Every finding on record at Forsyth Rehabilitation & Health Care Center

Based on observation, interview, and record review, the facility failed to store, prepare and distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility failed to keep dented cans separated from other cans, when the facility staff failed to ensure all food items were properly labeled and sealed, failed to ensure expired foods were discarded, when the facility staff failed to ensure fans in food areas were free from dirt and debris, and when staff stacked dishes while still wet. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 93 residents.1. Review of the 2022 Food and Drug Administration (FDA) Food Code showed the following information:-Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard;-Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food;-If the integrity of the packaging has been compromised, contaminants may find their way into the food. Review of the facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), undated, showed dented cans are to be set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vending procedure.Observation on 08/25/25, at 10:20 A.M., of the canned food rack showed the following:-One seven pound and five ounce (oz) can of baked beans with a large dent on the bottom near the rim;-One six pound and 10 oz can of pineapple tidbits with a large dent on one entire side of the can;-One six pound and six oz can of sliced pears with a medium dent;-One six pound and six oz can of peaches with a medium dent near the bottom at the rim and a smaller dent on the bottom near the rim.Observation on 08/28/25, at 10:40 A.M., of the canned food rack showed the following:-One seven pound and five ounce (oz) can of baked beans with a large dent on the bottom near the rim;-One six pound and 10 oz can of pineapple tidbits with a large dent on one entire side of the can;-One six pound and six oz can of sliced pears with a medium dent;-One six pound and six oz can of peaches with a medium dent near the bottom at the rim and a smaller dent on the bottom near the rim;-One three pound and two oz can of cream of potato soup with small dent on top at the rim;-One three pound and two oz can of cream of mushroom soup with a small dent on the rim at the top.During an interview on 08/28/25, at 9:35 A.M., Dietary Aide (DA) L said the following:-Dented cans should not be on the rack with other cans;-He/she would remove a dented can from the rack and notify the Dietary Manager (DM);-He/she was unsure if there is a designated place to store dented cans;-He/she would not use food from a dented can unless he/she dropped it and cause the dent and used the food right away.During an interview on 08/28/25, at 9:51 A.M., DA M said the following:-Staff should not use food from a dented can;-He/she pulls dented cans and stores them in the designated area which is the DM's office.During an interview on 08/28/25, at 10:02 A.M., Dietary [NAME] (DC) N said the following:-Staff should never use food from a dented can;-Staff should pull dented cans from the rack and store in the DM's office.During an interview on 08/28/25, at 10:19 A.M., the DM said the following:-Staff should never use food from a dented can;-Staff should pull dented cans from the rack and store in her office;-She notified the food representative for credit.During an interview on 09/02/25, at 5:11 P.M. the Administrator said staff should not use dented cans and should store in a separate designated area.2. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, updated 03/04/23, showed the following:-Facility staff must ensure their proper storage, keeping track of when to discard perishable foods, and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated;-Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable), or discarded.Review of the facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), undated, showed the following:-All food items will be labeled. The label must include the name of the food and the date by which it should be consumed or discarded;-Discard food that has passed the expiration date, and discard food that has been prepared in the facility after send days of storing under proper refrigeration;-Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers.Observation on 08/25/25, at 10:20 A.M., of the kitchen showed the following:-The following containers of seasonings with the lids open to air: rosemary leaves, garlic powder, parsley flakes, celery salt, two containers of onion powder, ground nutmeg, dill weed, lemon and pepper seasoning, salt, ground ginger, and mediterranean style oregano;-Two plastic squeeze bottles containing a substance resembling dressing with no label, and one medium sized jar of white liquid with no label in the standing refrigerator;-In the walk-in refrigerator was a plastic four-quart container of apple sauce with an unsealed lid, a gallon sized plastic bag with containing sausage patties with no label, a two-gallon plastic bag containing one hot dog labeled 08/06/25, and a gallon size plastic bag containing lunch meat labeled 08/18/25;-In the walk-in freezer was four crusts in a plastic bag open to air with no label, large plastic bag containing bread sticks with a hole in the bag open to air with no label, large plastic bag containing rolls open to air with no label, and a two-gallon plastic bag of some type of leftover meat with no label.Observation on 08/28/25, at 10:40 A.M., of the kitchen showed the following:-The following containers of seasonings with the lids open to air: rosemary leaves, garlic powder, parsley flakes, celery salt, two containers of onion powder, ground nutmeg, dill weed, lemon and pepper seasoning, salt, ground ginger, and mediterranean style oregano;-In the walk-in refrigerator was a two-gallon plastic bag containing sliced cheese unsealed and open to air, bag of cooked chicken labeled 8/23-8/26, and bag of hot dogs labeled 8/26, and a bag of salad labeled 8/27.Observation on 08/28/25, at 11:15 A.M., of the kitchen showed the following:-In the walk-in freezer was a blue bag containing green beans unsealed and open to air, a bag of beef patties inside a box unsealed and open to air, four crusts in a plastic bag open to air with no label, large plastic bag containing bread sticks with a hole in the bag open to air with no label, large plastic bag containing rolls open to air with no label, and a two-gallon plastic bag of some type of leftover meat with no label.During an interview on 08/28/25, at 9:35 A.M., DA L said the following:-Staff should store opened food in a sealed container labeled with the date opened and the use by date;-Leftover food items such as pudding, drinks, and soup should be used within three days.During an interview on 08/28/25, at 9:51 A.M., DA M said staff should store opened food in a sealed container labeled with the food name, date opened, and the use by date.During an interview on 08/28/25, at 10:02 A.M., DC N said the following:-All stored opened food should be sealed, labeled, and dated with the open date and use by date;-Leftovers should be used within three days;-Staff should discard all expired foods.During an interview on 08/28/25, at 10:19 A.M., the DM said the following:-All stored opened food should be sealed, labeled, and dated with the open date and use by date;-Leftovers should be used within three days;-Staff should dump all expired foods.During an interview on 09/02/25, at 5:11 P.M., the Administrator said opened food should be labeled, dated and sealed. Leftovers should be stored for three days and then discarded.3. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination.Review showed the facility did not provide a policy or cleaning schedule related to cleaning the fans in the walk-in refrigerator or freezer.Observation on 08/25/25, at 10:20 A.M., of the kitchen showed the following:-Fans inside the walk-in refrigerator had dirt and dust on them, and they were blowing directly over food;-Fans inside the walk-in freezer had dirt and dust on them, and they were blowing directly over food.Observation on 08/28/25, at 10:40 A.M., of the kitchen showed fans inside the walk-in refrigerator had dirt and dust on them, and they were blowing directly over food.Observation on 08/28/25, at 11:15 A.M., of the kitchen showed fans inside the walk-in freezer had dirt and dust on them, and they were blowing directly over food.During an interview on 08/28/25, at 9:51 A.M., DA M said maintenance was responsible for cleaning the fans in the walk-in refrigerator and freezer.During an interview on 08/28/25, at 10:02 A.M., DC N said the following:-Maintenance was responsible for cleaning the fans in the walk-in refrigerator and freezer;-The fans in the walk-in refrigerator and freezer should not have dust or dirt particles on them.During an interview on 08/28/25, at 10:19 A.M., the DM said the following:-Maintenance was responsible for cleaning the fans in the walk-in refrigerator and freezer;-She was unsure of the schedule related to cleaning the fans in the walk-in refrigerator and freezer;-The fans in the walk-in refrigerator and freezer should not have dust or dirt particles on them.During an interview on 09/02/25, at 1:35 P.M, the Maintenance Director said the following:-He thought it was his responsibility to clean the fans in the walk-in refrigerator and freezer, but was unsure;-He had not cleaned them since he started his position in February of 2025, and no one informed him it was his responsibility;-The fans should not have dirt and debris on them.During an interview on 09/02/25, at 5:11 P.M., the Administrator said there should be no dirt or debris on fans over food. 4. Review of the Missouri Food Code, published 2022, showed dishes are required to be air dried before being stacked and stored. Review of the facility policy titled, Dish and Utensil Handling, undated, showed the following:-All silverware, dishes and glasses shall be handled to ensure sanitary conditions and infection control;-Dishes, cups, and glasses will be air-dried prior to storing;-Plates, soup bowls, salad bowls, and bread plates are stored on a rack covered.Observation on 08/28/25, at 10:40 AM., showed the following:-Plastic bowls stacked on a shelf under a table while still wet;-Plate covers stacked on the steam table while still wet.During an interview on 08/28/25, at 9:35 A.M., DA L said the following:-He/she washes dishes in the facility;-He/she stacked bowls upside down in the tub and does not allow for time for them to air dry;-He/she should not stack dishes with water, but the bowls drains since they are turned upside down;-He/she washes the insulated plate covers, dumps the water out, and stacks on the serving table to use for meal serve out with no drying process.During an interview on 08/28/25, at 9:51 A.M., DA M said all dishes should be air dried before stacking, and no dishes should be stacked wet.During an interview on 08/28/25, at 10:02 A.M., DC N said staff should air dry all dishes and bowls and insulated plate covers should not be stacked with water in them.During an interview on 08/28/25, at 10:19 A.M., the DM said staff should air dry all dishes before putting away for use, and no dishes should be stacked wet.During an interview on 09/02/25, at 5:11 P.M. the Administrator said dishes should be dried completely before stacking.

