it as needed as of 05/30/25.Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/17/25, showed the following:-Moderately impaired cognition;-Required oxygen therapy;-Oxygen therapy continuous not assessed;-Oxygen therapy as needed not assessed. Observation of the resident on 07/28/25 at 2:00 P.M. showed the resident sat in his/her wheelchair with a portable oxygen tank at 2L per nasal cannula. During an interview on 07/28/25 at 2:00 P.M., the resident said he/she wears his/her oxygen as needed and not continuously. Observation on 07/29/25 at 11:48 A.M. showed the resident taking off his/her nasal cannula. 4. During an interview on 07/31/25 at 2:50 P.M., CNA H said that he/she knows how to take care of a resident by looking at the care plan, getting the information in report or from the charge nurse. During an interview on 07/31/25 at 2:45 P.M., the Assistant Director of Nursing (ADON) said that she was responsible for care plans, but all nursing staff can update any changes to the care plan. The interdisciplinary team met weekly to discuss changes. During an interview on 07/31/25 at 5:01 P.M., the DON said that she would expect for the care plans and interventions to be up to date and accurate, and to reflect a resident's current needs. During an interview on 07/31/25 at 5:00 P.M., the Administrator said she would expect care plans and interventions to be accurate and up to date.

Based on observation, interview and record review, the facility failed to follow physician's orders and facility policy when they did not notify the physician of blood glucose results (the amount of sugar in the blood outside of the parameter outlined in the physician's orders and facility policy for one resident, (Resident #2) in a sample of 17 residents. The facility also failed to adequately monitor pain for one resident (Resident #2) who had multiple diabetic wounds to his/her feet and arthritis. The facility census was 54. Review of the undated facility policy, Blood Glucose Test Procedure, showed the following:-Record test results in electronic medical record (EMR);-Report any values less than 50 or greater than 400 to the physician. Unless otherwise instructed by physician. Review of the undated facility policy, Notification of Changes, showed the facility will notify the resident, consult with the resident's physician and the resident's legal representative or an interested family member when a significant change in the resident's physical, mental or psychosocial status occurs, or a need to alter treatment significantly. Review of the Resident Assessment Instrument (RAI) manual, updated October 2025, showed the following:-Eschar tissue: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound;-Stage 1 Pressure injury: An observable, pressure related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues;-Diabetic foot ulcers: Ulcers caused by the neuropathic and small blood vessel complications of diabetes. Diabetic foot ulcers typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape and the wound edges are even with a punched-out appearance. These wounds are typically not painful;-Unstageable: If a pressure ulcer's tissues are obscured such that the depth of soft tissue damage cannot be observed, it is unstageable. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable. During an interview on 07/31/25 at 2:30 P.M., the Director of Nurse said there was no specific policy on monitoring or premedicating a resident prior to treatments for pain. 1. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 05/22/25, showed the following:-Cognition intact;-Diagnosis of heart failure, kidney failure, diabetes mellitus (inability to regulate blood sugar) and restless leg syndrome;-Resident was not on a scheduled pain medication regimen;-Resident did not receive as needed pain medications in the last five days;-Occasionally has pain rated at a five;-Resident takes opioid medications;-Resident has two stage 1 pressure ulcers (intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes);-Is receiving pressure ulcer care. Review of the resident's July 2025 physician order sheets (POS) showed orders for the following:-Tramadol (medication for pain) 50 milligrams (mg), take one tablet every six hours as needed; order start date of 05/27/25;-Tylenol 8 Hour Arthritis Pain (medication for pain) 650 mg, take one tablet every eight hours PRN; start date of 05/27/25;-Hydrocodone-Acetaminophen (medication for pain) 5/325 milligrams (mg), take one tablet every four hours as needed (PRN), order date of 07/09/25;-Monitor pain every shift for one week related to a medication change from 07/11/25 to 07/18/25; order date of 07/11/25. Review of the resident's Medication Administration Record (MAR), dated 07/11/25 to 07/18/25, showed the order for pain monitoring entered and discontinued on 07/11/25; the MAR did not have the order entered where staff could monitor the order and would not prompt the staff to do a pain assessment because the order did not show it was due. Review of the resident's EMR, including the POS and nursing notes, showed no documentation staff obtained an order to discontinue monitoring for pain or to explain why the monitoring was not completed. Review of the resident's July 2025 POS showed an order, dated 07/14/25, for Accu checks (finger prick procedure to determine the amount of sugar in the blood) four times a day, call the physician with a blood glucose greater than 400. Review of the resident's MAR, dated 07/16/25, showed staff documented the resident's blood glucose at the mid-day check was 497, and the afternoon check (dinner time) was 409. There was no documentation staff reported the resident's blood glucose to the physician per the facility policy and the resident's physician's order. Review of the resident's EMR, including nursing notes, showed no documentation staff notified the physician on 07/16/25 of the resident's blood glucose results of 497 or 409. Review of the resident's MAR, dated 07/17/25, showed staff documented the resident's blood glucose at the mid-day check was 465, and the afternoon check (dinner time) was 482. There was no documentation staff reported the resident's blood glucose levels to the physician per the facility policy and the resident's physician's order. Review of the resident's EMR, including nursing notes, showed no documentation staff notified the physician on 07/17/25 of the resident's blood glucose results of 465 or 482. Review of the resident's care plan, dated 07/17/25, showed the following:-I have good communication skills and can make my needs known; I will let you know if I need something;-I am working with therapy on my ambulation;-I was admitted with three pressure wounds, including one to my heel. I have a diabetic ulcer to my left and right great toe and my left mid-foot;-I have pain to my back, shoulders and legs. I am on scheduled and have PRN pain medication to help with pain. If I am having more pain, please offer me a hot pack or offer to reposition me to allow for better pain control;-The care plan did not address how often staff should monitor for pain or if staff should be offering an intervention prior to therapy or wound treatments. Review of the resident's MAR, dated 07/18/25, showed staff documented the resident's blood glucose at the mid-day check was 461 and the afternoon check was 487. There was no documentation staff reported the resident's blood glucose levels to the physician per the facility policy and the resident's physician's order. Review of the resident's EMR, including nursing notes, showed no documentation staff notified the physician on 07/18/25 of the resident's blood glucose results of 461 or 487. Review of the resident's July 2025 POS showed orders for the following:-07/23/25, cleanse left ball of foot with wound cleanser and apply skin prep every shift (three times daily);-07/24/25, cleanse left heel with normal saline, pat dry with gauze, and apply skin prep to the peri-wound area, then apply Hydrofera (a type of wound dressing) blue ready to the wound bed, cover with foam dressing, check daily (day shift) and change every three days. Review of the resident's Medication Administration Record, dated 07/29/25, showed the resident received hydrocodone-acetaminophen 5-325 mg at 7:42 A.M. Review of the resident's EMR showed no documentation of Quarterly Pain Assessments completed for the resident. During an interview on 07/29/2025 10:43 A.M., the resident said nursing staff made him/her walk too much and his/her left foot hurt with pain rated nine out of ten, (with ten being the worst pain possible). His/Her heels and toes have wounds from his/her shoes. It hurt down his/her left leg, across the bottom of his/her foot, midfoot, joints and toes, and up the leg. Staff make him/her walk on it even though he/she doesn't want to. They changed the dressing on the foot this morning. Observation on 07/30/25 at 10:45 A.M., showed the following:-Registered Nurse (RN) N and the Director of Nursing (DON) entered the resident's room to provide dressing changes;-The resident said that his/her pain was a seven. His/Her feet hurt and his/her shoulders, especially his right shoulder, and the pain went down his/her arm; RN N and the DON did not respond to the resident's reporting of pain at the time; -The resident had a diabetic ulcer on the tip of his/her right great toe that measured 1 centimeter (cm) in length and width;-The resident had an unstageable pressure ulcer on the right heel that measured 0.5 cm length and width, that had fragile new skin starting to cover; -The diabetic ulcer to the resident's left great toe showed red center that measured 1.5 cm in length x1.5 cm in width with a callus formed on the periwound; the center of the wound bed showed a 0.5 x 0.5 dark red spot;-The resident's ball of his/her left foot had a diabetic ulcer that measured 0.5 cm in length x 1 cm in width;-The resident's left heel had a pressure wound with eschar covering the wound bed that measured 1 cm in length x 2 cm in width; the RN N described the scab as weak;-The resident grimaced when the wounds were directly touched during the dressing changes. Review of the resident's Progress Notes/Medication Administration Note, dated 07/30/25, at 11:00 A.M., showed staff administered tramadol 50 mg. The resident complained of pain 7 /10 in bilateral (both) wrists and bilateral lower extremities and requested pain medication. During an interview 07/31/2025 2:53 P.M., the DON said the following: -If a resident has routine pain, the facility does pain documentation for a week; -The facility routinely does Quarterly Pain Assessments; -The facility uses the pain scale with faces (1-10 scale correlated with facial expressions) or PANAM (Pain Assessment in Advanced Dementia (PAINAD) scale, a specific tool used to assess pain in individuals with advanced dementia or other conditions affecting their ability to communicate verbally) or the 1-10 pain scale where resident's rate their pain 1-10 with 10 being the worst pain;-Staff are expected to ask and monitor residents about their pain; if they are having any signs or symptoms, restlessness, or physical outward signs of pain; -She does not know why the monitoring entered on 07/11/25 was entered and then looked like it was discontinued; -She expected staff to offer pain medication prior to completing wound dressings;-She nor RN N asked the resident about his/her pain prior to completing his/her wound care, but should have;-Staff are expected to report blood glucose results to the physician when they are over 400 or less than 50;-Those values (less than 50 or over 400) could be urgent to emergent depending on the resident and their situation, and need to be reported immediately for each time the resident has that value;-Staff are expected to follow the physician's orders, and document actions taken, if an order is not completed for any reason, staff are expected to document why and what actions were taken.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #3), out of eight sampled residents, was safely transferred from a wheelchair to bed with a mechanical lift. Staff used a lift sling with two torn attachment loops for the transfer, hooking the sling to the lift with the two attachment loops below the torn loops. During the transfer, the lower loops tore, causing the resident to fall from the lift. The resident sustained a laceration to the back of his/her head which required treatment in the emergency room . The facility census was 55. On 4/16/25 at 12:55 P.M., the administrator was notified of the past noncompliance which occurred on 4/8/25. On 4/8/25, the administrator became aware of the resident's fall from a mechanical lift during a transfer. Upon discovery, the facility investigated and notified the appropriate parties. Staff reviewed the mechanical lift policy, were educated on what to look for on a lift sling, including frays, tears, and worn areas, when to report the issues found on the sling, and how to exchange it with a new sling located at the Director of Nursing's office or nurses' station on the weekends. The restorative aide started weekly audits of the lift slings to monitor of frays, tears, etc. then reports the findings to the Director of Nursing and/or Administrator. The deficiency was corrected on 4/10/25. Review of the facility's Mechanical Lift policy, undated, showed the following: -A mechanical lift is used appropriately to facilitate transfers of residents; -Lower lift and place hooks in the appropriate holes of the lift sheet; -Using lever gently raise and move resident to destination; -Lower resident and position comfortably. 1. Review of the Drive Medical Full Body Patient Sling Owner's Manual (for the mechanical lift), dated 1/15/16, showed the following: -The maximum weight capacity was 600 pounds; -Inspect patient slings for wear prior to each use; -If signs of tearing, fraying, or wear are found discard the sling immediately, worn out slings are not safe for use and may result in injury or death. Review of the email sent from Drive DeVilbiss Healthcare's Customer Solutions Complaints Lead sent to the state agency, dated 4/16/25 at 2:08 P.M., showed a sling should not be used if any of the loops are broken, if stitching is torn, or if the label/tags are unreadable and if any of those occur the sling must be replaced. 