Based on observation, interview, and record review, the facility failed to maintain a complete and effective infection prevention and control program when the facility failed to ensure staff were educated on enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities); failed to ensure staff wore appropriate protective personal equipment (PPE) when providing catheter care for two residents (Resident #1 and #66) with a catheter (flexible tubing that is used to drain urine from the bladder) and when accessing a peripherally inserted venous catheter (PICC - a tube inserted into a large vein near the heart got long term IV access) for one resident (Resident #101); when the facility failed to ensure EBP was care planned for two residents (Resident #1 and #66) with a catheter and one resident (Resident #101) with a PICC; and when the facility failed to post clear signage on the doors or walls outside of three resident rooms (Resident #1, Resident #64, and Resident #101) indicating the type of precautions and required PPE. The facility census was 93.Review of the Centers for Disease Control's (CDC) Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 07/12/22, showed the following:-Multidrug-Resistant Organisms (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs;-EBP are infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities;-EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO;-Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care;-EBP use of PPE refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing;-Examples of high-contact resident care activities requiring gown and glove use for EBP includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central line, urinary catheter, feeding tube, and tracheostomy/ventilator, and wound care on any skin opening requiring a dressing;-Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility policy titled, Infection Prevention and Control Manual-Enhanced Barrier Precautions, undated, showed the following:-Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MRDOs) in nursing homes;-EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MRDO as well as those at increased risk for MDRO acquisition (residents with wounds or indwelling medical devices). This is because devices and wounds are risk factors placing residents at higher risk for carrying or acquiring a MRDO;-If splashed and sprays are anticipated during the high contact activity, face protection should be used in addition to the gown and gloves;-EBPs are recommended for residents with an infection or colonization (living inside the body without causing active illnesses) with a MRDO or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MRDO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators;-High-contact resident care activities include bathing/showering, transferring positions of residents, providing hygiene, changing bed linens, changing briefs or assisted toileting, caring for or using an indwelling medical device, and performing would care;-Methicillin-resistant Staphylococcus aureus (MRSA-an infection caused by bacteria commonly found on the skin or in the nose genetically distinct from other strains of staph infections) is an example of an epidemiologically (identifying the where, when, and who of diseases )important MRDO targeted by the Center for Diseases Control (CDC). 1. Review of Resident #1's face sheet (basic resident profile information) showed the following:-admission date of 08/01/25;-Diagnoses pneumonia due to klebsiella pneumoniae (unknown bacteria) and acute kidney failure with tubular necrosis (damage to the kidney tubules impairing the ability to filter blood leading to a buildup of wastes). Review of the resident's comprehensive Minimum Data Set (MDS-federally mandated assessment tool administered by staff), dated 08/11/25, showed the following:-Severe cognitive impairment;-Resident required substantial/maximum assistance from staff with activities of daily living (ADLs);-Resident has indwelling catheter. Review of the facility's current list of residents on EBP did not include the resident. Review of the resident's progress notes showed the following:-On 08/01/25, at 3:32 P.M., resident admitted to facility this morning around 9:45 A.M., via ambulance with foley (catheter) intact. Resident incontinent of bowel;-On 08/23/25, at 1:15 P.M., foley catheter in place and with clear yellow urine noted;-On 08/24/25, at 1:36 P.M., foley catheter in place with clear yellow urine noted;-On 08/30/25, at 1:46 P.M., foley catheter in place with clear urine noted;-On 08/31/25, at 1:22 P.M., foley catheter in place with clear urine noted;-On 08/31/25, at 7:28 P.M., foley catheter with a closed draining system, amber color urine present and draining well, good urine output this evening. Review of the resident's care plan, dated 08/08/25, showed staff did not care plan related to the resident being on EBP or having a catheter. Review of the resident's current physician order sheet showed an order, revised on 08/26/25, with a start date of 09/05/25, to change foley catheter one time every month starting on the 28th for 28 days, change every 28 days. Observation on 08/26/25, at 3:55 P.M. showed no EBP sign on the resident's door. Observation on 08/27/2025, at 1:28 P.M. showed no EBP sign on the resident's door. Observation on 08/28/25, at 8:58 A.M., showed no EBP sign on door. Observation on 08/28/25, at 1:03 P.M., showed no EBP sign on the resident's door. Observation on 08/29/25, at 11:04 A.M., showed the following:-No EBP sign on the resident's door;-Certified Nurse Assistant (CNA) D and CNA E provided catheter care to the resident and donned only gloves and no other PPE;-CNA D and CNA E gathered trash, washed hands, and exited room. Observation on 09/02/25, at 9:33 A.M., showed no EBP sign on door. During an interview on 08/29/25, at 11:25 A.M., CNA D said the following:-EBP means staff should wear gown and gloves;-Not all residents with a foley catheter are on EBP;-The resident is not on EBP because there is no sign on the door. During an interview on 08/29/25, at 11:36 A.M., CNA E said the following:-Staff know if a resident is on EBP because there are signs on the door;-Not all residents with foley are on EBP. During an interview on 09/02/25, at 9:44 A.M., Licensed Practical Nurse (LPN) A said the following:-The resident is not on EBP;-The resident does have a catheter, but did not know residents with catheters should be on EBP;-Staff should include EBP in the care plan. During an interview on 08/29/25, at 2:50 P.M., CNA I said staff have to don both gown and gloves to provide catheter care to a resident due to EBP. During an interview on 09/02/25, at 10:49 A.M., LPN F said the following:-Residents are on EBP due to having catheters, continuous infections, and antibiotic-resistant infections;-The resident has a catheter and should be EBP;-He/she is unsure if staff should include EBP in the care plan. During an interview on 09/02/25, at 2:49 P.M. the Assistant Director of Nursing (ADON) said the resident should be on EBP, have an EBP sign on the door, and staff should include EBP in the care plan. During an interview on 09/02/25, at 4:09 P.M. the Director of Nursing (DON) said the resident should be on EBP, have an EBP sign on the door, and staff should include the EBP in the care plan. During an interview on 09/02/25, at 5:11 P.M., the Administrator said staff should be donning gloves and gowns when providing cares for a resident with a catheter, and an EBP sign should be on the door to alert staff when entering the room. 2. Review of Resident #66's face showed the following:-admission date of 10/03/24;-Diagnoses included benign prostatic hyperplasia (BPH – age associated prostate gland enlargement that can cause urination difficulty). Review of the resident's quarterly MDS, dated [DATE]. showed the following:-Cognitively intact;-Required one staff assistance with showers, toileting, mobility, and transfers;-Used a wheelchair for mobility;-Resident had an indwelling catheter. Review of the resident's care plan, dated 04/29/25, showed the following:-Resident had a urinary catheter;-The resident will show no signs or symptoms of a urinary infection;-Catheter care every shift and as needed;-Monitor, record, and/or report to the physician for signs and symptoms of a urinary tract infection (UTI).(Staff did not care plan related to EBP due to catheter). Review of the resident's current POS showed the following:-An order, dated 02/10/25, for a urinary catheter 18 French (F - size) and 10 milliliter (ml) balloon, change as needed for occlusion (blockage);-An order, dated 02/10/25, for urinary catheter care every shift. During an observation on 08/26/25, at 11:16 A.M., the resident placed his/her call light on due to a complaint of the urinary catheter not secured correctly in the stat lock (a skin adhesive device designed to secure a urinary catheter in place). CNA B entered the resident's room, sanitized his/her hands, and applied gloves. The CNA did not apply a gown. CNA B then unclamped the catheter tubing from the stat lock and adjusted it. CNA B then wiped the catheter tubing with cleansing wipes and placed the tubing back into stat lock and clamped it shut. CNA B then removed gloves and sanitized his/her hands. The resident had an EBP sign on the outside of his/her room door indicating what precautions should be used. 3. Review of Resident #101's face showed the following information:-admission date of on 08/19/25;-Diagnoses included endocarditis (an infection of the heart's inner lining, usually involving the heart valves), sepsis (a condition where the body responds improperly to an infection), and congestive heart failure (CHF-chronic condition where the heart doesn't pump blood as well as it should), Review of the resident's current POS showed the following:-An order, dated 08/19/25, to flush PICC line with10 ml normal saline every shift;-An order, dated 08/20/25, for ceftriaxone (an antibiotic) sodium solution 2 grams, administer 2 grams intravenously once a day;-An order, dated 08/20/25, to flush PICC line before and after IV antibiotic every day for 6 weeks. Review of the resident's care plan, dated 08/21/25, showed the following:-Resident required staff assistance with transfers and toileting;-Had an intravenous line (IV – a tube inserted in the vein to deliver medications or fluids) access right peripherally inserted venous catheter (PICC-a tube inserted into a large vein near the heart got long term IV access) line;-Resident on antibiotics due to endocarditis;-Resident will have not have any complications related to IV access; -Staff should check the IV site daily for redness, swelling, or drainage and report any findings to the nurse;-Staff should monitor, document, and/or report to the physician and signs or symptoms of infection at IV site.