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/30/25, showed the following: -The resident had severely impaired cognition; -He/She was dependent on staff for transfers. Review of the resident's Care Plan, dated 2/5/25, showed the following: -The resident was nonverbal most of the time; -He/She needed extensive assistance from two staff for transfers and used the mechanical lift as needed. Review of the resident's Nurse's Note, dated 4/8/25 at 8:33 A.M., showed the following: -Certified Nurse Aide (CNA) A and CNA B were transferring the resident from wheelchair to bed with the mechanical lift when the bottom of the lift pad broke causing the resident to fall onto the floor; -Staff placed the lift pad on the green loops on all loop holders of the lift while the resident was being transferred; -When the lift sling loops broke, it caused the resident to fall and hit his/her head on the bed frame resulting in a five centimeter laceration to the back of his/her scalp; -The CNAs called the nurses to the resident's room immediately; -The nurses assessed the resident, applied pressure to the back of the resident's head to control bleeding, and received an order from the primary care physician to send to the resident to the emergency department. Observation of the resident's lift sling photos, dated 4/8/24 at 11:56 A.M., showed the purple loops and green loops of the bottom two attachment straps were broken and the top left side sustained a rip of approximately 10 inches from the outer aspect of the sling inward toward the center. Review of the resident's Nurse's Note, dated 4/8/25 at 1:30 P.M., showed the following: -The emergency department staff called the facility to report the resident's head computed tomography (CT, diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) scan was negative and the resident received three staples to the left, backside of the head; -The hospital planned for the resident to return to the facility. During an interview on 4/16/25 at 9:12 A.M., CNA A said the following: -He/She and CNA B used the mechanical lift with the full body sling to transfer the resident from the wheelchair to bed; -The green loops used on the connection straps were not frayed or worn, so they thought it would be safe to use. They were to use the purple loops, but two of them were broken; -As they were transferring the resident, he/she heard a pop sound, the resident went down towards the floor feet first and the resident's head hit the bed frame; -The back of the resident's head was bleeding and CNA B went to get the nurse immediately. During an interview on 4/16/25 at 9:18 A.M., CNA B said the following: -He/She and CNA A took the mechanical lift into the resident's room to transfer the resident from the wheelchair to bed; -The purple loops on the lift sling were broken, so they used the green loops for the transfer, which broke; -While CNA B had his/her hands on the resident to help guide, he/she heard the sling pop, then the resident started to fall feet first onto the floor and the resident's head hit the bed frame. During an interview on 4/16/25 at 9:22 A.M., Laundry Staff C said the following: -The laundry staff wash the lift slings separately in the washing machine and hang them up to dry; -The laundry staff are supposed to look for any frayed or broken areas and report the issues to the nurse so the sling could be replaced; -He/She had not found any damaged lift slings. During an interview on 4/16/25 at 10:00 A.M., Restorative Aide (RA) E said the following: -RA E was assigned to complete weekly audits on the lift slings; -The facility had a supply of slings available in case a sling needs to be removed room use; -The facility stored a couple of new lift slings at the nurses' station over the weekends in case a sling needed to be replaced; -He/She was unaware of the frayed/worn sling prior to the incident. During an interview on 4/16/25 at 12:10 P.M., the Director of Nursing said the following: -If a lift sling has any broken, frayed, or worn areas it should be reported immediately and the sling taken out of use; -CNA A and CNA B thought the lift sling would be safe to use because the green loops were intact and didn't have any signs of fray; -She educated all staff on not using lift slings with any frayed areas, broken areas, or tears in the material and any issues with a sling must be reported and the sling replaced immediately; -RA E does a weekly audit on the slings to ensure the lift slings are safe for use; -She identified the problem after the incident and immediately worked on a plan to prevent this incident from happening again. During an interview on 4/16/25 at 12:55 P.M., the Administrator said the following: -Her expectation was the staff checked lift slings before use and exchange the sling with a new one when any issue was identified; -Her staff identified the problem, and a plan was implemented to prevent any further incidents like this from happening in the facility in the future. MO252451

Based on interviews and facility document review, the facility failed to ensure the designated Dietary Manager (DM) had the required education, certification, or experience to qualify her for the position. This had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: During an interview on 10/18/2023 at 2:09 PM, the Administrator stated the facility had no policy or procedure addressing the requirements to serve in the dietary management position. A review of the DM's employee file revealed the facility initially hired the DM in August 2022 as a housekeeper and laundry aide. No documentation of training was found within the DM's employee file regarding her move from housekeeping and laundry to the position of DM, nor was there any information regarding any food service certifications. An Employee 60 Day Review, dated 01/16/2023, indicated the DM was learning new role, including ordering, cooking, and supervising, and an Employee 90 Day Review, dated 03/27/2023, indicated the DM continues to learn. The DM's employee file also revealed she had experience at two local gas station convenience stores where kitchen, scheduling, inventory, ordering, and workplace improvement were listed as job duties between April 2006 and April 2022. During an interview on 10/18/2023 at 12:05 PM, the DM stated the Contracted Certified Dietary Manager (CCDM) provided her training, which included food safety. She stated she had no formal training, and her experience came from previous employment at a couple of convenience stores in town. During an interview on 10/18/2023 at 2:09 PM, the Administrator stated the facility had no training record for the DM. She stated the DM started with the facility in August 2022 and then moved into the role of DM in October 2022. She stated the facility had no certificate of completion for any food service or managerial program. The Administrator stated training had been arranged in a nearby town, but the DM was unable to make the scheduled training. During a follow-up interview on 10/18/2023 at 2:29 PM, the DM stated this was the first skilled nursing home kitchen she had worked in. She stated her previous kitchen experience was at a gas station convenience store in town. The DM stated she had discussed attending the ServSafe training (a training program developed to maintain standards and safety in the food service industry) with the Contracted Registered Dietitian (CRD) and the CCDM, but the training had already started, and she was unable to join that training. The DM stated she had no education as a dietary manager, dietitian, or any other professional food industry training. During a follow-up interview on 10/18/2023 at 3:08 PM, the Administrator stated the DM oversaw the day-to-day activities of the kitchen. She stated she had spoken with the CRD several times throughout the year about getting the DM into formal training, but it was unable to be arranged. She stated the DM received training from the former supervisor, Dietary Cook #13, who was still employed and supported the DM. During a follow-up interview on 10/19/2023 at 9:40 AM, the DM stated the CCDM spent two days in the facility training her when she accepted the position in October 2022. During an interview on 10/19/2023 at 9:58 AM, the CRD stated the CCDM worked for her and finished the training that she started in the facilities she contracted with and was in the facilities daily during the training period. She stated the CCDM also completed kitchen audits and provided training to dietary staff. The CRD stated the CCDM completed the DM ' s training and completed mock inspections of the kitchen with the DM, going over any concerns and issues identified. She stated the former supervisor, Dietary Cook #13, also assisted with training the DM and was still employed, providing managerial support. The CRD stated she reviewed the training book kept in the kitchen and could not find all of the training that had been provided to the DM and confirmed training information was missing. During a follow-up interview on 10/19/2023 at 5:22 PM, the Administrator stated she knew the DM required some classes or two years of experience. She stated that due to the rural nature of the area, it was hard to find anyone with the right qualifications, and the DM was the closest match they could find.

Based on observations, interviews, facility document and policy review, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff maintained meal temperature monitoring records for each meal service; failed to ensure staff maintained monitoring records of the sanitizer concentrations for the three-compartment sink to ensure items were properly sanitized; and failed to ensure staff thawed a roll of ground beef in accordance with professional standards. These failures had the potential to affect 52 of 52 residents who received meals from the dietary department. Findings included: 1. A review of an undated facility policy titled Department Meal Service: Meal Service Temperatures revealed, Purpose To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service. The policy also indicated, Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. The procedural section of the policy indicated, Temperatures shall be recorded on the Temperature Report Form at each meal. During initial kitchen observation and interview on 10/16/2023 at 10:24 AM, a review of the Food Temperatures log for the timeframe from 07/30/2023 through 10/15/2023 revealed no meal temperature data had been logged for the following meals: -Breakfast meals: 08/05/2023, 08/24/2023, 09/07/2023, 10/01/2023, 10/04/2023, 10/05/2023, or 10/14/2023. -Lunch meals: 08/05/2023, 08/08/2023, 08/20/2023, 08/23/2023, 08/24/2023, 09/05/2023, 09/07/2023, 10/01/2023, 10/04/2023, 10/05/2023, 10/11/2023, or 10/14/2023. -Dinner meals: 08/01/2023, 08/02/2023, 08/04/2023, 08/05/2023, 08/08/2023, 08/09/2023, 08/11/2023, 08/12/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/19/2023, 08/22/2023, 08/23/2023, 08/25/2023, 08/26/2023, 08/29/2023, 08/30/2023, 09/01/2023, 09/02/2023, 09/05/2023, 09/06/2023, 09/08/2023, 09/09/2023, 10/01/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/06/2023, 10/07/2023, 10/10/2023, 10/11/2023, 10/13/2023, or 10/14/2023. No food temperature logs were provided for the timeframe from 09/10/2023 through 09/30/2023. The Contracted Certified Dietary Manager (CCDM) stated the meal temperature logs should be filled out each day at every meal. During an interview on 10/16/2023 at 10:36 AM, Dietary Cook #13 stated meal temperature logs should be documented for each meal every day. She stated logging meal temperatures was important for food safety. During an interview on 10/18/2023 at 2:29 PM, the Dietary Manager (DM) stated the CCDM had provided training about documenting the hot and cold meal temperatures on the log for food safety. She stated temperatures needed to be logged every day for every meal. The DM stated the dietary department recently hired new staff and they must have forgotten to log the meal temperatures. During an interview on 10/19/2023 at 3:08 PM, the Administrator stated meal temperatures should be taken correctly and logged for each meal. 2. A review of the United States FDA 2022 Food Code, dated 01/18/2023, revealed, Chapter 2. Management and Personnel, 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are used, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH [power of hydrogen], temperature, and exposure time for chemical SANITIZING. During initial kitchen observations on 10/16/2023 at 10:36 AM, the three-compartment sink was observed, in which the facility utilized a quaternary ammonium sanitizing solution. At this time, a review of the Three Compartment Sink Sanitizing Solution PPM [parts per million; a measurement of concentration] Log, for the timeframe from 09/01/2023 through 10/16/2023 revealed no documented sanitizer PPM data on 09/02/2023, 09/03/2023, 09/06/2023, 09/07/2023, 09/11/2023, 09/13/2023, 09/17/2023, 09/18/2023, 09/20/2023, 09/21/2023, 09/25/2023, 09/27/2023, 09/30/2023, 10/04/2023, 10/05/2023, 10/11/2023, 10/14/2023, or 10/15/2023. During an interview on 10/16/2023 at 10:36 AM, Dietary Cook #13 stated the sanitizer sinks were filled at 10:00 AM and then refilled every couple of hours to make sure the sanitizer stayed effective. She stated the PPM should be logged every time the sink was filled. Dietary Cook #13 stated logging the PPM was important to make sure the machine was functioning properly and getting the ratio right. During an interview on 10/18/2023 at 2:29 PM, the DM stated the sanitizer PPM log should be filled out every time the sink was refilled, which was three times a day. She stated the dietary department recently hired new staff and they must have forgotten to log the PPM data. 3. A review of the United States FDA 2022 Food Code, dated 01/18/2023, revealed, Chapter 3. Food, 3-501.13 Thawing. Except as specified in [paragraph] (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 [degrees] C [Celsius] [41 degrees Fahrenheit] or less; or (B) Completely submerged under running water: (1) At a water temperature of 21 [degrees] C [70 degrees Fahrenheit] or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 [degrees] C [41 degrees Fahrenheit], or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under [paragraph] 3-401.11(A) or (B) to be above 5 [degrees] C [41 degrees Fahrenheit], for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5 [degrees] C [41 degrees Fahrenheit]. During lunch meal observations in the kitchen on 10/18/2023 at 11:54 AM, a roll of ground beef was observed sitting in a pan on the counter next to the three-compartment sink. The ground beef was still frozen but was not placed under running water to thaw outside the refrigerator. During an interview on 10/18/2023 at 11:56 AM, the DM stated when staff had to thaw something, they put it in a pan, labeled it with the date, and put it in the refrigerator for the next day. The DM said the meat thawing on the counter was planned for the evening meal on 10/18/2023. During lunch meal observations in the kitchen on 10/18/2023 at 1:01 PM, the roll of ground beef was observed sitting in a pan on the counter. The ground beef was still frozen, was still not under running water to thaw outside the refrigerator, was starting to thaw with visibly melted frost dripping into the pan and was starting to get soft on the outside of the roll. During a return visit to the kitchen on 10/18/2023 at 2:26 PM, the roll of ground beef had been cut in half. One section remained on the counter in a plastic bag, while the other was labeled and dated and put in the refrigerator. During a follow-up interview on 10/18/2023 at 2:29 PM, the DM stated the ground beef was an 8-pound roll thawing on the counter for use at the dinner meal. She stated that when dietary staff needed meat for a meal, they would put it into its own pan and let it thaw. She stated she would also thaw bags of ready-made scrambled eggs on the counter if they were not taken out the night before. She stated food should be stored at 36 degrees F or below to prevent foodborne illness and bacteria growth. During an interview on 10/18/2023 at 3:08 PM, the Administrator stated meat should be thawed in the bottom of the refrigerator but was unfamiliar with other methods to thaw raw meat safely.

Based on observations, interviews, document review, and facility policy review, the facility failed to properly store and secure medications for 2 (Hall 100 medication cart and facility medication/treatment cart) of 3 medication carts observed and failed to ensure proper labeling of eye drops for 1 (Resident #43) of 3 residents observed for eye drop administration during medication pass. Specifically, the facility failed to ensure medications remained in direct line of sight of staff or were in a locked compartment, failed to properly store tramadol under a double lock, and failed to date an eye drop container when opened. Findings included: A review of an undated document titled Medication storage in the facility revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review revealed Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designed for that purpose. Under the section titled Controlled Medication Storage it revealed, Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. 1. Medication pass observation was conducted on 10/17/2023 at 10:07 AM with Registered Nurse (RN) #1. RN #1 removed an Exelon patch (medication used to treat dementia) from a transparent plastic zip-style bag that contained multiple Exelon patches. RN #1 placed the bag with several Exelon patches remaining in the bag on top of the facility treatment/medication cart. RN #1 left the treatment/medication cart unlocked, left the bag containing Exelon patches on the top of the cart unsecured, and proceeded into Resident #152's room. The resident was in a recliner behind a wall beside the bathroom and adjoining room wall. RN #1 had to lean over the resident behind the bathroom wall to place the patch on the resident's shoulder. The treatment/medication cart was at a 30-to-45-degree angle in the entranceway of Resident #152's room. RN #1 was not within sight of the treatment/medication cart while in the resident's room applying the patch. During an interview on 10/17/2023 at 10:10 AM, RN #1 acknowledged she did not lock the treatment/medication cart, had left the bag containing Exelon patches lying on top of the cart unsecured, and that the cart was not within her line of sight. RN #1 said she should have put the Exelon patches back in the cart and locked it. During an interview on 10/19/2023 at 4:17 PM, the Director of Nurses (DON) stated her expectation was the medication carts should always be locked if left unattended. The DON stated if the medication cart was unlocked, the nurse should be able to see the cart. During an interview on 10/19/2023 at 3:37 PM, the Administrator stated that her expectation was the medication cart should be locked or the nurse should be in the line of vision of the medication cart. The Administrator acknowledged the potential risk was residents could get into the cart or take something off the cart. 2. A review of a document titled Controlled Substances from the Drug Enforcement Agency (DEA) website, www.dea.com, dated 09/18/2023, revealed that tramadol was a Schedule IV-controlled substance (a classification system given to drugs based on the drug ' s acceptable medical use and the drug ' s abuse or dependency potential) under the narcotic category. Observation of the 100-hall medication cart on 10/19/2023 at 11:16 AM with Licensed Practical Nurse (LPN) #6 revealed four cards of tramadol (narcotic medication used to treat moderate to severe pain) in the bottom drawer of the medication cart. The cards of tramadol were not observed to be stored under double lock. During an interview on 10/19/2023 at 11:16 AM, LPN #6 stated the tramadol did not have to be double locked because it was a Schedule I substance and not considered a controlled substance. She stated they received information from the pharmacy on where the medications needed to be stored or placed in the carts. During an interview on 10/19/2023 at 4:17 PM, the DON stated her expectation was for controlled medications to be double-locked. She stated tramadol was okay to be stored under one lock because it was a Schedule I medication. She stated the pharmacy should notify them of the medication classes to be locked, and if there was ever a question, they called the pharmacy. During an interview on 10/19/2023 at 3:42 PM, the Administrator confirmed that controlled substances needed to be stored behind two locks. 3. A review of Resident #43's Admission Record indicated the facility admitted the resident on 03/14/2022. A review of Resident #43's Physician's Orders revealed an order dated 03/14/2022 to administer Trusopt (eye drops used to treat glaucoma) 2% one drop to both eyes twice daily. Medication pass observation was conducted on 10/18/2023 at 10:31 AM with Registered Nurse (RN) #1. RN #1 retrieved an open dorzolamide (Trusopt) eye drop container from the medication cart to administer to Resident #43. Observation of the eye drop container revealed no open date. During an interview on 10/18/2023 at 11:16 AM, RN #1 stated eye drops should be dated with an open date when first opening the container. RN #1 confirmed the dorzolamide 2% she administered to Resident #43 did not have an open date. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) stated that when staff opened eye drops, the container should be dated with an open date. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated they did not know about dating eye drops.

Based on interviews and document review, the facility failed to ensure three (Certified Nursing Assistant (CNA) #7, #8, and #11) of five CNAs had at least 12 hours of in-service training per year. Findings included: During an interview on 10/19/2023 at 4:56 PM, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Health Information Manager (HIM) stated the facility had no policy related to required training for CNAs. A review of a Centers for Medicare and Medicaid Services (CMS) memorandum dated 04/07/2022 regarding the Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers revealed In response to the COVID-19 PHE [Public Health Emergency] and under the Secretary's authority set out at section 1135 of the Social Security Act, CMS enacted several temporary emergency declaration blanket waivers which were intended to provide health care providers with extra flexibilities required to respond to the COVID-19 pandemic. The memorandum indicated, CMS is ending the specific emergency declaration blanket waivers for SNFs/NFs [Skilled Nursing Facilities/Nursing Facilities], Additionally, Providers are expected to take immediate steps so that they may return to compliance with the reinstated requirements according to the timeframes listed below. Further review revealed Emergency Declaration Blanket Waivers for Various Provider-Types Ending 60 days from Publication of this Memorandum: included In-service Training for LTC [long-term care] facilities - 42 CFR [code of federal regulations] 483.95 (g)(1) [F947]. CMS modified the nurse aide training requirements for SNFs and NFs which required the nursing assistant to receive at least 12 hours of in-service training annually. A review of CNA #7's Inservice Training Record for 2022 revealed she completed 11.5 hours of in-service training. A review of CNA #8's Inservice Training Record for 2022 revealed she had completed 5 hours of in-service training. A review of CNA #11's Inservice Training Record for 2022 revealed she had completed 8.75 hours of in-service training. During a telephone interview on 10/19/2023 at 3:21 PM, CNA #7 stated she had worked at the facility for seven years as a CNA. She stated she had decreased to part-time status to accommodate schooling and had missed several in-service trainings. During a telephone interview on 10/19/2023 at 3:52 PM, CNA #8 stated she had worked at the facility for five years. She stated she worked nights, and a lot of the training meetings were scheduled for 2:00 PM, but she only attended the 7:00 AM training meetings. During an interview on 10/19/2023 at 4:53 PM, the DON stated she was in charge of the CNA training program and made sure there were plenty of in-services scheduled throughout the year. She stated training was completed via in-services, videos, and handouts. The DON stated she could only schedule the training and could not force staff to attend. According to the DON, she was unaware the CMS training waiver ended in June 2022. The DON stated she thought the CNA training waiver was lifted in May 2023. During an interview on 10/19/2023 at 5:22 PM, the Administrator stated she was aware facility CNAs had to have 12 hours of in-service training per year. She stated the training year restarted every January. The Administrator stated there was no reason the CNAs should not have received their mandated training hours. The interview with the Administrator revealed she also believed the CMS training waiver was lifted in the spring of 2023 and was unaware it was lifted in June 2022.

Based on interviews, record review, and facility document review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) form included all current mental illness diagnoses for one (Resident #26) of one sampled resident reviewed for PASARR requirements. Findings included: A review of a document provided by the facility titled What to submit to COMRU [Central Office Medical Review Unit] for client entering a Skilled Nursing Facility, dated January 2020, revealed that when completing a Level One Nursing Facility Pre-Admission Screening for MI/ID [mental illness/intellectual disability], staff should Be sure to complete all blanks and Be sure Section B#2 (Mental Illness Diagnosis) is answered - Refer to client's diagnosis list. A review of Resident #26's Admission Record revealed the facility admitted the resident on 04/04/2022. The Diagnosis Information section of the Admission Record indicated, No Data Found. A review of Resident #26's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/2022, revealed Resident #26 had an active diagnosis of post-traumatic stress disorder (PTSD). A review of Resident #26's Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition, completed by the Administrator and signed by the facility's physician, Physician #14, on 04/25/2022, revealed the question for, Does the individual have a current, suspected, or history of a Major Mental Illness as defined by the Diagnostic & Statistical Manual of Mental Disorders (DSM) current edition? was answered no, and the box to indicate a diagnosis of PTSD was not marked. During a phone interview on 10/19/2023 at 10:02 AM, Physician #14 confirmed that he reviewed and signed PASARR forms once the form was completed by the hospital or nursing home staff. Physician #14 stated he was not aware Resident #26 had a diagnosis of PTSD at the time of their admission to the facility but may have missed it. During an interview on 10/19/2023 at 3:17 PM, the Administrator stated she was the one who completed the PASARR screenings with the information received from the hospital, and the facility's physician signed them once they were completed. The Administrator acknowledged the omission of a diagnosis of PTSD on Resident #26's screening and said she missed the diagnosis. The Administrator stated there was no process in place to check the accuracy of the PASARR after she completed the screenings.