(Staff did not care plan related to EBP.) Observation on 08/28/25, at 9:50 A.M. showed LPN H sanitize his/her hands and entered the resident's room to provide IV antibiotics via a PICC line. LPN H placed supplies on the resident's bedside table and explained the procedure to the resident. LPN H applied gloves, but did not apply a gown and placed and prepared the IV medication to administer to the resident. LPN H cleansed the PICC line in the resident's right arm with an alcohol wipe and flushed the line with 10 ml of normal saline. The LPN then opened the IV line and started to administer the medication to the resident. LPN H then removed gloves and washed his/her hands and left the room. There was no sign indicating resident was on EBP prior to entering room. During an interview on 08/28/25, at 12:39 P.M., LPN K said EBP are for a resident with a tracheostomy, a wound, feeding tube, or IV. EBP is used for a resident with any indwelling tube. Staff should wear a gown and gloves to provide any direct care to a resident. 4. Review of Resident #64's face sheet showed the following:-admission date of 02/06/12;-Diagnoses included personal history of methicillin resistant staphylococcus aureus infection (past infection with this antibiotic resistant bacterium. Review of the facility's current list of residents on EBP included the resident. Review of the resident's MDS, dated [DATE], showed the following:-Cognitively intact;-Required substantial/maximum assistance from staff for toileting hygiene, dressing lower body, taking on/off footwear, and showers/bathing. Review of the resident's care plan, last revised 06/25/25, showed the following:-Resident is on EBP due to personal history of methicillin resistant staphylococcus aureus infection;-Resident will be free of active infections while on enhanced barrier precautions;-Staff should wear gown and gloves when performing high-contact resident care activities. Observation on 08/27/25, at 2:18 P.M., showed no EBP sign on the resident's door. Observation on 08/09/25, at 2:17 P.M., showed no EBP sign on the resident's door. Observation o 09/02/25, at 9:35 A.M., showed no EBP sign on the resident's door. Observation on 09/02/25, at 2:20 P.M., showed no EBP sign on the resident's door. During an interview on 08/29/25, at 3:10 P.M., CNA J said the resident is not on EBP. During an interview on 09/02/25, at 9:44 A.M., LPN A said the resident was on EBP due to white blood cell count, and staff should don gown and gloves to provide personal cares. During an interview on 08/29/25, at 2:50 P.M., CNA I said the following:-Residents on EBP should have a sign on their door, and there should be information in the resident record;-Staff should wash hands and don gown and gloves to provide personal cares for residents on EBP. During an interview on 08/29/25, at 3:10 P.M., CNA J said staff should don gown and gloves every time care is performed in the room of a resident on EBP. During an interview on 9/02/25, at 9:44 A.M., LPN A said the following:-Staff know if a resident is on EBP because a sign should be on the door;-Staff discuss new residents on EBP during monthly meetings;-Staff should include EBP in the care plan;-Staff should also know what residents are on EBP through communication. During an interview on 09/02/25, at 2:01 P.M., the MDS Coordinator said staff should include EBP in the care plan. During an interview on 09/02/25, at 2:49 P.M., the ADON said the following:-She completes audits on EBP and checks upon admission;-Staff know a resident is on EBP because of the sign on the door and banners in the electronic record;-Staff should include EBP in the care plan. 5. During an interview on 09/02/25, at 4:09 P.M., the DON said the following:-Residents on EBP should have a sign on their door;-Residents on EBP have a red stop sign in their electronic record;-Staff should include EBP in the care plan. During an interview on 09/02/25, at 5:11 P.M., the Administrator said the following:-Staff should be donning gloves and gowns for cares on residents on EBP;-Residents on EBP should have signs on their doors and other education.

Based on observation, interview, and record review, the facility failed document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to care plan side rails; and failed to complete ongoing assessments to ensure the side rails are appropriate for use for eight residents (Resident #1, Resident #2, Resident #12, Resident #19, Resident #47, Resident #86, Resident #77, and Resident #100). The facility census was 93.Review of the facility's policy titled Bed Rails, dated December 2024, showed the following:-Prior to the installation of bed rails, attempts to provide the residents with alternative measures to meet their need for positions, mobility, or transfer ability while in bed will be made;-When alternatives are deemed ineffective or not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails, including the risk of entrapment. In addition, informed consent is obtained from the resident or resident's representative;-Bed rails (which can also be referred to as safety rails) are defined as adjustable metal or rigid plastic bars that attach to the bed. The rails are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one eighths length;-Bed rails may not be designed as part of the bed by the manufacturer and may be installed on or used along the side of the bed;-Bed rails may include, but are not limited to bed rails, safety rails, U-bars, halo bars, grab bars, assist bars. 1. Review of Resident #1's face sheet (basic resident profile information) showed the following:-admission date of 08/01/25;-Diagnoses included vascular dementia (brain damage caused by multiple strokes), generalized anxiety disorder and type two diabetes mellitus (long term condition in which the body has trouble controlling blood sugar and using it for energy). Review of the resident's comprehensive Minimum Data Set (MDS-federally mandated assessment tool administered by staff), dated 08/11/25, showed the following:-Severe cognitive impairment;-Resident required substantial/maximum assistance from staff with activities of daily living (ADLs). Observation on 08/26/25, at 3:55 P.M., showed a metal quarter side rail on right side of the resident's bed in raised position and extremely loose. The side rail was not raised straight in the air. It was at an angle due to being loose. Observation on 08/27/25, at 1:28 P.M., showed the side rail remained in raised position and loose at an angle. Observation on 08/28/25, at 8:58 A.M., showed the side rail remained in raised position and loose at an angle. Observation on 08/28/25 , at 1:03 P.M., showed the side rail remained in raised position and loose at an angle. Observation on 09/02/25, at 9:33 A.M., showed the side rail remained in raised position and loose at an angle. Review of the resident's care plan, dated 08/08/25, showed staff did not care plan regarding the resident's use of a side rail. Review of the resident's record showed staff did not document completion of a side rail assessment or any measurements for the risk of entrapment. Review of the resident's record showed staff did not document review of the risks and benefits of side rails with the resident's representative and did not obtain a signed consent for side rail usage. During an interview on 09/02/25, at 9:44 A.M., Licensed Practical Nurse (LPN) A said the following:-The resident slept in his/her bed;-The resident required assistance with transferring in and out of bed, but did use the side rail for positioning while in bed;-He/she does not check side rails for safety daily, and did not notice the resident's side rail was loose. During an interview on 09/02/25, at 1:35 P.M., the Maintenance Director said the following:-He tightened the resident's side rail today and will be checking that daily as the resident pulls on it quite a bit;-He had never checked the resident's side rail before today. During an interview on 09/02/25, at 2:49 P.M., the Assistant Director of Nursing (ADON) said the following: -She was unsure if the resident had side rails on his/her bed upon admission;-The resident was cognitively able to side rails for repositioning. During an interview 09/02/25, at 4:09 P.M., the Director of Nursing (DON) said the following:-The resident had a rental bed for hospice with the rails on and had not had an assessment;-The resident kicks and shakes the bed and might be making the side rails loose. 2. Review of Resident #2's face sheet showed the following: -admission date of 01/31/25;-Diagnoses included dementia, and muscle weakness. Observations on 08/26/25, at 9:06 A.M., showed the resident in his/her room in in a wheelchair. The resident's bed had quarter side rails on each side of the bed in the up position. Observations on 08/27/25, at 2:14 P.M., showed the resident in his/her bed, with a fall mat on floor and side rails on both sides of the bed in the up position. Observations on 08/29/25, at 9:14 A.M., showed the resident in his/her bed, with a fall mat on floor and side rails on both sides of the bed in the up position. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident had significant memory loss and severe cognitive decline;-Resident required substantial assistance for rolling left or right in bed. Review of the resident's care plan, dated 04/02/25, showed staff did not care plan related to the resident side rail use. Review of the resident's August 2025 POS showed staff did not have an order for side rail use. Review of the resident's medical record showed the following: -Staff did not document a side rail assessment/evaluation;-Staff did not document side rail safety check form and completion of a regular inspection of bed frames and side rails;-Staff did not document resident's side rail/grab bar informed consent and release. 3. Review of Resident #12's face sheet showed the following information:-admission date of 04/14/23;-Diagnoses included dementia, insomnia (difficulty sleeping), and post traumatic stress disorder (anxiety disorder due to prior traumatic exposure). Review of the resident's MDS, dated [DATE], showed the following information:-Cognitively impaired;-Memory impairment. During an interview on 08/27/25, at 1:32 P.M., in the residents' room, the resident said he/she didn't know why the rails were on his/her bed. The resident said she did not use them. Observation on 08/28/25, at 9:09 A.M., showed the resident lying in bed with side rails up on both sides of the bed. Review of resident's side rail measurements showed the last measurements completed by staff on 07/19/23. Review of the resident's care plan, dated 08/18/25, showed staff did not care plan related to the side rail use. Review of residents' record showed staff did not document completion of a side rail safety assessment. 