Based on observations, interviews, record review, and facility policy review, the facility failed to follow physician orders related to wound care for one (Resident #43) of three residents reviewed for wound care. Findings included: Review of an undated facility policy titled Physician Services revealed, All physician or other health care professional verbal orders, including telephone orders, will be immediately recorded, dated, and signed by the person receiving the order. The policy also noted, All physician orders will be followed as prescribed and if not followed the reason shall be recorded on the resident's medical record during that shift. Review of an undated facility policy titled Clean Dressing Change revealed, It is the policy of the facility to ensure change dressings [sic] in accordance with State and Federal Regulations, and national guidelines. The facility policy indicated Procedure: 1. Verify and review physician's order for procedure. The policy also indicated 19. Apply clean dressing as ordered and ensure the dressing is dated. Review of Resident #43's Admission Record indicated the facility admitted the resident on 03/14/2022. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The MDS indicated the resident had two unhealed venous and arterial ulcers. The MDS also identified diabetic foot ulcer(s) under a section for other ulcers, wounds, and skin problems. Review of Resident #43's Resident Care Plan, dated 09/28/2023, revealed the resident had diabetic foot ulcers to both feet. The Resident Care Plan directed staff to continue to treat the wounds per physician orders. The Resident Care Plan indicated the resident would see a physician at a wound clinic soon. The Resident Care Plan directed staff to monitor the resident's skin weekly and to pay extra attention to the resident's feet. The Resident Care Plan contained instructions for staff to report any new or worsening areas that were concerning. Review of hospital Progress Note Details, dated 10/04/2023, indicated Resident #43 was seen at the hospital's wound center for two wounds on his/her feet. The document contained right great toe and second left toe wound orders directing staff to cleanse the wounds with normal saline, apply Betadine (antiseptic)-moistened gauze to the wound beds, cover the wounds with gauze, and secure. The order contained a directive to change the dressings daily and as needed. Review of Resident #43's October 2023 Physician's Orders revealed orders for the right great toe and left second toe. Each order directed staff to cleanse the respective wound with wound cleanser, apply Betadine-moistened gauze to the wound bed, and cover with dry gauze daily and as needed until healed. The orders were dated 10/05/2023. Review of Resident #43's Treatment Administration Record [TAR] and Weekly Summary Report revealed a wound treatment order, dated 10/05/2023, directing staff to clean the wounds to the right great toe and the left second toe with wound cleanser, apply Betadine-moistened gauze to the wound beds, cover with dry gauze, and change daily and as needed until healed. Further review of the document revealed initials were present for the date 10/18/2023, indicating staff documented the treatment had been provided as ordered. Observation of wound care completed by Registered Nurse (RN) #1 on 10/18/2023 at 10:31 AM revealed the nurse gathered wound care supplies, including a bottle of povidone iodine (generic Betadine) and a bottle of saline wash. It was observed that the nurse cleaned the wound with saline (wound cleanser) as ordered. Further observation revealed the nurse moistened gauze with povidone iodine solution, wiped the right great toe wound as well as the area around the right great toe, and discarded the gauze. Observation revealed another gauze was moistened with povidone iodine solution, and the nurse wiped the left second toe wound as well as the area around the left second toe, then discarded the gauze. Observation revealed the nurse then applied saline-moistened gauze over the right great toe wound bed and applied another saline moistened gauze over the left second toe wound bed. Observation showed each wound was covered with a dry dressing and secured with tape. During an interview on 10/18/2023 at 11:16 AM, RN #1 stated wound care recommendations were made by a wound nurse, noting a charge nurse transcribed the recommendations to the physician orders and the TAR. During the interview, RN #1 read Resident #43's wound orders and confirmed that the order called for Betadine-moistened gauze, not saline-moistened gauze, to be applied to the wound bed. During an interview on 10/19/2023 at 9:56 AM, Resident #43's primary physician, Physician #14, stated the wound care practitioners' recommendations should be followed. Physician #14 said he did not make any changes to Resident #43's wound care orders from the wound care consultation that occurred on 10/04/2023 at the hospital. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) said she misinterpreted and failed to clarify Resident #43's wound orders. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated staff should follow physician orders for wound care. She said if there was a misunderstanding related to an order, she expected staff to obtain an order clarification.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff maintained infection control practices to prevent the spread of infection during treatments of wounds and administration of medications for one (Resident #43) of two residents observed for wound care and two (Resident #21 and Resident #152) of eight residents observed during medication pass. Findings included: A review of an undated facility policy titled Hand Hygiene Guidelines, revealed, Key times to wash hands included before and after treating a cut or wound. The policy revealed Sanitizers can quickly reduce the number of germs on hands in many situations. A review of an undated facility policy titled Clean Dressing Change, revealed, It is the policy of the facility to ensure change [sic] dressings in accordance with State and Federal Regulations, and national guidelines. The policy revealed Procedure: 1. Verify and review physician ' s order for procedure. 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change. 3. Identify the resident and explain the procedure. 4. Evaluate resident ' s pain and the need for pain medication. 5. Put on gloves. Adjust bedside table to waist level. Clean bedside stand/table with germicidal disposable cloth. Establish a clean field. 6. Place resident ' s trash can within easy reach, 7. Remove gloves and perform hand hygiene. 8. Set up supplies on barrier. 9. Position the resident for comfort. 10. Perform hand hygiene. 11. Put on clean gloves. 12. Remove dressing and place in the resident ' s trash can. 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound with gauze and prescribed cleaning solution using single outwards strokes. 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves. 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene. A review of a Safety Data Sheet for the hand sanitizer brand used by the facility revealed the product description indicated, A gelled alcohol hand sanitizer with Aloe for hand washing to decrease bacteria on the skin. During an interview via phone on 10/18/2023 at 1:54 PM, the hand sanitizer brand representative stated it was not recommended to apply the hand sanitizer to gloves because the product was a highly flammable liquid and not to be used on latex or any type of gloves. 1. A review of Resident #43's wound care Progress Note Details dated 10/04/2023 revealed the resident had two wounds to the feet. One wound to the right big toe from a partial amputation that did not heal after surgery, and one wound to the left second toe. The provider described each wound as a chronic [NAME] Grade 2 Diabetic Ulcer. Further review of the note revealed wound care orders for the left second toe wound, and right great toe wound to cleanse the wounds with normal saline, apply a betadine-moistened gauze to the wound bed, and cover with gauze daily or as needed. Observation of Resident #43's wound care completed by Registered Nurse (RN) #1 on 10/18/2023 at 10:31 AM revealed the nurse gathered wound care supplies, including a bottle of povidone-iodine and a bottle of saline wash, and placed them on a towel that was on the resident's bed. The povidone-iodine and bottle of saline were observed touching the resident's socks and pants. RN #1 donned gloves and removed the resident's right boot and socks. Continued observation revealed the nurse used hand sanitizer on the gloves and used the same gloves to remove the old dressing from each foot. The nurse again applied hand sanitizer on the gloves and used the same gloves to clean the wound on the left second toe and the wound to the right great toe. When cleaning the wounds, RN #1 used a saline-moistened gauze to clean the wound to the right great toe in a vertical and repeated back-and-forth motion from the wound to the foot, just above the right great toe. RN #1 then used the same saline-moistened gauze to clean around the right great toe, touching the wound several times. Further observation revealed the nurse proceeded to clean the left second toe wound with a saline-moistened gauze in a vertical and repeated back-and-forth motion from the wound to the foot, just above the left second toe. RN #1 then used the same saline-moistened gauze to clean around the left second toe, touching the wound and skin. Further observation revealed RN #1 applied hand sanitizer to the same gloves, and without changing gloves, the nurse took a gauze moistened with povidone-iodine solution and wiped it over the right great toe wound and around the right great toe. With the same gloved hands, RN #1 obtained another gauze moistened with povidone-iodine solution, and the nurse wiped the left second toe wound and around the left second toe. With the same gloved hands, RN #1 then applied a saline-moistened gauze over the right great toe wound bed. Using the same gloves, RN #1 applied another saline-moistened gauze over the left second toe wound bed. Each wound was covered with a dry dressing using tape. It was further observed that RN #1 applied hand sanitizer over the gloves before dating both dressings. RN #1 used the same gloves throughout the entire treatment of both wounds. During an interview on 10/18/2023 at 11:16 AM, RN #1 stated if there was more than one wound, treatments should have been done separately to prevent cross-contamination. RN #1 confirmed wound treatments to Resident #43's left second toe and right great toe were completed together because the treatment orders to both toes were the same. RN #1 confirmed the supplies touched the resident's clothing, and the nurse did not ensure everything was out of the way to prevent contamination. RN #1 stated she used hand sanitizer over the same gloves throughout the treatment process, stating she learned the practice from a physician's office where she worked in the past. 2. Medication pass observation was conducted on 10/17/2023 at 8:52 AM with Registered Nurse (RN) #1. RN #1 applied hand sanitizer, then donned gloves and thumbed through the medication book, picked up a writing pen lying on the cart to write an open date on a new insulin pen, then applied hand sanitizer to the outside of her gloves, touched and closed the medication book, and touched keys to lock a drawer. RN #1 proceeded into Resident #21's room and administered the insulin. Medication pass observation was conducted on 10/17/2023 at 10:07 AM with RN #1. RN #1 applied hand sanitizer, donned gloves, and then touched the cart surface, retrieving an Exelon patch from a bag. She then applied hand sanitizer to the outside of her gloves, touched the medication administration book to close it, and touched a writing pen to write initials and date on the Exelon patch. RN #1 proceeded into Resident #152's room and applied the patch. During an interview on 10/18/2023 at 1:51 PM, RN #1 acknowledged that after performing hand sanitization with alcohol-based hand sanitizer during medication pass observation on 10/17/2023, she had donned gloves and applied hand sanitizer to the gloves then proceeded to touch the medication administration book (MAR), a writing pen to write a date and initials on the Exelon patch to be applied to Resident #152, as well as applying hand sanitizer to gloves before touching a book, a pen, and keys during insulin pen preparation for Resident #21. RN #1 stated, Sometimes I forget and touch stuff. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) stated staff should not use hand sanitizer over the gloves but should take the gloves off and use hand sanitizer on the hands. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated staff should not use hand sanitizer over the gloves. During an interview on 10/19/2023 at 9:25 AM, the Director of Nursing (DON) stated that when a resident had more than one wound, staff should complete wound care for one wound at a time to prevent cross-contamination. The DON stated that when cleaning a wound, the nurse should clean from the inside center (wound bed) of the wound, working out away from the wound, and then discard the used gauze. The DON stated that cleaning the area outside the wound and then touching the wound with the same gauze contaminated the wound. The DON stated the staff should not use hand sanitizer on gloves but should take the gloves off and use hand sanitizer on the hands. During an interview on 10/19/2023 at 10:32 AM, the Administrator stated when cleaning a wound, staff should clean the wound from inside of the wound toward the outside of the wound. The Administrator stated staff should not use hand sanitizer on gloves and should change gloves between treatment steps. The Administrator stated if the resident had multiple wounds, staff should complete the treatment to one wound at a time.

Based on observation, interview, and record review, the facility failed to follow the spreadsheet menu when preparing and serving the lunch meal on 3/4/19 to residents on pureed and mechanical soft diets. The facility failed to add bread to the pureed entrée and pureed vegetable, failed to serve gravy with the meal, and failed to ensure staff served the correct portion of food items as directed by the spreadsheet menu. The facility census was 55. 1. Review of the facility dietary listing, dated 2/21/19, showed two residents with a physician's order for a pureed diet. Review of the spreadsheet menu for lunch on 3/4/19, showed residents on a pureed diets should receive the following items: -1/2 cup pureed Salisbury steak with pureed bread; -1/2 cup whipped potatoes; -1/4 cup gravy; -1/2 cup pureed vegetable blend with pureed bread. Observation on 3/04/19 at 11:54 A.M. showed Dietary Staff A placed two pieces of Salisbury steak into the food processor, added a small amount of brown gravy, blended the mixture to a pureed consistency, and placed it into a pan. Dietary Staff A did not add bread to the pureed Salisbury steak. Observation on 3/04/19 at 12:02 P.M. showed Dietary Staff A added two servings of vegetables to the food processor with some liquid, blended the mixture to a pureed consistency, and placed it into a pan. Dietary Staff A did not add bread to the pureed vegetables. Observation on 3/04/19 at 12:05 P.M. showed Dietary Staff A began the lunch service in the main dining room. A small silver ice cream scoop (no measurement visible on the utensil) was located in the pan of pureed Salisbury steak, and a 2-ounce (1/4 cup) dipper was located in the pan of pureed vegetables. Observation on 3/04/19 between 12:43 P.M. and 1:07 P.M. showed staff served the two residents on pureed diets a 1/4 cup portion of pureed Salisbury steak without gravy, whipped potatoes without gravy, and the unmeasured portion of pureed vegetable blend. During an interview on 3/5/19 at 10:30 A.M., the dietary manager said dietary staff used the silver ice cream scoop on a regular basis to serve residents. She thought the scoop was 1/2 cup but the scoop was not actually labeled to indicate the serving size. During an interview on 3/04/19 at 3:35 P.M., the dietary manager said staff know how to make pureed items by referring to the dietary spreadsheet menu. If the food item on the spreadsheet showed bread should be pureed with the item, then staff should add 1/2 slice of bread to the food item and then blend. Staff should use the correct serving utensils when serving food. Staff should have served gravy over the pureed entrée and mashed potatoes for lunch, but they ran out of gravy. 2. Review of the facility Dietary Listing, dated 2/21/19, showed nine residents with a physician's order for a mechanical soft diet. Review of the spreadsheet menu for lunch on 3/4/19, showed residents on a mechanical soft diet should receive the following items: -1/2 cup ground Salisbury steak; -1/2 cup whipped potatoes; -1/4 cup gravy. Observation on 3/04/19 between 12:05 P.M. and 1:07 P.M. showed staff served all residents on a mechanical soft diet ¼ cup of ground Salisbury steak instead of ½ cup as directed on the diet spreadsheet. Staff did not serve gravy on top of the ground meat. During an interview on 3/04/19 at 1:08 P.M., Dietary Staff A said staff should put gravy on top of mechanical meat, but they ran out of gravy very early in the meal service. During an interview on 3/04/19 at 3:35 P.M., the dietary manager said staff know how to make mechanical (ground) items by referring to the dietary spreadsheet menu. Staff should use the correct serving utensils when serving food. Staff should have served gravy over the ground entrée for lunch, but they ran out of gravy. 3. Review of facility policy, Meal Production, revised (MONTH) (YEAR), showed the following: -Menus shall be followed which have been written and approved by a registered, licensed dietician in compliance with the Federal and State regulations and consistent with standards of practice on nutritional care; -Purpose: To ensure proper nutritional care of the residents and to comply with nutritional standards and regulations governing menus and nutritional care. Review of the facility policy, Meal Service, revised (MONTH) (YEAR), showed meals shall be prepared according to the facility approved menu.