4. Review of Resident #19 face sheet showed the following information:-admission date of 11/13/23;-Diagnoses included schizophrenia(disorder that affects a person's ability to think, feel, and behave clearly), history of falls, and depression. Review of the resident's MDS, dated [DATE], showed the following information:-Cognitively intact;-Mild memory impairment;-Set up assist for functional abilities. Observations and interview on 08/25/25, at 10:21 A.M., showed the resident lying in bed with side rails up on right side of the bed. The resident said he/she used the side rails to pull herself/himself up in bed. Observation on 08/28/25, at 9:06 A.M., showed the resident lying in bed with side rails on up on right side of the bed. Review of residents' side rail measurements showed staff last completed measurements on 12/11/23. Review of the resident's care plan, dated 03/03/25, showed staff did not care plan related to the resident's side rails. Review of resident's record showed staff did not document completion of the side rail safety assessment. 5. Review of Resident #47's face sheet showed the following: -admission date of 08/26/24;-Diagnoses included muscle weakness and depression. Observations on 08/25/25, at 1:42 P.M., showed the resident in his/her wheelchair in his/her room. The resident's bed had quarter side rails on each side of the bed in the up position. Observations on 08/29/25. at 9:20 A.M., showed the resident in bed with lights off and blanket pulled over him/herself. Side rails on both sides of bed were in the up position. Observations made on 09/02/25, at 9:26 A.M., showed the resident in bed with lights off and blanket pulled over him/herself. Side rails on both sides of bed were in the up position. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident had some memory loss and significant cognitive decline;-Required minimal assistance for rolling left or right in bed. Review of the resident's care plan, dated 6/20/25, showed staff did not care plan related to the resident's use of side rails. Review of the resident's August 2025 POS showed staff did not have physician's order for side rail use. Review of the resident's medical record showed staff did not document side rail assessment/evaluation; did not document side rail safety check form and completion of a regular inspection of bed frames and side rails; and did not document resident's side rail/grab bar informed consent and release. 6. Review of Resident #86's face sheet showed the following information:-admission date of 06/12/25;-Diagnoses included chronic pain and chronic osteomyelitis (an autoimmune disease that causes bone inflammation). Review of the resident's admission MDS, dated [DATE], showed the following information:-Resident was cognitively intact;-Required substantial staff assistance for bed mobility and transfers. Observations on 08/25/25, at 10:20 A.M., on 08/26/25 at 2:51 P.M., and on 08/27/25 at 3:15 P.M., showed the resident sitting in his/her wheelchair in his/her room with both side rails up. Observations on 08/27/25, at 9:41 A.M., showed resident resting in bed with both side rails up next to head of the bed. Review of the resident's care plan, last revised 08/06/25, showed staff did not care plan related to the resident's side rail use. Review of the resident's current POS showed staff did not document an order for the use of side rails. Review showed the facility did not provide any evaluation, consent, or measurements for resident's side rails. Review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, or ongoing assessments to ensure the side rails were appropriate for use. 7. Review of Resident #77's face sheet showed the following information:-admission date of 10/08/24;-Diagnoses included congestive heart failure (CHF-chronic condition where the heart doesn't pump blood as well as it should). Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Resident was cognitively intact;-Used wheelchair for mobility;-Supervision to partial assistance needed with showers, toileting, and mobility. Observation and interview on 08/25/25, at 11:00 A.M., showed the resident sat up in a wheelchair in his/her room with a grab bar on the bed in the up position. The resident reported the half side rail on the right side of the bed was used for mobility, Observation on 08/26/25, at 11:14 A.M., showed the resident resting in bed with the right half side rail up. Review of the resident's care plan, dated 04/28/25, showed staff did not care plan related to the resident's side rail use. Review of the resident's current POS showed staff did not document an order for side rail use. Review showed the facility did not provide any evaluation, consent, or measurements for resident's side rails. Review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, or assessments to ensure the side rails were appropriate for use. 8. Review of Resident #100's face showed the following information:-admission date of 08/14/25;-Diagnoses included fracture of the humerus (upper arm bone) on right arm. Observation and interview on 08/26/25, at 3:03 P.M., showed the resident was resting in bed with both half side rails in the up position at the head of the bed. The resident reported he/she uses the left side rail to pull up in bed, but he/she was unable to use the right side due to wearing a cast. Observations on 08/25/25, at 10:25 A.M., and on 08/27/25, at 3:07 P.M., showed the resident was resting in bed with both half side rails up next to head of the bed. Review of the resident's care plan, dated 08/25/25, showed staff did not care plan related to the resident's side rail use. Review of the resident's current POS showed staff did not document an order for side rail use. Review showed the facility did not provide any evaluation, consent, or measurements for resident's side rails. Review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, or ongoing assessments to ensure the side rails were appropriate for use. 9. During an interview on 08/29/25, at 2:50 P.M., Certified Nurse Assistant (CNA) I said the following:-He/she notifies the nurse if he/she believes a resident could benefit from a side rail, and the nurse will discuss with it the Assistant Director of Nursing (ADON) and the Director of Nursing (DON);-He/she raises and lowers side rails to ensure they are functioning every night when he/she lays a resident down for the night. During an interview on 08/29/25, at 3:10 P.M., CNA J said the following:-He/she will let the DON and ADON know if a resident requests or may need side rails;-He/she checks the side rails when putting them in the raised position at night, so the resident doesn't fall out of bed;-He/she would report loose side rails. During an interview on 09/02/25, at 9:44 A.M., LPN A said the following:-The facility has a process to ensure side rails are safe;-The ADON and DON get maintenance involved for measuring for safety and should be care planned;-Residents use side rails for bed repositioning and transferring in and out of bed;-Side rails should never be used to keep a resident from rolling out of bed and would be considered a restraint. During an interview on 09/02/25, at 10:49 A.M. LPN F said the ADON and DON complete side rail evaluations and maintenance does the measurements. Staff will usually catch an issue if loose just by moving side rails up and down throughout the day. During an interview on 08/28/25, at 9:10 A.M., LPN H said the following:-Residents should have a diagnosis that would call for the use of side rails or grab bars;-Side rails are for mobility or as a safety feature for the resident;-The DON or the ADON are responsible for measuring the side rails;-Side rails are not on the bed prior to the resident arrival to the facility;-The resident will usually request side rails, and he/she will put a request into the DON or ADON;-The DON and the ADON will conduct a side rail assessment;-He/she did not know if the resident needed to sign anything prior to obtaining side rails;-He/she did not know who installed the side rails;-Side rails should be included in the care plan. During an interview on 08/28/25, at 12:39 P.M., LPN K said the facility only used half side rails. Side rails required an assessment and a consent. He/she had never seen a consent for side rails at the facility. Side rails should be used to assist a resident with mobility. Side rails should be assessed regularly and included in the care plan. During an interview on 08/28/25, at 12:00 P.M., Registered Nurse (RN) G said the following:-The residents decide if they want side rails;-Side rails are used for positioning in bed;-Side rails need to be assessed because they can be an entrapment risk;-He/she did not know who was responsible for assessing side rails. During an interview on 09/02/25, at 1:35 P.M., the Maintenance Director said the following:-He had never completed a side rail assessment, but was his responsibility as of today;-He will be completing measurements and regular periodic safety checks along with the housekeeping supervisor. During an 09/02/25, at 2:01 P.M., the MDS Coordinator said side rails should be included in the care plan. During an 09/02/25, at 2:49 P.M., the ADON said the following: -Side rail consents should be completed by nurse on admission, and the ADON, DON, and maintenance complete the rest of the process including measurements;-The process does not include any type of interventions prior to unless they are on the unit first and then therapy says they need them;-Staff should complete periodic checks for safety, aides should always be checking. There are no quarterly or regular documented safety checks or assessments. During an interview on 09/02/25, at 4:09 P.M. the DON said the following:-Residents request side rails upon admission and sign a consent;-The ADON and DON did complete measurements, but the new ownership wants maintenance to complete the measurements;-Measurements will be completed annually or if there is a mattress change or any other changes;-Safety checks were previously completed quarterly at care plan meetings. During an interview on 09/02/25, at 5:11 P.M., the Administrator said the following;-Side rails should include an order, assessment, measurement, and consent with risks and benefits;-Interventions should be attempted first when possible;-Side rails should be care planed;-Staff should complete monthly safety checks;-Side rails should never be used as a restraint.

Based on interview, observation, and record review, the facility failed promote each resident's right to self-determination when the facility failed to provide services to maintain good grooming and personal hygiene in accordance with resident preferences for five residents (Resident #86, #77, #84, #82, and #64). The facility census was 93.Review showed the facility did not provide a policy related to showers. 1. Review of Resident #86's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 06/12/25;-Diagnoses included diabetes (a chronic condition in which the body cannot regulate blood sugar levels properly), chronic pain, high blood pressure, and chronic osteomyelitis (an autoimmune disease that causes bone inflammation). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/18/25, showed the following information:-Resident was cognitively intact;-Used wheelchair for mobility;-Dependent for showers, dressing, and toileting;-Required substantial staff assistance for bed mobility and transfers. Review of the resident's care plan, dated 08/06/25, showed staff did not care plan related to the resident's cares or need for assistance. Review of the resident's June 2025 shower sheets showed the resident received a shower on 06/25/25. Review of the resident's July 2025 shower sheets showed the resident received a shower on 07/10/25, 07/23/25, and 07/31/25. Review showed the facility did not provide resident shower sheets for the month of August 2025. Observation on 08/25/25, at 10:20 A.M., showed the resident sat in a wheelchair watching television. The resident's hair appeared to be greasy. During an interview on 08/27/25, at 3:15 P.M, the resident said he/she felt dirty with greasy hair and when he/she did not receive a shower. 2. Review of Resident #77's face sheet showed the following information:-admission date of 10/08/24;-Diagnoses included diabetes, high blood pressure, and congestive heart failure (CHF-chronic condition where the heart doesn't pump blood as well as it should). Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Resident was cognitively intact;-Used wheelchair for mobility;-Supervision to partial assistance needed with showers, toileting, and mobility. Review of the resident's care plan, dated 04/28/25, showed the following:-Resident had a self-care deficit and required one staff assistance with activities of daily living (ADL-basic tasks that individuals perform to maintain their daily life);-At risk for falls. Review of the resident's June 2025 shower sheets for June 2025 showed the resident received a shower on 06/19/25 and 06/26/25.Review of the resident's July 2025 shower sheets showed the resident received a shower on 07/03/25, 07/11/25, 07/25/25, 07/31/25. Review of the resident's August 2025 shower sheets showed the resident received a shower on 08/15/25. During an interview on 08/26025, at 1:10 P.M., the resident the facility had been pulling the shower aide to the floor, and he/she usually gets one a week. He/she would like to have more showers. 3. Review of Resident #84's face sheet showed the following information:-admission date of 01/17/24;-Diagnoses included chronic obstructive pulmonary disease (COPD - a chronic lung disease typically causing breathing difficulty), chronic pain, communication deficit, muscle weakness, shortness of breath. Review of resident admission MDS, dated [DATE], showed the following information:-Resident was cognitively intact;-Used a wheelchair for mobility;-Partial / moderate assist for upper and lower body dressing;-Set up assistance for showers, toileting. Review of the resident's care plan, dated 04/15/25, showed the following:-Resident has an ADL performance deficit due to activity intolerance;-Staff will assist resident with shampoo and shower at least one time a week;-Resident needs one staff member to assist with transferring, toileting, bathing. Review of the resident's June 2025 shower sheets showed the resident received a shower on 06/26/25 and 06/30/25. Review of the resident's July 2025 shower sheets showed the resident received a shower on 07/21/25 and 07/28/25. Review of the resident's August 2025 shower sheets showed the resident received a shower on 08/12/25 and 08/26/25. During an interview on 08/25/25, at 1:30 P.M., the resident stated the following:-The facility was frequently short on staff;-The shower aides got pulled to the floor to help;-He/she did not believe residents were getting their showers like they are supposed to because of low staffing;-There was only one shower aide for the whole building;-He/she would like at least two showers a week and feels lucky to get one shower a week;-He/she feels frustrated because of the lack of showers. 4. Review of Resident #82's face sheet (basic resident profile information) showed the following:-admission date of 11/16/19;-Diagnoses included congestive heart failure (CHF-chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (COPD-group of diseases that block airflow and make it difficult to breathe), obstructive and reflux uropathy (urine flow is blocked in the urinary tract), chronic kidney disease, obsessive compulsive disorder (excessive thoughts that lead to repetitive behavior), peripheral vascular disease (condition in which narrowed blood vessels reduce blood flow to the limbs), repeated falls, and dementia. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Required partial to moderate assistance for bathing. Review of the resident's care plan, last revised on 05/08/25, showed the following:-Resident had a self-care deficit with ADLs, such as bathing, hygiene, dressing, and toileting related to CHF, COPD, and weakness;-Resident will be appropriately dressed and groomed through next review;-Provide resident with clean and matching clothing daily and as needed;-Resident will be shampooed and showered at least one time weekly with fingernails and toenails cleaned and checked;-Resident required assistance of one staff for dressing, transferring, toileting, and bathing. Review of the resident's progress notes for July 2025 and August of 2025 showed staff did not document pertaining to showers/bathing. Review of the resident's July 2025 shower sheets showed the following information:-On 07/11/25, staff provided a shower and noted redness to skin;-On 07/21/25, staff documented the resident refused a shower, and the resident signed the sheet. Staff did not document further attempts;-On 07/25/25, staff provided a shower and noted redness to skin;-On 07/28/25, staff documented the resident refused a shower. The resident did not sign the sheet. Staff did not document of further attempts;-On 07/29/25, staff provided a shower and noted redness to the skin. Review of the resident's August 2025 shower sheets showed on 08/26/25, staff provided a shower and documented a patch on the skin. During interviews on 08/25/25, at 2:16 P.M., on 08/26/25, at 1:39 P.M., and on 08/27/25, at 2:34 P.M., the resident said the following:-It has been at least two weeks since he/she had a shower;-He/she would like to have two showers per week;-He/she felt dirty, and his hair felt greasy before he/she got a shower. During an interview on 08/29/25, at 3:10 P.M., Certified Nurse Aide (CAN) J said the resident had been complaining about not receiving showers. During an interview on 09/02/25, at 9:44 A.M., Licensed Practical Nurse (LPN) A said the resident preferred two showers per week, but sometimes only received one. During an interview on 09/02/25, at 2:49 P.M., Assistant Director of Nursing (ADON) said the resident will only accept showers from certain staff. 5. Review of Resident #64's face sheet showed the following:-admission date of 02/06/12;-Diagnoses included stroke (CVA), COPD, chronic ischemic heart disease (condition where the arteries that supply blood to the heart become narrowed or blocked over time), anxiety disorder, major depressive disorder, hereditary and idiopathic neuropathy (group of inherited disorders that affect the peripheral nervous system), hemiplegia affecting left nondominant side (condition that causes paralysis or weakness on one side of the body), repeated falls, seizure disorder, personal history of methicillin resistant staphylococcus aureus infection (past infection with this antibiotic resistant bacterium), and contracture of left wrist. Review of the resident's MDS, dated [DATE], showed the following:-Cognitively intact;-Required maximum assistance from staff for showers/bathing. Review of the resident's care plan, last revised 06/25/25, showed the following:-Resident had an ADL self-care performance deficit related to left side hemiplegia, prior CVA requiring removal of blood to relieve pressure;-Resident will maintain current level of function through the next review date;-Resident required maximum assistance from staff for dressing;-Resident required maximum assistance from staff for transfers. Review of the resident's July 2025 and August of 2025 progress notes showed staff did not document pertaining to showers/bathing. Review of the resident's July 2025 shower sheets showed the following:-On 07/21/25, staff provided a shower and noted abnormal skin color on the left foot;-On 07/28/25, staff documented the resident wanted a shower on 07/29/25, after breakfast;-Staff did not document any other showers for the month of July of 2025. Review of the resident's August 2025 shower sheets showed the following:-On 08/26/25, staff documented the resident refused a shower, the resident did not sign the sheet;-On 08/27/25, staff provided a shower. During an interview on 08/25/25, at 2:58 P.M., the resident said the following:-He/she would like more showers;-He/she has not had a shower for at least a couple of weeks;-He/she received showers sometimes once a month and sometimes once every couple of weeks;-He/she did have his/her hair washed in the beauty shop last week. During interviews on 08/27/25, at 2:18 P.M. and 3:07 P.M., the resident said the following:-He/she received a shower before noon today and felt better;-He/she felt dirty and neglected before the shower because it had been at least two weeks since the last one;-He/she does not believe he/she has had two showers per week the entire stay in the facility;-He/she has expressed the preference for two showers per week to the ADON and Director of Nursing (DON). During an interview on 08/29/2025, at 3:10 P.M., CNA J said the resident has been complaining about not receiving showers. During an interview on 09/02/25, at 9:44 A.M., LPN A said the resident preferred two showers per week, and he/she did not realize the shower last week was the first for the month. During an interview on 09/02/25, at 2:49 P.M., the ADON said the resident will only accept showers from certain staff and takes 45-minute showers. During an interview on 09/02/25, at 4:09 P.M. the Director of Nursing (DON) said the resident can be difficult about when and who he/she allows to give a shower. 6. During an interview on 08/27/25, at 9:28 A.M., CNA E said he/she was the shower aide. Showers are scheduled once a week, but he/she gets pulled from showers to work the floor a lot. He/she is behind with showers at times. Shower sheets are completed are if a resident receives a shower. The resident will sign a shower sheet if he/she refuses a shower. The nurse will sign the shower sheet for residents that are unable to do so. During an interview on 08/29/25, at 2:50 P.M., CNA I said the following:-He/she does not usually give showers unless they carry over from the day shift or a resident prefers evenings;-Facility policy is residents should receive one shower per week;-If a resident prefers two showers per week, staff will try to squeeze them in for a second one. During an interview on 08/29/25, at 3:10 P.M . CNA J said the following:-The facility has an assigned shower aide during the week;-He/she gives showers when they are behind because of pulling the shower aide to the floor;-Residents should get at least one shower per week;-Staff document resident refusals on the shower sheet, have resident sign, and turn into the nurse. During an interview on 08/28/25, at 12:39 P.M., LPN K said showers should be given three times a week. Residents are not getting showers three times a week due to staffing. Residents have complained to him/her about not getting showers. During an interview on 09/02/25, at 9:44 A.M., LPN A said the following;-Residents should receive two showers per week;-Staff should document refusals on the shower sheet and turn into the ADON;-Residents are not receiving two showers per week due to short staffing and the shower aide being pulled to the floor;-He/she doubts residents have been receiving even one shower during some weeks. During an interview on 09/02/25, at 10:49 A.M. LPN F said the following:-Residents should receive two showers per week;-The facility is short staffed, and the shower aide gets pulled to the floor;-Residents have complained about not receiving showers. During an interview on 09/02/2025, at 2:01 P.M., the MDS Coordinator said best practice would be for staff to include resident shower preferences for frequency, day, time in the care plan. During an interview on 09/02/25, at 2:49 P.M. the ADON said the following:-Facility policy is for residents to receive two showers per week, and this is not happening;-The facility is having a difficult time finding staff, and the shower aide gets pulled to the floor;-Residents are receiving an average of one shower per week;-Residents have complained about not receiving showers;-Staff document refusals on the shower sheet and have the resident sign the sheet. During an interview on 09/02/25, at 4:09 P.M. the DON said the following:-Residents should have a minimum of one shower per week;-The facility is having staffing issues, and the shower aides are pulled to the floor;-There have probably been weeks where residents did not receive one shower per week;-They have received approval to bring in agency staff, but they call in often. During an interview on 09/02/25, at 5:11 P.M. the Administrator said the following:-Residents should receive at last two showers per week;-It is the DON's responsibility to ensure showers are done;-Shower aides are being pulled to the floor;-He was not aware residents have not been receiving two showers per week. Complaint 1711133, 2585798

Based on observation, interview, and record review, the facility failed to ensure staff provided respiratory care per standards of practice when staff failed to have a process in place to ensure routine cleaning of a continuous positive airway pressure (CPAP - a mask that uses air pressure to keep the airway open during sleep) device, failed to obtain orders for the use of the CPAP, and failed to include the use of a CPAP on the care plan for one resident (Resident #100). The facility census was 93.1. Review of Resident #100's face showed the following information:-admission date of 08/14/25;-Diagnoses included fracture of the humerus (upper arm bone) on right arm and anemia (deficiency of red blood cells).Review of the resident's discharge instructions from the hospital, dated 08/14/25, showed the resident used a CPAP at bedtime.Observation and interview on 08/26/25, at 2:51 P.M., showed a CPAP sitting on the resident's bedside table. The resident reported he/she was unable to use the CPAP without assistance due to a broken arm, but staff were putting it on him/her.During an interview on 08/27/25, at 3:07 P.M., the resident reported the staff put water in the CPAP and put it on him/her most nights. He/she wore the CPAP every night and had someone help care for it when at home. Staff told her they were aware on how to use the CPAP when he/she was admitted to the facility.Review of the resident's care plan, dated 08/25/25, showed staff did not care plan regarding resident using a CPAP.Review of the resident's current Physician Order Sheet (POS) showed no order for cleaning or use of a CPAP.During an interview on 08/27/25, at 9:28 A.M., Certified Nursing Assistant (CNA) E said CNA's were responsible for applying, removing, and cleaning CPAPs. He/she had never observed a CPAP for the resident. During an interview on 08/28/25, at 9:10 A.M., Licensed Practical Nurse (LPN) H said the following:-Residents that utilize a CPAP should have physician orders;-The CPAP's are cleaned weekly on night shift;-The resident had a CPAP;-The resident did not have any orders for the use of a CPAP; -The use of a CPAP should be included in the care plan. During an interview on 08/28/25, at 12:39 P.M., LPN K said a resident with a CPAP needed to have orders. The resident had a CPAP that he/she brought from home. LPN K assumed he/she had orders for the CPAP. Staff would not know that a resident needed to use a CPAP without orders. CPAP's should have an order to clean them to ensure that it is done routinely. CPAP's should be included on the care plan.