Based on observation and interview, the facility failed to ensure sanitary practices in the kitchen by not ensuring food and non-food contact surfaces were maintained clean and free of a buildup of debris; failed to ensure pans were not stacked wet; failed to maintain an airgap between the ice machine and the floor drain; failed protect food items in the refrigerator from drips of condensation; and failed to ensure scoops were not stored in contact with food within containers. The facility census was 47. 1. Observation on 02/21/17 at 11:45 A.M. showed the interior surfaces of the microwave had worn surfaces that exposed rust. Further observation of the inside showed a heavy buildup of brown and black crusty debris on the top and sides. Observation on 02/21/17 at 12:25 P.M. showed the Dietary Manager heated soup for a resident using the the dirty microwave. Observation on 02/22/17 at 2:50 P.M. showed the microwave still had the same black and brown buildup of debris on the interior of the unit as well as the same rust on the bottom of the microwave. During interview on 02/23/17 at 9:50 A.M., the Dietary Manager confirmed the condition of the microwave including the amount of debris on the inside top that was crusted and loose and had the potential to fall on food. He/she said the microwave was supposed to be cleaned after each shift. 2. Observations on 02/21/17 at approximately 11:55 A.M. and 2:50 P.M. showed metal steam table pans that were stacked and stored on a shelf underneath the steam table. Water was observed in between the pans when they were pulled apart. During interview on 02/23/17 at 9:50 A.M., the Dietary Manager said he/she confirmed the wet metal pans that were stacked and stored on the shelf and were wet in between when pulled apart. He/she said pans were supposed to air dry and not be put away wet, but he/she stacked them wet this morning since he/she was running late. 3. Observation on 02/21/17 at 11:55 A.M. showed the can opener had a buildup of crusty white debris on the blade and also had a buildup of metal filings on the ledge assembly directly behind the blade. Observation on 02/22/17 at 2:50 P.M. showed the same white colored debris remained on the can opener blade with metal filings on the ledge directly behind the blade. Observation and interview on 02/23/17 at 9:50 A.M. showed the can opener still had a white colored debris on the blade and metal filings on the ledge behind the blade. The Dietary Manager confirmed the observation and said the can opener was supposed to be cleaned daily. 4. Observation on 02/21/17 at 2:20 P.M. showed the ice machine had a 1-inch drain pipe that was approximately 1 inch above the floor drain and provided a 1-inch air gap rather than the required 2-inch gap (the air gap to prevent against backflow and contaminated ice is required to be twice the width of the drain pipe). The Dietary Manager confirmed this observation. During interview on 02/23/17 at 9:50 A.M., the Dietary Manager said he/she didn't know about a required gap between the end of the drain pipe and above the floor drain. 5. Observation on 02/21/17 at 2:05 P.M. showed a ceiling vent located above the dish machine have a buildup of fuzzy debris on the vent. Observation on 02/22/17 at 2:50 P.M. showed the ceiling vent on the ceiling in the dish machine room that measured approximately 14-inches by 14-inches still had a buildup of fuzzy debris on the vent. 6. Observation on 02/21/17 at 2:10 P.M. showed two coffee cans next to the coffee pot in the kitchen. Further observation when the lids to each were removed showed a small plastic drink cup stored inside the can directly on top of the coffee grounds. Observation on 02/23/17 at approximately 9:50 A.M. showed a plastic scoop stored inside a container of food thickener powder. Further observation showed a plastic cup stored inside the decaffeinated coffee. During interview on 02/23/17 at 9:50 A.M., the Dietary Manager said he/she was aware scoops were not to be stored inside containers and in direct contact with the contents of the containers. The Dietary Manager confirmed the observation of the plastic cup stored inside one of the two coffee cans as well as the thickener scoop stored inside and lying on top of the thickener powder. 7. Observation on 02/21/17 at approximately 11:00 A.M. showed water condensation drip formations at the top of the reach-in cooler where staff stored various drinks and drink pitchers. The drip formations were dripping onto everything stored directly below but were mainly dripping onto the lids of drink pitchers used to store drinks such as tea and juice that were for resident consumption during meals. Observation on 02/22/17 at 2:50 P.M. showed condensation dripping on the drink pitchers stored directly under the cooling units. Observation and interview on 02/23/17 at 9:50 A.M. showed large drips of condensation dripping onto drink pitchers stored below these drips. The Dietary Manager confirmed the drips and what was stored directly below these drips and said the drips had just recently started. 8. During interview on 02/23/17 at 9:50 A.M., the Dietary Manager said there was a cleaning list for the kitchen but staff had not been filling it out. He/she had given one inservice since he/she started to work at the facility approximately four months ago. He/she said the topic of the inservice was cleaning and completing cleaning tasks.

Based on observation, interview, and record review, the facility failed to ensure four residents (Residents #1, #3, #8 and #9), who were unable to perform their own activities of daily living, in a review of 11 sampled residents, were provided the necessary care and services to maintain good personal hygiene. The facility census was 47. 1. During an interview on 2/23/17 at 12:08 P.M., the Director of Nursing (DON) said she expected staff to follow the guidelines in the Certified Nurse Assistant (CNA) manual for providing perineal care and oral hygiene. 2. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility manual, showed the following: -The purpose of peri-care is to clean the peri area for the resident who is unable to or has difficulty with adequately cleaning self, prevents itching, burning, and odor, and prevents infections. The manual showed the resident who is continent should have peri-care daily with morning care; the resident who is incontinent, after each voiding or stool; and perineal care is very important in maintaining the resident's comfort. More frequent care is required for residents who are incontinent. -The purpose of oral hygiene was that a clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident. Oral care should be done to remove food particles, plaque, to stimulate the circulation of the gums, eliminate bad breath thus making food more appetizing and to prevent infections. Residents should have oral hygiene before breakfast, after meals and at bedtime. Oral care should be administered to the resident who is helpless. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility manual, showed the procedures staff were to follow when they provided peri care for a male (steps 7 through 13) included the following: -Cover the resident; -Expose the perineal areas included, wash the penis from the tip downward, rinse, and dry (specific instructions for uncircumcised); -Wash and rinse the scrotum; -Wash and rinse other skin areas between the legs; -Wash and rinse the anal area; -Pat the area dry. For the female resident (steps 7 through 14) included the following: -Cover the resident; -Expose the peri area; wash the inner legs and outer peri area along the outside of the labia (Labia Majora); -Use a clean area of the washcloth for each wipe of the peri area; -Wash the outer skin folds from front to back; -Wash the inner labia (Labia Minora) from front to back; -Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area) from front to back; -Rinse the area well, start from the innermost area and proceed outward; -Wash and rinse the anal area; -Pat the peri area dry. 3. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 1/5/17, showed the following: -Severely impaired cognition; -Required extensive assistance of one staff for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident's care plan, dated 1/12/17, showed the resident was incontinent of bladder and required extensive assistance from two staff for toileting needs and with morning and night cares. Observation on 2/21/17 at 5:35 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -Certified Nurse Assistant (CNA) A and CNA B entered the room, transferred the resident to bed and prepared to perform incontinence care for the resident; -CNA A washed the resident's bilateral groin area with a moistened wash cloth. A moderate amount of feces was observed on the wash cloth; -CNA B rolled the resident to his/her left side. CNA A washed the resident's buttock area (smears of feces were observed on the cloth), removed the resident's urine and feces soiled incontinence brief and tucked a clean incontinent brief under the resident; -CNA A and CNA B rolled the resident to his/her back and fastened the brief; -Staff did not wash all areas of the resident's skin after the resident had been incontinent of bowel and bladder. Observation on 2/22/17 at 7:18 A.M. showed the following: -The resident lay in his/her bed; -CNA D and Nurse Assistant (NA) C entered the room and prepared to perform incontinence care for the resident; -CNA D untaped the urine soiled incontinence brief, picked up a moistened wash cloth and wiped the resident's groin area; -CNA D and NA C assisted the resident to his/her left side; -CNA D removed the soiled incontinence brief, picked up a clean wash cloth and wiped the resident's rectal area. Smears of feces were observed on the wash cloth; -While laying on his/her left side, the resident urinated a large amount which trickled between his/her legs and groin areas; -CNA D wiped the resident's rectal and buttock area with a clean cloth and repeated one time; -NA C tucked a clean, cloth incontinent pad under the resident and assisted the resident to his/her right side; -CNA D tucked a clean incontinence brief under the resident and assisted the resident to his/her left side; -NA C pulled the clean brief under the resident and both secured the brief into place; -Staff did not cleanse all areas of the genitalia during incontinent care and did not re-wash areas soiled after the resident urinated during cares. During interview on 2/22/17 at 7:40 A.M., CNA D said the the following: -When providing perineal care, staff should wash all parts of the resident's genitalia and any skin contaminated by urine or feces; -The resident had refused complete perineal care in the past, but he/she should have attempted (when providing incontinence care on 2/22/17); -He/she should have cleaned the resident's frontal area and legs after he/she urinated during cares. During interview on 2/23/17 at 9:10 A.M., CNA A and CNA B said all areas of the resident's genitalia and skin soiled by urine or feces should be cleansed during perineal care for an incontinent resident. 4. Review of Resident #8's significant change in status MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required extensive assistance of one staff for toilet use and personal hygiene; -Frequently incontinent of urine. Review of the resident's care plan, dated 1/12/17, showed the following: -Oral care: The resident had his/her own natural teeth and could brush them himself/herself but required staff to remind him/her to do so; -Toileting: Required extensive assistance of one person for toileting. The resident could pull his/her pants up and down but needed help with the brief. The resident could wipe himself/herself but required follow up care if needed; -Bladder function: The resident was incontinent of urine and required staff assistance on the bathroom before and after meals. Observation on 2/22/17 at 7:04 A.M. showed the following: -The resident lay in bed; -Nurse Aide (NA) F and NA G assisted the resident to sit on the side of the bed and walk to the bathroom; -NA F assisted the resident to pull down his/her pants and brief and sit on the toilet; -The resident's incontinent brief was soaked with urine; -The resident urinated in the toilet and placed the wet brief in the trash; -NA F put a clean incontinence brief on the resident; -The resident stood up with the walker and NA F pulled up the resident's pants without providing any incontinent care; -NA F told the resident he/she was ready to go on to breakfast; -NA F and NA G did not remind or offer to assist the resident to brush his/her teeth; -The resident walked out of the bathroom and down the hall to the dining room for breakfast. During an interview on 2/22/17 at 12:42 P.M., NA F said the resident's brief had been soaked with urine when he/she assisted the resident that morning. NA F said he/she had not provided any incontinent care or offered to brush the resident's teeth. 5. Review of Resident # 9's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognitive status; -Required extensive assistance of one staff for personal hygiene; -Required extensive assistance of two staff for toileting; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, dated 1/12/17, showed the following: -The resident needed help with brushing his/her teeth before breakfast and before going to bed; -Staff were to offer to assist the resident to the bathroom in the morning and make sure he/she was clean and dry. They were to brush his/her teeth and hair and wash his/her face; -The resident needed extensive assistance from two people for toileting needs. He/she preferred to use the bathroom in his/her room during the day; -Staff were to assist the resident to the toilet before and after meals to promote continence; -Staff were to assist the resident to the bathroom after breakfast as he/she usually had a bowel movement every morning. Observation and interview on 2/21/17 at 5:30 P.M., showed the resident in the wheelchair, next to his/her bed. CNA L confirmed the resident was lying down after supper for the night. CNA L did not offer to take the resident to the bathroom, or brush his/her teeth or face. CNA L assisted the resident into bed. The resident wore the same shirt and sweater he/she had worn during the day. The sweater was soiled with food. CNA L did not take off the resident's shirt or sweater and assist the resident to put on bed clothes. CNA L left the room and then returned to the room with CNA M. CNA M and CNA L provided incontinence care for the resident and then left the room. CNA M and CNA L did not offer or provide oral care or wash the resident's face. Observation and interview on 2/23/17 at 7:32 A.M. showed the resident had a foul smell to his/her breath before CNA J and CNA K got him/her up for breakfast. CNA J and CNA K did not offer to take the resident to the toilet. CNA J took the resident to the bathroom and washed his/her face. CNA J said he/she was taking the resident to breakfast. CNA J did not offer or provide oral care for the resident. During an interview on 2/23/17 at 8:10 A.M., CNA J said he/she did not brush the resident's teeth. CNA J said he/she provides oral care after the resident has eaten and sometimes before. He/she did not know what the resident's care plan directed in regards to oral care. 6. Review of Resident #3's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for personal hygiene; -Swallowing disorders included loss of liquids/solids, holding food and coughing/choking. Review of the resident's care plan, dated 12/15/16, showed the resident was confused and needed help with his/her oral care needs in the morning and after dinner. He/she did not have teeth so staff were to use a toothette to swab the resident's mouth and let the resident rinse with mouth wash. Observation on 2/23/17 at 9:00 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -CNA D and CNA E entered the resident's room, transferred him/her to bed, removed the resident's pants and brief, and performed perineal and catheter care for the resident; -Staff positioned the resident with foam wedges, covered the resident with blankets and lowered the bed; -Staff did not offer or provide any oral care. During interview on 2/23/17 at 10:00 A.M., CNA D and CNA E said oral care should be offered or completed for a resident in the morning, after breakfast and after lunch. 7. During interview on 2/23/17 at 12:08 P.M., the DON said the following: -He/she would expect staff to provide perineal care to a resident who had been incontinent of urine, after removing the soiled brief; -He/she would expect staff to perform frontal perineal care on a resident who had been incontinent of bowel; -He/she would expect staff to clean a resident's frontal perineal area if they had urinated immediately after care was provided; -He/she would expect perineal care for an incontinent resident to include the front side, the backside and any skin contaminated by urine or feces; -He/she would expect staff to offer oral care to a dependent resident after meals; -He/she would expect staff to remove a dependent resident's soiled clothing before assisting them to bed for sleep.

Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents and injuries during gait belt transfers (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) for three residents (Residents #1, #8 and #10), in a review of 11 sampled residents. The facility census was 47. 1. Review of the Nurse Assistant in Long Term Care Facility, Student Manual Revised Edition 2001, showed the following: -The nurse assistant should never transfer or ambulate residents by grasping their upper arms or under their arms; -Such a transfer could result in skin tears, damage to nerves and arteries, and possible dislocation of the shoulder; -The gait belt increases the comfort and safety of the resident during the transfer procedure; -The gait belt prevents injury to the resident that could be caused by pulling on his/her arms, shoulders, or wrist; -The gait belt is to be applied snugly around the resident's waist, over clothing below the ribs so the nurse assistant may grasp the belt securely. The belt must be applied securely to prevent it from sliding above the resident's waist; -If a resident is non-weight bearing, the certified nurse assistant (CNA) should transfer him/her using a mechanical lift; -Procedure for one person transfer from bed to chair and chair to bed showed instructions to place your hands underneath the gait belt; -If resident is able, have him/her place hands on arms of the wheelchair and push; -If resident is unable to push off the chair, resident may place his/her arms on nurse assistant's arms; -CAUTION: Do not allow resident to hold you around your neck or shoulders. -Safety Measures for a resident that is weak, you must have control of the shoulders and hips during the transfer, do not attempt to transfer a resident who cannot bear any of his/her weight by yourself. 2. Review of Resident #8's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/5/17, showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Independent with walking and transfers; -Balance was unsteady but could stabilize without human assistance. Review of the resident's care plan, dated 1/12/17, showed the resident could walk and transfer independently. Observation on 2/22/17 at 7:04 A.M. showed the following: -The resident lay in bed; -Nurse Aide (NA) F and NA G entered the resident's room to assist him/her with morning care; -NA F and NA G assisted the resident to sit up on the side of the bed; -NA F and NA G put pants on the resident up to his/her knees and placed a walker in front of him/her; -NA F told NA G they did not need to put a gait belt on the resident because he/she was independent with transfers; -The resident attempted to stand with the walker and was unable to do so; -NA F and NA G stood on each side of the resident and lifted him/her under his/her arms to a standing position. During an interview on 2/22/17 at 8:30 A.M., NA G said he/she had not worked in the facility very long. The resident needed assistance to stand up from the bed earlier that morning and NA G had lifted the resident under his/her arm. NA G had not been instructed not to lift residents under their arms. During an interview on 2/22/17 at 12:42 P.M., NA F said he/she had lifted the resident under his/her arm to a standing position from the bed that morning. NA F said he/she did not realize there was anything wrong with lifting a resident under the arms. NA F was in a nurse aide training program but had not been taught that yet. 3. Review of Resident #10's annual MDS, dated [DATE], showed the following: -He/she understood others; -Required extensive assistance from one staff for transfers. Review of the resident's care plan, dated 1/18/17, showed the following: -The resident needed extensive assistance from one person for transfers; -The resident was prone to skin tears as his/her skin was fragile. -An update on 2/8/17 showed the resident had a skin tear to the left arm that occurred during a transfer. Review of the resident's physician orders [REDACTED]. Observation on 2/22/17 at 6:20 A.M. showed the following: -The resident lay in his/her bed; -Certified Nurse Assistant (CNA) H and NA C entered the resident' room, performed morning cares, assisted the resident to sit on the side of the bed and placed a wheelchair beside the bed; -NA C applied a gait belt around the resident's waist and instructed the resident to hug him/her around the neck; -NA C hugged the resident around his/her waist area, clasped his/her hands over the gait belt and transferred the resident to the wheelchair. During interview on 2/22/17 at 12:40 P.M., NA C said the following: -He/she had been employed at the home since the beginning of February; -He/she had not been trained on gait belt transfers and had been trained by four different CNAs; -He/she did not know how to perform a proper one staff transfer with a gait belt. 4. Review of Resident #1's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assist of two staff for transfers; -Walking in room or corridor did not occur. Review of the resident's care plan, dated 1/12/17, showed the resident did not walk. He/she needed extensive assistance from two staff for transfers and needed assistance to stand and pivot. Review of the resident's POS, dated February 2017, showed the resident's [DIAGNOSES REDACTED]. Observation on 2/21/17 at 5:35 P.M. showed the following: -The resident sat in his/her wheelchair near the bed in his/her room; -CNA A and CNA B entered the room and prepared to transfer the resident to bed; -CNA A applied a gait belt loosely around the resident and placed the resident's walker in front of him/her; -CNA A stood on the resident's left side and held the gait belt at the resident's left side; -CNA B stood behind the resident's wheelchair and held the gait belt on the resident's right side; -Staff counted to three and began to raise the resident, who had his/her hands on top of either side of the walker. The resident was shaky and unsteady as the gait belt moved up from the resident's waist to his/her chest. The resident lifted his/her walker off the ground as staff attempted to guide him/her to the bed; -The resident sat on the bed. 5. During interview on 2/23/17 at 10:50 A.M., the Director of Therapy said the following: -He/she would expect a gait belt to be applied snugly before a transfer and it may need to be adjusted once the resident stood; -He/she would not expect staff to instruct a resident to hug them around the neck prior to a one/two person transfer. During interview on 2/23/17 at 12:08 P.M., the Director of Nursing said the following: -He/she would expect staff to use a gait belt when transferring a resident who had difficulty standing from the bed to a chair; -He/she would not expect staff to lift a resident under their arms during a transfer; -He/she would expect one staff on either side of the resident to hold the gait belt during a two person transfer with a gait belt.

Based on observation, interview, and record review, the facility staff failed to ensure newly hired nurse aides demonstrated competency skills and techniques necessary to care for the residents. Those competencies included areas in basic resident care skills and appropriate infection control precautions. This failure involved three nurse aides (NA) who provided direct resident care. The facility census was 47. 1. Review of the facility's Nurse Aide Orientation Checklist showed the following: -During the orientation process and prior to assuming the position of nurse assistant at the facility, the following procedures shall be demonstrated by the nurse assistant preceptor; -The preceptor will be assigned by the charge nurse to observe these procedures as outlined in the certified nurse assistant's instruction manual; -It is the responsibility of the employee to perform all of the procedures listed correctly and efficiently; -Areas included oral and denture care, gait belt use, perineal care for a male and female, and hand washing. 2. Review of Resident #8's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/5/17, showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required extensive assistance of one staff for toilet use and personal hygiene; -Frequently incontinent of bladder. Review of the resident's care plan, dated 1/12/17, showed the following: -The resident had his/her own natural teeth and could brush them himself/herself but required staff to remind him/her to do so; -The resident required extensive assistance of one person for toileting. The resident could pull his/her pants up and down but needed help with the brief. The resident could wipe himself/herself but required follow up care if needed; -The resident was incontinent of urine and required staff assistance on the bathroom before and after meals. Observation on 2/22/17 at 7:04 A.M. showed the following: -Nurse Aide (NA) F and NA G entered the resident's room to assist him/her with morning care; -NA F and NA G assisted the resident to sit up on the side of the bed; -NA F and NA G put pants on the resident up to his/her knees and placed a walker in front of him/her; -NA F told NA G they did not need to put a gait belt on the resident because he/she was independent with transfers; -The resident attempted to stand with the walker and was unable to do so; -NA F and NA G lifted the resident under his/her arms to assist him/her to a standing position; -NA F and NA G pulled up the resident's pants and walked with him/her to the bathroom; -NA F assisted the resident to pull down his/her pants and brief and sit on the toilet; -The resident's incontinent brief was urine soaked; -The resident removed the brief and held it in his/her hands; -The resident urinated in the toilet and placed the wet brief in the trash; -NA G removed the resident's urine saturated bed linen, and placed them in the dirty linen barrel; -The resident's mattress was wet with urine; -NA G left the room and returned several minutes later with clean linen to make the resident's bed; -NA G made the resident's bed with clean linen without sanitizing the mattress; -NA F put a clean incontinent brief on the resident; -The resident stood up with the walker and NA F pulled up the resident's pants without providing any incontinent care; -NA F told the resident he/she was ready to go on to breakfast; -NA F and NA G did not remind or offer to assist the resident to brush his/her teeth or wash his/her hands; -The resident walked out of the bathroom and down the hall to the dining room for breakfast. During an interview on 2/22/16 at 8:30 A.M., NA G said the resident was incontinent that morning and his/her bed linen was wet with urine. NA G said he/she did not know if he/she should have sanitized the resident's bed before he/she put clean linen on it because he/she had not worked in the facility very long. NA G said he/she had not been taught to not lift a resident under their arms. NA G said he/she had worked in the facility for one week. During an interview on 2/22/17 at 12:42 P.M., NA F said the resident's brief had been soaked with urine when he/she assisted the resident that morning. NA F said he/she had not provided any incontinent care or offered to brush the resident's teeth and should have done so. NA F said he/she had forgotten to remind or offer to wash the resident's hands after the resident used the bathroom and before he/she went to breakfast. NA F said he/she had lifted the resident under his/her arm to a standing position from the bed that morning. NA F said he/she was not aware there was anything wrong with lifting a resident under the arms. NA F was in a nurse aide training program but had not been taught that yet. NA F said he/she had worked at the facility as a NA for two months and would take the test to become a CNA in a few weeks. NA F said he/she was orienting NA G that day. 3. Review of Resident #10's annual MDS, dated [DATE], showed the following: -He/she understood others; -Required extensive assistance from one staff for transfers. Review of the resident's care plan, dated 1/18/17, showed the following: -The resident needed extensive assistance from one person for transfers; -The resident was prone to skin tears as his/her skin was fragile. -An update on 2/8/17 showed the resident had a skin tear to the left arm that occurred during a transfer. Review of the resident's physician orders [REDACTED]. Observation on 2/22/17 at 6:20 A.M. showed the following: -The resident lay in his/her bed; -Certified Nurse Assistant (CNA) H and NA C entered the resident' room, performed morning cares, assisted the resident to sit on the side of the bed and placed a wheelchair beside the bed; -NA C applied a gait belt around the resident's waist and instructed the resident to hug him/her around the neck; -NA C hugged the resident around his/her waist area, clasped his/her hands over the gait belt and transferred the resident to the wheelchair. During interview on 2/22/17 at 12:40 P.M., NA C said the following: -He/she had been employed at the facility since beginning of February; -He/she had not been trained on gait belt transfers and had been trained by four different CNAs; -He/she had not had 16 hours of orientation with a licensed nurse prior to providing direct resident care. -He/she did not know how to perform a proper one staff transfer with a gait belt; -He/she had not begun the CNA class yet but was told it would begin next week. 4. During an interview on 2/22/17 at 11:15 A.M., the Director of Nursing (DON) said when NAs are hired, they spend their first day of orientation watching videos and completing paperwork. The NAs usually work with a CNA for about three weeks before they can work on their own. The DON then visits with the NA to see how they are feeling about their progress. The NAs have a check off sheet that included gait belt transfers, perineal care, handwashing and gloving, and infection control practices. These sheets are initialed by the CNA who the NA is orienting with at the time the skill is demonstrated by the NA. The charge nurse makes the assignments for all the aides. An NA doesn't usually train another NA but NA F had been initialed off on his/her tasks and had completed his/her orientation period and was orienting NA G that day. NAs did not spend 16 hours of training with a licensed nurse.