Based on interview and record review, the facility failed to carry out and document a physician order timely for a discontinued medication and failed to implement monitoring of fluid intake for one resident (Resident #77). The facility census was 93. Review showed the facility did not provide a policy regarding physician orders.1. Review of Resident #77's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 10/08/24;-Diagnoses included diabetes (metabolic disorder characterized by high blood sugar levels), high blood pressure, and congestive heart failure (CHF-chronic condition where the heart doesn't pump blood as well as it should).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 04/18/25, showed the resident was cognitively intact.Review of the resident's care plan, dated 04/28/25, showed the following:-Resident had a self-care deficit and required one staff assistance with activities of daily living (ADL-basic tasks that individuals perform to maintain their daily life);-The resident was on diuretic therapy related to edema (swelling).Review of the resident's Physician P progress note, dated 07/10/25, showed an implementation of 1.5-liter fluid restriction. Resident should limit fluids to 1.5 liters (about 6 cups) per day, weigh every day, and report any sudden weight change (more than two pounds daily).Review of the resident's care plan, dated 04/28/25, showed staff did not update the care plan with the new orders for routine weights and fluid intake limit. Review of the resident's physicians' orders showed staff did not update the care plan with the new orders for routine weights and fluid intake limit.Review of the resident's Physician P progress note, dated 07/17/25, showed the following:-Resident should maintain 1.5-liter daily fluid restriction;-Nursing staff to monitor for signs of fluid overload;-Continue daily weight monitoring.Review of the resident's care plan, dated 04/28/25, showed staff did not update the care plan with the new orders for routine weights and fluid intake limit. Review of the resident's physician progress note, dated 08/15/25, showed a fluid restriction continued of 1.5-liter limit, though patient finds this challenging to maintain.Review of the resident's care plan, dated 04/28/25, showed staff did not update the care plan with the new orders for routine weights and fluid intake limit. Review of the resident's physicians' orders showed staff did not update the care plan with the new orders for routine weights and fluid intake limit.Review of the resident's physician progress note, dated 08/24/25, showed the following:-Interim Events: Mid-July: Lasix (diuretic) reduced from 40 milligrams (mg) daily to 30 mg daily, then increased back to 40 mg with 1.5L fluid restriction;- Discontinued Tradjenta (used to treat blood sugar levels) 5 mg daily due to inappropriate with heart failure;- Plan to maintain fluid restriction of 1.5L daily with discontinued Tradjenta 5 mg, ensure adequate and hydration within fluid restriction parameters;-Medications reviewed and reconciled with Tradjenta discontinued due to contraindication with heart failure.Review of resident's current Physician Order Sheet (POS), dated 08/28/25, showed an order, dated 01/31/25, for Tradjenta 5 mg tablet, give one tablet once daily and no order for 1.5-liter fluid restriction or fluid intake monitoring.Review of the resident's care plan, dated 04/28/25, showed staff did not update the care plan with the new orders. Review of the resident's physicians' orders showed staff did not update the care plan with the new orders for routine weights and fluid intake limit.During an interview on 08/28/25, at 9:10 A.M, Licensed Practical Nurse (LPN) H said the physician's orders are received via fax or verbally. The nurse enters all new orders into the electronic charting system. He/she does not check progress notes for new orders. He/she was unaware of any orders placed in the progress notes. A resident should have an order for fluid restriction, and it should be included in the care plan. During an interview on 08/28/25, at 12:39 P.M., Licensed Practical Nurse (LPN) K said physician orders could be written or verbal. The resident's physician was at the facility on Sunday and gave written orders for some residents. He/she can also call the physician for orders if needed. He/she had never had an issue with obtaining orders. Some physicians place orders in the progress notes. He/she reviews the progress notes for the last 30 days to ensure no orders were missed. Every now and then physician orders are missed. The resident had a note in the communication book today indicating he/she had a new order for 1.5-liter fluid restriction. Care plans guide staff to provide the best care to the residents. During an interview on 08/28/25, at 1:12 P.M., the Dietary Manager (DM) said the nurse notifies dietary of new orders by submitting a dietary slip. Residents on fluid restriction should have an order indicating how much fluids they are allowed. The amount of fluid allowed per the order is included on the resident's meal ticket. He/she advised the cooks and dietary assistants of any resident on fluid restriction. He/she received a new order for fluid restriction for the resident yesterday. The resident had never been on fluid restriction before.During an interview on 08/28/25, at 11:20 A.M., the Director of Nursing (DON) said the resident's two physicians are new to the facility and do not write orders like the other physicians do. The new physicians are writing orders in the progress notes in the electronic charting system and do not notify the nurse. The resident's order for Trajenta was discontinued on 08/24/25 in the physician note, but was not communicated to the nurses. During an interview on 08/28/25, at 11:53 A.M., the resident's Physician O said the nurse should carry out the orders listed in the progress note.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or the Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) at the initiation, reduction, or termination of Medicare Part A benefits for two sampled residents (Resident #16 and Resident #107) who remained in the facility upon discharge from Medicare Part A services. The facility census was 93.Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following information:-The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons;-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of SNFABN (form CMS-10055);-The SNFABN provides an estimated cost of items or services in case the beneficiary has to pay for them his/herself or through other insurance they may have;-If the SNF provides the beneficiary with the SNFABN at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.Review showed the facility did not provide a policy related to giving the residents or resident representative the NOMNC form CMS-10123 or the SNFABN form CMS-10055.1. Review of Resident #16's SNF Beneficiary Protection Notification Review showed the following information:-On 05/01/25, Medicare Part A skilled services started;-Staff noted 06/20/25 as the last covered day of Medicare Part A service.(Facility staff did not document providing the resident, or his/her legal representative, the required SNFABN form CMS-10055 or the NOMNC form CMS-10123.)2. Review of Resident #107's SNF Beneficiary Protection Notification Review showed the following information:-On 04/07/25, Medicare Part A skilled services started;-Staff noted 05/14/25 as the last covered day of Medicare Part A service. (Facility staff did not document providing the resident or his/her legal representative the required SNFABN form CMS-10055 or the NOMNC form CMS-10123)3. During an interview on 09/02/25, at 3:15 P.M., the Business Office Manager confirmed the facility failed to provide Resident #16 and Resident #107 the required SNFABN form CMS-10055 or the NOMNC form CMS-10123. She said she did not know why the forms had not been given to the residents.During an interview on 09/02/25, at 3:30 P.M., the Administrator said he did not know the facility failed to provide Resident #16 and Resident #107 the required SNFABN form CMS-10055 or the NOMNC form CMS-10123. He said he did not know why the forms had not been given to the residents, and was not sure which staff were responsible for the two forms.