Based on observation, interview, and record review, the facility failed to ensure staff washed their hands and changed gloves after each direct resident contact and when indicated by professional standards of practices during personal care for two of 11 sampled residents (Residents #1 and #8); and failed to sanitize a mattress after it had been saturated with urine for one resident (Resident #8). The facility census was 47. 1. Review of the facility's undated policy, Wash Hands, showed it provided no direction for staff as to when and how often to wash hands. Review of the facility's undated policy, Put on and Remove Daily Care Nonsterile Gloves, showed it provided no direction for staff as to when staff should change gloves. 2. Review of the Guidelines for Hand Hygiene in Health Care Setting, dated 10/25/02, from the Center for Disease Control and Prevention, showed the following recommendations: -Decontaminate hands before having direct contact with patients; -Decontaminate hands after contact with a patient's intact skin; -Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; -Decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient; -Decontaminate hands after removing gloves; -Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. Indications for, and limitations of glove use include the following: -Hand contamination may occur as a result of small, undetected holes in examination gloves; -Contamination may occur during glove removal; -Wearing gloves does not replace the need for hand hygiene; -Failure to remove gloves after caring for a patient may lead to transmission of microorganisms from one patient to another. 3. Review of the Nurse Assistant in a Long-Term Care Facility Manual, Revision 2001, showed the following: -Handwashing is the single most important means of preventing the spread of infection; Handwashing should be done when you first come on duty and before going home, before and after contact with each resident, before and after glove use, after contact with any waste or contaminated material, before contact with any food. Always wash hands after using gloves; -Gloving: Gloves should be worn when contact is likely with any body fluids, any body opening, used tissues or wipes. Gloves do not eliminate the need to wash your hands; they just provide a barrier between you and potentially infectious microorganisms. Never touch unnecessary articles in the room while wearing gloves. Remove gloves before leaving the resident's room. Do not wash or disinfect examination gloves; -Handling of linens: Keep linen away from uniform. Place used linen in a nonporous bag (e.g., plastic bag) at the side of the bed. NEVER put linen directly on the floor. Place closed, bagged linen in designated soiled linen container. 4. Review of Resident #8's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/5/17, showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required extensive assistance of one staff for toilet use and personal hygiene; -Frequently incontinent of bladder. Review of the resident's care plan, dated 1/12/17, showed the following: -Required extensive assistance of one person for toileting. The resident could pull his/her pants up and down but needed help with the brief. The resident could wipe himself/herself but required follow up care if needed; -The resident was incontinent of urine and required staff assistance on the bathroom before and after meals. Observation on 2/22/17 at 7:04 A.M. showed the following: -Nurse Aide (NA) F and NA G entered the resident's room to assist him/her with morning care; -NA F and NA G washed their hands and put on gloves; -NA F and NA G assisted the resident to stand; -The resident's bed and linen was saturated with urine; -NA F and NA G pulled up the resident's pants and walked with him/her to the bathroom; -NA F assisted the resident to pull down his/her pants, unfasten the incontinence brief, and sit on the toilet; -The resident's incontinent brief was soaked with urine; -The resident removed the brief and held it in his/her hands; -The resident urinated in the toilet and placed the wet brief in the trash; -NA G removed the resident's urine saturated bed linens, placed them in the dirty linen barrel, removed his/her gloves and washed his/her hands; -The resident's mattress was wet with urine; -NA G left the room and returned several minutes later with clean linen to make the resident's bed; -NA G made the resident's bed with clean linen without sanitizing the mattress; -NA F removed his/her gloves and sanitized his/her hands, and put a clean brief, pants and shirt on the resident; -The resident stood up with the walker and NA F pulled up the resident's pants; -NA F told the resident he/she was ready to go on to breakfast; -The resident walked out of the bathroom and out into the hall to the dining room for breakfast; -NA F did not remind or offer to assist the resident to wash his/her hands after using the toilet and handling the urine soaked brief. During an interview on 2/22/16 at 8:30 A.M., NA G said the resident was incontinent that morning and his/her bed linen was wet with urine. NA G said he/she did not know if he/she should have sanitized the resident's bed before he/she put clean linen on it because he/she had not worked in the facility very long. During an interview on 2/22/17 at 12:42 P.M., NA F said he/she had forgotten to remind or offer to wash the resident's hands after the resident used the bathroom and before he/she went to breakfast. 5. Review of Resident #1's significant change MDS, dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident's care plan, dated 1/12/17, showed the resident was incontinent of bladder. He/she required extensive assistance from two staff for his/her toileting needs and AM/PM cares. Observation on 2/21/17 at 5:35 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -Certified Nurse Assistant (CNA) A and CNA B entered the room, and without washing their hands, put on gloves; -CNA A applied a gait belt around the resident and placed a walker in front of the resident; -CNA A and CNA B transferred the resident to the bed; -CNA B removed the resident's shoes as CNA A obtained a clean incontinence brief from the closet; -CNA A moistened wash cloths in the sink, sprayed them with perineal wash and laid them on a towel at the head of the resident's bed; -CNA A un-fastened the urine soiled incontinent brief; -CNA B rolled the resident to his/her left side; -CNA A cleansed the resident's buttock. Smears of feces were observed on the wash cloth; -CNA A tucked the soiled incontinent brief from under the resident, and without removing his/her soiled gloves, placed a clean brief under the resident and assisted the resident to roll to his/her right side; -CNA A removed the soiled brief, placed it in the trash, and without removing his/her soiled gloves, assisted the resident to his/her back; -Without removing his/her soiled gloves, CNA A picked up a clean washcloth and wiped the resident's groin. A moderate amount a feces was observed on the cloth. CNA A turned the cloth over, which placed the fecal soiled area against his/her gloved hand, and wiped the resident's other groin. Feces was observed on the wash cloth; -CNA A and CNA B switched to opposite sides of the bed. Without removing his/her soiled gloves, CNA A picked up a clean wash cloth and cleansed the resident's anal and buttock areas, obtaining smears of feces on the cloth with each wipe. CNA A repeated this step and then obtained a clean cloth and repeated the same. The CNA flipped the cloth after each wipe which placed the fecal soiled side against the palm of his/her gloved hand; -Without removing his/her soiled gloves, CNA A picked up a clean towel and dried the resident's backside, assisted the resident to his/her left side, removed the soiled linens, and carried the soiled linens out of the room to the shower room across the hall. -CNA A removed his/her gloves in the shower room, returned to the resident's room, and washed his/her hands. During interview on 2/23/17 at 4:10 P.M., CNA A said the following: -Gloves should be changed when they become soiled; -Hands should be washed when gloves are changed and when they become soiled; -Clean items should not be touched with soiled hands or gloves; -Soiled linens should not be carried into the hallway; -Soiled gloves should not be worn in the hallway or out of the room. 6. During interview on 2/23/17 at 12:08 P.M., the Director of Nursing said the following: -He/she would expect staff to wash their hands before and after care for a resident, anytime they become soiled and when changing gloves if soiled with feces or other; -He/she would expect staff to change gloves when moving from dirty to clean areas and anytime they became soiled; -He/she would not expect staff to touch clean items with soiled hands. -He/she would expect staff to wash a resident's hands if they witnessed him/her touch a urine soiled incontinent brief.