Based on observation, interview, and record review, the facility failed provide care per standards of practice to all residents when staff failed to to assess, identify, and provide appropriate treatment for a skin condition and failed to notify the physician of the change in condition for one resident (Resident #1) who developed a skin condition on the resident's face and head that required prescription shampoo and cream to treat. The facility census was 71 residents. Review of the facility's policy titled Wound Prevention, revised 8/2023, showed the following: -Conduct a comprehensive assessment upon move in to identify any existing wounds, skin conditions, or risk factors for wound development; -Perform routine skin assessments on all residents during regular monthly assessments; -Document and review the assessed information to establish appropriate wound prevention measures for each resident; -Promote good hygiene practices, including regular showering, and regular changing of soiled garments or incontinence products; -Ensure the use of mild, pH-balanced, fragrance-free soaps, moisturizers, and protective creams suitable for the individual resident's skin condition; -Document all wound prevention measures, assessments, and interventions in resident's service plan and medical records; -Promptly report an new wounds, changes in skin condition, or concerns related to wound preventions to the appropriate healthcare personnel. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and diabetes mellitus (commonly known as diabetes, is a chronic condition characterized by high blood sugar levels). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/01/24, and showed the following information: -Moderate cognitive impairment; -The resident had no ulcers, wounds, or skin problems; -The resident received no applications of ointment/medications. Review of the resident's monthly summary, dated 11/07/24, showed the condition of the resident's skin was fair, warm, and dry. Review of the resident's care plan, updated on 11/12/24, showed the following information: -The resident was at risk for skin breakdown related to history of burns, diabetes melilites, and oxygen use; -The resident's skin would remain intact; -The staff would observe the resident for presence of risk factors; -Staff would conduct a systematic skin inspection weekly and with showers. Review of the resident's weekly skin assessment, dated 12/04/24, completed by Registered Nurse (RN) C showed the resident's skin intact with no skin issues and no interventions or treatments in place. Review of the resident's weekly skin assessment, dated 12/11/24, completed by Licensed Practical Nurse (LPN) G showed the resident's skin intact with no skin issues and no interventions or treatments in place. Observation on 12/16/24, at 10:05 A.M., showed the following: -The resident had scaly patches of skin, yellowish in color, on his/her forehead, in the temple area on both sides of his/her face, and on the resident's head; -A partially used tube, labeled ketoconazole (antifungal) cream 2%, was observed on the resident's bed side table; -The resident had a prescribed bottle of medicated shampoo, ketoconazole shampoo 2%, in his/her cabinet; -The directions on the prescription read, shampoo scalp and beard one time daily for two weeks, let soak five minutes and rinse; -The fill date on the bottle showed 12/01/24; -The tamper/safety seal was secured to the bottle showing that the shampoo had not been opened. During an interview on 12/16/24, at 10:05 A.M., the resident said the following: -The resident washed his/her face in his/her bathroom; -The resident applied the ketoconazole cream to his/her face one to two times a day; -The resident said he/she had a fungus on his/her skin that caused his/her skin to build up and get crusty; -The resident said his/her dermatologist prescribed the cream and shampoo. Review of the resident's medical record showed staff did not document notifying the resident's physician the skin condition on the resident's face. During an interview on 12/16/24, at 1:33 P.M., the resident's physician said he was not aware of the resident having a fungus or skin condition affecting the resident's face or head. During an interview on 12/16/24, at 1:21 P.M., Certified Medical Technician (CMT) B said the following: -The nurse was responsible for completing weekly skin assessments on the resident; -The nurse is responsible for providing treatments, including creams, to the residents; -The resident appeared to have psoriasis (a chronic skin condition that causes inflamed, raised plaques of skin that are often covered in silvery scales) on his/her face. During an interview on 12/16/24, at 1:50 P.M., RN C said the following: -The resident had dry skin around his/her face and was referred to the physician; -The resident was advised to wash his/her face and apply lotion; -RN C had offered several times to assist the resident with washing his/her face; -The resident did have a rash; -RN C completes skin assessments; -RN C had notified the physician of the resident's skin condition before and the resident was on the physician's list to be seen; -RN C did not remember when he/she had notified the physician about the resident's skin condition. During an interview on 12/16/24, at 3:35 P.M., Certified Nurse Aide (CNA) E said the following: -He/she had not noticed any changes in the resident's skin condition; -When CNA E notices anything new regarding a resident's skin condition he/she reports it to the RN; -RN's are responsible for completing skin assessments with the residents. During an interview on 12/16/24 at 3:37 P.M., CNA F said the resident regularly had dry skin. During an interview on 12/16/24, at 3:45 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should report a change in the resident's skin condition to the charge nurse, who would then report it to the physician; -The ADON saw the resident this morning, but did not notice the dry skin on the resident's face; -The ADON was not aware that the resident had any orders for shampoo or cream to treat the dry skin or fungus. During an interview on 12/16/24 at 3:54 P.M., the Administrator said the following: -Residents should be receiving thorough skin assessments by the nurse; -Any changes in the residents' skin should be documented on the skin assessment; -Any change in a resident's skin should also be reported to the physician. MO00246507

Based on observation, interview, and record review, the facility staff failed ensure each resident's right to self-determination was supported when facility staff failed to offer and provide showers as preferred for one resident (Resident #1). The facility census was 71. Review of the facility's policy titled, Activities of Daily Living (ADLs), undated, showed the following: -This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating and communication. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and diabetes mellitus (commonly known as diabetes, is a chronic condition characterized by high blood sugar levels). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 11/01/24, and showed the following information: -Moderate cognitive impairment; -Required setup or clean-up assistance when shower/bathing. Review of the resident's monthly summary, dated 11/07/24, showed the following: -The resident required assistance with grooming and hygiene; -The resident required set-up assess with showering/bathing. Review of the resident's care plan, updated on 11/12/24, showed the following: -The resident had self-care deficits with ADLs such as bathing, hygiene, dressing, and toileting related to weakness and shortness of breath; -The resident will shampoo and shower two times a week with fingernails and toenails cleaned and checked; -The resident required one staff assistance with help getting dressed, toileting, and bathing. Review of the resident's shower sheets, dated 10/01/24 through 12/16/24, showed the following: -One shower sheet, dated 11/22/24, showed the resident showered by him/herself after supper; -There were no other shower sheets for the resident during that timeframe. Observation on 12/16/24, at 10:05 A.M., showed the following: -The resident had scaly patches of skin, yellowish in color, on his/her forehead, in the temple area on both sides of his/her face, and on the resident's head; -A partially used tube, labeled ketoconazole (an antifungal medication) cream 2%, was observed on the resident's bed side table; -The resident had a prescribed bottle of medicated shampoo, Ketoconazole shampoo 2%, in his/her cabinet; -The directions on the prescription read, shampoo scalp and beard one time daily for two weeks, let soak five minutes and rinse; -The tamper/safety seal was secured to the bottle showing that the shampoo had not been opened. During an interview on 12/16/24, at 10:05 A.M., the resident said the following: -The resident washes his/her face in his/her bathroom; -The resident has not had a shower in three weeks; -The resident has asked staff for a shower and staff blow him/her off; -The resident got tired of asking staff for a shower; -The resident had not refused any showers; -The resident wanted a shower at least once a week. During an interview on 12/16/24, at 1:10 P.M., Certified Nursing Assistant (CNA) A said the following: -Residents received a shower at least once a week; -A shower aide was available every day during the week; -Showers were documented on shower sheets and kept in the shower book at each nursing station; -CNA A was not sure when the resident last received a shower or how often the resident showered. During an interview on 12/16/24, at 1:21 P.M., Certified Medical Technician (CMT) B said the following: -Residents received showers twice a week; -CMT B was not aware of the resident's shower schedule. During an interview on 12/16/24, at 1:33 P.M., the resident's physician said the resident should receive a shower at least twice a week and/or as needed. During an interview on 12/16/24, at 1:50 P.M., Registered Nurse (RN) C said the following: -Residents received showers at least twice a week; -Resident showers were documented on shower sheets and kept in the shower books at each nursing station; -The resident was advised to wash his/her face and apply lotion; -The resident wants to do what the resident wants to do when he/she wants to do it; -The resident was not compliant with following physician orders or facility policy. During an interview on 12/16/2,4 at 2:04 P.M., CNA D said the following: -CNA D was a shower aide; -Residents' showers were documented on shower sheets and kept in the shower book at the nurses' station; -The last shower sheet for the resident was from 11/22/24 and showed the resident does self after supper. During an interview on 12/16/24, at 3:35 P.M., CNA E said the resident's shower day was Friday. The resident often refuses showers. During an interview on 12/16/24, at 3:37 P.M., CNA F said the following: -The resident showers him/herself and did not ask for help; -The resident was very independent; -The resident was offered a shower every Friday; -The resident was allowed to shower anytime he/she asked; -The resident had not showered on Fridays during the day for several weeks; -Resident showers are documented on shower sheets and kept in the shower book; -Residents refusing showers are documented on the shower sheet and kept in the shower book. During an interview on 12/16/24, at 2:40 P.M., the Director of Nursing (DON) said the following: -The resident typically showers on his/her own; -The resident has a history of refusing showers; -Residents should receive a shower at least twice a week. During an interview on 12/16/24, at 3:54 P.M., the Administrator said the following: -Resident showers are done a minimum of once a week, preferably twice a week; -Shower refusals by residents should be documented on a shower sheet and kept in the shower book. MO00246507