Based on observation, interview and record review, the facility staff failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that are significant to the resident. Staff failed to acknowledge residents' preferences for time to awaken for two residents (Residents #6 and #11) in a review of 12 sampled residents and two additional resident (Residents #25 and #26). Staff woke the residents starting at 5:00 A.M. so all residents would be up by 7:00 A.M. for breakfast and not according to their individual preferences. The facility census was 55. 1. Record review of the Resident's Rights for Long-Term Care in Missouri booklet, provided by the facility, undated, showed the following: -You (the resident) should be treated with consideration and respect, will full recognition of your dignity and individuality. You should not be required to do things against your will. -As a resident of a long-term care facility, you (the resident) have rights which are guaranteed and protected by law. These resident rights support the principle of dignity and respect for every person who lives in a long-term care setting. -Every facility must protect and promote these rights for all residents and must inform you of these rights when you are admitted . 2. Review of Pioneer Network, Culture Change definition, undated, showed Culture Change is the common name given to the national movement for the transformation of older adult services based on person-directed values and practices where the voices of elders and those working with them are considered are respected. Core person-directed values are choice, dignity, respect, self-determination and purposeful living. Culture change transformation supports the creation of both long and short-term living environments as well as community-based settings where both older adults and their caregivers are able to express choice and practice self-determination in meaningful ways at every level of daily life. 3. Review of the facility's Certified Nurse Assistant (CNA) Admission Information Form showed the following information and questions: -The resident's vital signs, height and weight, presence of glasses and dentures and last bowel movement; -The resident's preferred name, preferred time to get up in the morning, and preferred bedtime; -The resident's desire to nap; -The resident's preferred type of bath and preferred time of bathing; -The resident's preferred bedside beverage. 4. During interview on 4/7/16 at 2:50 P.M., the Assistant Director of Nursing (ADON) said the CNA staff or Restorative Assistant completed the resident's CNA Admission Form and asked the resident or the resident's family at admission about preferred wake time and preferred bedtime. The information was reviewed quarterly but was not documented anywhere. 5. Review of Resident #11's annual Minimum Data Set (MDS), a federally mandated assessment instrument to be completely by the facility, dated 8/6/15, showed the following: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -Required extensive assistance on two staff members with bed mobility, transfers and toileting; -Required extensive assistance of one staff member with dressing and eating; -Required total assistance of one staff member with locomotion on and off the unit, and personal hygiene. Review of the resident's Care Card, located on the resident's closet door, dated 2/9/16, showed the following: -The resident was rarely able to express himself/herself and rarely able to understand others; -One staff member should assist the resident with dressing, eating and personal hygiene; -Two staff members should assist the resident with bed mobility, transfers, toileting and bathing; -The resident liked to hold a baby doll. Review of the resident's care plan, dated 2/9/16, showed the following: -admission date of [DATE]; -The resident had [MEDICAL CONDITION], was confused and had poor memory; -The resident required extensive assistance with care needs; -He/she liked to get up around 6:30 A.M. so he/she could sleep in a little until right before breakfast was served. The resident liked to go to bed right after supper. Review of the resident's medical record showed no documentation of a Certified Nurse Assistant (CNA) admission form indicating the resident's preferred time to rise in the morning. Observation and interview on 4/6/16 at 5:50 A.M. showed the following: -CNA E and CNA Q walked into the resident's room and turned on the lights; -Both residents in the room lay in bed with their eyes closed; -CNA E asked CNA Q, Which one? -CNA Q said it didn't matter; -CNA Q woke Resident #11 and said, Ready to get dressed, you don't look awake; -CNA Q rolled the resident from side to side and provided incontinence care. He/she applied an incontinence brief and rolled the resident to his/her back. The resident mumbled and closed his/her eyes; -CNA Q asked the resident, Are you falling back to sleep? CNA Q applied the resident's socks; -CNA Q rolled the resident from side to side and applied the resident's pants; -CNA Q said the resident usually fell back to sleep everyday; -CNA Q and CNA E transferred the resident from bed to the wheelchair. CNA Q said the resident didn't want to wake up; -CNA Q asked the resident, Are you ready? The resident said, No. CNA Q laid a doll in the resident's lap; -The resident lowered his/her head and closed his/her eyes; -CNA Q asked the resident if he/she wanted to get something to drink as he/she wheeled the resident in the wheelchair into the hallway. Further observation on 4/6/16 showed the following: -From 6:15 A.M. to 7:00 A.M., the resident sat in the wheelchair in the dining room holding a doll. The resident's eyes were closed and his/her head was down; -At 7:30 A.M., three glasses of fluids sat on the table in front of the resident. The resident did not independently drink the liquids; -At 7:35 P.M., staff served the resident's breakfast tray and staff fed the resident. During interview on 4/6/16 at 6:45 A.M., CNA Q said the following: -He/she worked the night shift from 11:00 P.M. to 7:00 A.M.; -The night shift started getting residents up at 5:00 A.M. for breakfast; -One night shift staff member worked 12:00 A.M. to 8:00 A.M. to assist with breakfast from 7:00 A.M. to 8:00 A.M.; -One day shift staff member worked 5:00 A.M. to 1:00 P.M. to assist getting residents up for breakfast. During interview on 4/7/16 at 7:50 A.M., the resident's family member/responsible party said the following: -Staff told him/her the resident got up at 5:30 A.M. and went to bed at 6:30 P.M.; -Staff did not ask him/her the resident's usual wake or bed time; -The resident had [MEDICAL CONDITION] and was unable to answer questions. 6. Review of Resident #26's CNA admission information, dated 1/12/15, showed the resident would like to get up at 6:00 A.M. Review of the resident's annual MDS, dated [DATE], showed the following: -Usually made self understood and usually understood others; -Severely impaired cognition; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting; -Required total assistance of one staff for personal hygiene; -Used a wheelchair for mobility; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 1/20/16, showed the following: -Facility admission date of [DATE]; -The resident needed extensive assist from two people for his/her Activities of Daily Living (ADLs); -He/she did not really care what time he/she got up but if he/she was upset and yelling, staff were not to try to get him/her up. Let him/her rest if this is what he/she wants; -The resident was incontinent of bladder and preferred staff checked him/her before and after meals; -He/she was at risk for skin breakdown because of his/her decreased mobility. He/she needed extensive assist from two people for his/her positioning needs and transfers. Observation on 4/6/16 showed the following: -At 5:27 A.M., the resident sat in his/her wheelchair in the darkened dining room with his/her eyes closed; -At 6:07 A.M., the resident sat in his/her wheelchair in the darkened dining room with his/her eyes closed; -At 6:15 A.M., the resident sat in his/her wheelchair in the darkened dining room with his/her eyes closed; -At 6:30 A.M., the resident sat in his/her wheelchair at the dining room table and watched other residents who sat at their respective tables; -At 6:32 A.M., the resident sat in his/her wheelchair and watched dietary staff pass the house supplement; -At 6:45 A.M., the resident sat in his/her wheelchair at the dining room table; -At 7:00 A.M., the resident sat in his/her wheelchair at the dining room table; -At 7:20 A.M., staff served the resident his/her breakfast; -At 7:27 A.M., the resident called out, I'm not trying to rush you but I need some sleep. The resident sat up straight in the wheelchair then leaned back. The resident did not eat breakfast; -At 7:30 A.M., the resident said, I need some rest. The Director of Nursing (DON) propelled the resident in his/her wheelchair back to his/her room; -At 7:32 A.M., Staff transferred the resident to his/her bed. During interview on 4/6/16 at 7:40 A.M., CNA E said Resident #26 was one of the first residents to get up. Staff will get the resident up around 5:00 A.M. or 5:15 A.M. During interview on 4/7/16 at 10:55 A.M., the resident's family member/responsible party, said the following: -The resident had never gotten up as early as 5:00 A.M. in the past; -He/she had talked with the staff about why his/her family member got up so early and was not given a reason; -He/she said staff did not ask him/her preferences on a get up time for his/her family member; -Typically the resident was a late riser. During interview on 4/7/16 at 11:00 A.M., CNA D said the following: -It was better to get the resident up first; -He/she became upset while getting up and had time to calm down in the dining room before the other residents arrived. 7. Review of Resident #25's annual MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED].>-Resident interview for mental status was not completed because the resident was rarely or never understood; -Unclear speech, rarely or never made self-understood and sometimes understood others; -The resident's short and long term memory were okay; -The resident's cognitive skills for daily decision making were moderately impaired. He/she made poor decisions and required cues or supervision; -Required extensive assistance of two staff members with bed mobility; -Required extensive assistance of one staff member with transfers, locomotion on and off the unit, dressing, toileting and personal hygiene; -Required limited assistance of one staff member with eating; -Did not reject care. Review of the resident's care plan, dated 2/24/16, showed the following: -admission date of [DATE]; -The resident had a stroke resulting in difficulty with speech, communication and right sided body weakness; -The resident's memory was better than it appeared; -The resident liked to get up between 6:00 A.M. and 7:00 A.M. He/she was not picky about what time to get up as long as it was not before 6:00 A.M. He/she liked to go to bed at 8:00 P.M. Review of the resident's Care Card, located on the resident's closet door, dated 2/25/16, showed the following: -Short and long term memory were good, ability to make decisions were poor; -Rarely able to express self and poor ability to understand others; -Required two staff member assistance with bed mobility; -Required one staff member assistance with transfers, locomotion on and off the unit, dressing, eating, toileting, and personal hygiene. Review of the resident's medical record showed no documentation of a CNA admission form indicating the resident's preferred time to rise in the morning. Observation on 4/6/16 at 5:50 A.M. showed the following: -CNA E and CNA Q walked into the resident's room and turned on the lights; -Both residents in the room lay in bed with eyes closed; -CNA E asked CNA Q, Which one? -CNA Q said it didn't matter; -CNA E woke Resident #25; -CNA E dressed, toileted and transferred the resident to a wheelchair; -While staff were providing care, the resident said, Tired' -At 6:15 A.M., CNA E said good to go and rolled the resident to the dining room. Further observation on 4/6/16 showed the following: -From 6:15 A.M. to 7:30 A.M., the resident sat in the wheelchair in the dining room. The resident occasionally closed his/her eyes; -At 7:30 A.M., staff served the resident breakfast. During interview on 4/6/16 at 2:45 P.M., the resident nodded yes he/she was tired and wanted to lay down. He/she did not like to get up in the morning. 8. Review of Resident #6's face sheet showed an admission date of [DATE]. Review of the resident's medical record showed no documentation of a CNA admission form indicating the resident's preferred time to rise in the morning. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Rarely understood others and unable to make self understood; -Problem with short and long term memory; -Severely impaired with daily decision making; -Extensive assist of one staff for transfers. Review of the resident's care plan, dated 1/20/16, showed the following: -Communication: Did not always understand questions and unable to form sentences; -Personal Care: Required assistance of one staff for transfers and preferred to get up around 6:30 A.M. Review of the resident's Physician order [REDACTED]. -[DIAGNOSES REDACTED]. -Up as tolerated with one staff assist in wheelchair. Observation on 4/6/16 at 5:15 A.M. showed the resident sat in his/her wheelchair in the main dining room. No staff were in the dining room. During interview on 4/6/16 at 5:55 A.M., CNA F said the following: -He/she did not have a list of residents to get up; -They tried to get up according to the resident's preference; -The resident was talking around 3:30 A.M. so they got him/her up at 5:00 A.M.; -Night shift was responsible for having everyone up by 7:00 A.M. During interview on 4/7/16 at 7:15 A.M., the resident's family member said the following: -They were not aware staff were getting the resident up at 5:00 A.M. and he/she felt that it was too early; -The only time the resident ever woke early was for church at 6:30 A.M. on Sundays; -Staff had not discussed a rising preference for the resident with them. 9. During interview on 4/6/16 at 6:20 A.M., Licensed Practical Nurse (LPN) T said the following: -He/she was the charge nurse on night shift; -He/she started passing medications at 5:00 A.M.; -The CNA staff started getting residents up at 5:00 A.M.; -One day shift staff member worked 5:00 A.M. to 1:00 P.M. to assist getting residents up for breakfast. During interview on 4/7/16 at 8:20 A.M., CNA F said the following: -He/she worked the night shift and recently worked from 12:00 A.M. to 8:00 A.M.; -The night shift started getting residents up as call lights were answered. Then started at one end and worked to the end of the hall assisting residents up for breakfast; -From 7:00 A.M. to 8:00 A.M., he/she helped with breakfast and fed dependent residents; -Usually the residents were all up by 7:30 A.M. for breakfast. During interview on 4/7/16 at 9:25 A.M., CNA E said the following: -He/she worked the day shift usually from 5:00 A.M. to 1:00 P.M.; -The expectation was to get all residents up for breakfast by 7:00 A.M. CNA E said, That's our plan; -Day shift would get the remaining residents up if still in bed after 7:00 A.M.; -He/she came to work at 5:00 A.M. on 4/7/16 and only one resident remained in bed at 7:00 A.M.; -Staff normally woke Resident #11 and Resident #25 early. Both residents often slept while the staff dressed them; -Resident #11 and Resident #25 usually returned to bed after breakfast or were given a shower and then returned to bed. During interview on 4/7/16 at 9:00 A.M., CNA J said the following: -He/she worked day shift from 7:00 A.M. to 3:00 P.M.; -CNAs complete the CNA admission form upon resident admission to the facility. The CNA admission form included the resident's preferred time to get up in the morning and preferred bedtime; -He/she did not know if the information was updated after the resident's admission to the facility; -At 7:00 A.M., one or two residents usually remained in bed. During interview on 4/7/16 at 11:00 A.M., CNA D said the following: -He/she worked the day shift and occasionally came in early at 5:00 A.M. to 1:00 P.M.; -Staff started getting residents up at 5:00 A.M., most residents were up by 7:00 A.M.; -Residents with [MEDICAL CONDITION] were sometimes more difficult to get up in the morning. During interview on 4/7/16 at 12:45 P.M., the Social Services Designee (SSD) said the following: -He/she obtained residents history on admission. Family members were interviewed if the resident was unable to provide the information; -He/she obtained information about the resident's preferences and choices; -The information did not include the resident's preferred time to rise in the morning or preferred bedtime; -The CNA admission form included the resident's preferred time to rise in the morning and preferred bedtime. During interview on 4/7/16 at 2:50 P.M., the ADON said the following: -He/she would expect staff to follow the resident's care plan when determining when to get residents up in the morning; -He/she had not directed night shift staff that all residents had to be out of bed before they were finished with their shifts at 7:00 A.M. -Staff start getting residents up at 5:00 A.M. every morning; -She was unsure what staff should do about residents that were sleeping; -A few residents in the facility got up later that 7:00 A.M. and ate after the usual morning breakfast time; -Most of the residents were up by 7:00 A.M.; -She was unsure about residents sleeping in wheelchairs for an hour or more before served breakfast. Positioning in the wheelchair then became a problem; -She understood that part of culture change included resident's having natural rising.