Based on observation, record review, and interview, the facility failed to support each resident's right to self-administer medication when the facility did not explore one resident's (Resident #1) ability to self-administer medications and creams the resident had in his/her room. The facility's census was 71. Review of the facility's policy titled, Medication Storage in the Facility, dated April 2017, showed the following: -Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate per facility policy; -A written order for the bedside storage of medications to be present in the resident's medical record; -Bedside storage of medications is indicated on the resident mediation administration record (MAR) and in the care plan for the appropriate medications; -For residents who self-administer medications, the following conditions are met for bedside storage to occur: the manner of storage prevents access by other residents. lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate; facility management should have a copy of the key in addition to the resident; the medications provided to the resident for beside storage are kept in the original containers; and the bedside medication record is reviewed per facility policy; -All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for beside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of the procedure and related policy when necessary; -Bedside medication storage is routinely monitored by facility nursing personnel. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and diabetes mellitus (commonly known as diabetes, is a chronic condition characterized by high blood sugar levels). Review of the resident's Admission Agreement, dated and signed by the resident on 04/21/23, showed all prescribed medications and medications such as antacids, cough syrups, laxatives, and ointments brought into the facility, must be left at the nurses' station. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/01/24, and showed the following information: -Moderate cognitive impairment; -Staff did not mark application of ointments/medications other than to feet. Review of the resident's care plan, updated on 11/12/24, showed the following information: -The resident was at risk for skin breakdown related to history of burns, diabetes melilites, and oxygen use; -The resident's skin would remain intact; -The staff would observe the resident for presence of risk factors; -The resident's skin would be kept clean and dry as possible. Review of the resident's December 2024 Physician Order Summary Report (POS) showed the following: -An order, dated 05/31/23, for abilify (used to treat bipolar disorder) 20 milligram (mg), 1 tab, once daily at 8:00 A.M.; -An order, dated 11/05/24, for lexapro (used to treat anxiety) 20 mg, 1 tab once a day at 12:00 P.M. (Staff did not document any orders related to medicated shampoo or medicated cream.) Review of the resident's physician progress note, dated 12/06/24, showed the following: -The resident was getting meds from a telehealth mental health doctor and had someone take him/her to a local pharmacy to get them; -A box was found in the resident's room that contained abilify and lexapro, both of which he/she received at the facility, but with different dosages; -The resident was educated about it being a dangerous practice and that doubling doses could have serious and dangerous effects. Review of the resident's current care plan showed staff did not update the care plan to reflect the medication storage of the duplicate medications in the resident's room. Review of the resident's medical record showed staff did not document regarding if the resident would be a able to store his/her medications at bedside. Observation on 12/16/24, at 10:05 A.M., of the resident's face and ears showed the following: -The resident had scaly patches of skin, yellowish in color, on his/her forehead, in the temple area on both sides of his/her face, and on the resident's head; -A partially used tube, labeled ketoconazole (antifungal) cream 2%, was observed on the resident's bedside table; -The resident had a prescribed bottle of medicated shampoo, ketoconazole shampoo 2%, in his/her cabinet; -The shampoo was prescribed by a physician and was filled on 12/01/24; -The directions on the prescription read, shampoo scalp and beard 1 time daily for two weeks, let soak five minutes and rinse. During an interview on 12/16/24, at 10:05 A.M., the resident said the following: -The resident washed his/her face in his/her bathroom; -The resident applied the ketoconazole cream to his/her face one to two times a day; -The resident said he/she had a fungus on his/her skin that caused his/her skin to build up and get crusty; -The resident said his/her dermatologist prescribed the cream and shampoo; -The resident did not know if staff were aware that he/she had the prescribed shampoo and cream at his/her bedside. During an interview on 12/16/24, at 1:10 P.M., Certified Nursing Assistant (CNA) A said the following: -All prescription medication was to be kept in the medication cart or medication room; -Residents were not allowed to keep any medication at bedside without an order from the physician; -A prescription was required for a resident using a medicated shampoo or cream; -CNA A was not aware of the resident had a medicated shampoo or a medicated cream. During an interview on 12/16/24, at 3:37 P.M., CNA F said the following: -CNA F was not aware of the resident having any prescribed medication at his/her bedside; -CNA F was not aware of the resident having prescribed shampoo and cream to treat a fungus; -CNA F would report to the certified medication technician (CMT) or registered nurse (RN) any found prescribed or over the counter medication found at a resident's bedside. During an interview on 12/16/24, at 1:21 P.M., CMT B said the following: -No prescribed medications or creams were to be kept bedside without a physician order; -The nurse was responsible for providing treatments, including creams, to the residents; -CMT B looked at the resident's physician orders and did not see orders for a cream or shampoo. During an interview on 12/16/24, at 1:50 P.M., RN C said the following: -Residents should not have prescribed medication or treatments at bedside without an order from the physician; -The resident sees other physicians when he/she is out of the building and will set up procedures, obtain new prescriptions, and not inform the facility; -The resident had brought other creams and medication into the facility previously; -The resident was not compliant with following physician orders or facility policy. During an interview on 12/16/24, at 1:33 P.M., the resident's physician said the following: -The resident had no orders for a medicated shampoo or cream; -All prescribed treatments should be on the resident's Medication Administration Record (MAR); -The physician felt the resident would be a candidate to have medications, including the cream and shampoo at his/her bedside; -The physician is fine with residents keeping treatments at bedside as long as there is an order for the treatment. During an interview on 12/16/24, at 2:40 P.M., the Director of Nursing (DON) said the following: -Last month the resident had brought into the facility two prescriptions, abilify and lexapro; -The resident set up telehealth psych services on his/her own and did not inform the facility; -The resident was already prescribed ability and lexapro from the facility physician; -The DON spoke with the resident regarding the facility policy on bringing in outside medications; -The resident said he/she understood the safety concern. During an interview on 12/16/24, at 3:54 P.M., the Administrator said over the counter medications and prescription medications should not be kept at a resident's bedside without a physician order. MO00246507

Based on interview and record review, the facility failed to maintain an infection and control program, per standards of practice and facility policy, when the facility failed to ensure two employees (Housekeeper A and Licensed Practical Nurse (LPN) B), of six sampled residents, received tuberculosis (TB-a communicable disease that affects the lungs) screening tests as needed. The facility census was 75. General requirements for Tuberculosis Testing in Long-Term Care Facilities per 19 CSR 20-20.100: -Long-term care facilities shall screen staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -All skin test results are to be documented in millimeters (mm) of induration; -All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a two-step TB test (skin test) within one month prior to starting employment; -If the initial test is negative, a second test is required within three weeks after employment begins, unless documentation is provided indicating a TB test in the past and at least one subsequent annual test within the past two years. Review of the facility's policy, Tuberculosis Control, Recommendations for Employees, undated, showed the following: -Every facility should have a tuberculosis surveillance program to include initial examination that provides a tuberculin skin test (Mantoux - five tuberculin units (TU) of purified protein derivative (PPD)) to all employees during pre-employment procedures, unless a previous reaction of greater than 10 mm is documented; -If the initial test is 0 to 9 mm, a second test should be given at least one week after and no more than three weeks after the first step; -The test is used as the baseline in determining treatment and follow-up of employees; -All employees with be screened for TB; -Once the decision is made to employ an individual, the individual will be asked for documentation of a prior PPD; -If the employee has documentation of a prior PPD, the first step PPD will be administered by the nursing department, documented on the employee immunization record, and must be read prior to or no later than the start date; -If an employee has had a documented evidence of prior two-step PPD, the decision tree for employee accepts position will be followed; -If the employee has a documented positive PPD in the past or an adverse reaction, the facility will follow the decision for a positive PPD; -All PPD's will be documented in the employee immunization record including new hires and annual administration. After the PPD has been administered, the results will be documented in mm. -Documented evidence of prior PPD will be maintained with the facility employee immunization records. 1. Record review of Housekeeper A's personnel file showed the following: -A date of hire 08/29/23; -Staff did not have documentation of administration a two-step TB at hire, or documentation of any prior TB tests or results. 2. Record review of LPN B's personnel file showed the following: -A date of hire of 06/06/23; -Staff did not have documentation of administration a two-step TB at hire, or documentation of any prior TB tests or results. 3. During an interview with on 01/18/24, at 3:25 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she is the infection preventionist and is responsible for ensuring TB testing is completed for all staff at the facility; -The first step of the TB test is supposed to be done upon hire and then read a few days later; -The facility staff is not supposed to start working until the first step TB test is read by a nurse; -All staff should be TB tested upon hire; -He/she did not realize that Housekeeper A did not have a record of a TB test being done in his/her employee file; -He/she was not aware that they did not have LPN A's TB test in her file. They thought that e/she had it done when he/she had started working at the hospital but they did not have any record of it. 4. During an interview on 01/19/24, at 1:47 P.M., the Director of Nursing (DON) said the following: -All new employees receive TB tests during orientation; -The TB test is read when staff come to orientation about 48 to 72 hours after administration; -He/she was not aware that Housekeeper A had not been TB tested prior to working at the facility. 5. During an interview on 01/18/24, at 3:15 P.M., the Administrator said the following: -The ADON is the infection preventionist and is in charge of TB testing the staff; -He/she was not aware that Housekeeper A had not had TB testing completed prior to him/her starting to work at the facility; -He/she was not aware that they did not have LPN B's TB test in her file. They thought that he/she had TB testing done when he/she had started working at the hospital but they did not have any record of it; -Generally, staff get their first TB test done upon hire and then they have it read when they come back for orientation.

Based on observations, interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed free from possible contamination and in sound condition in accordance with professional standards when staff failed to dispose of food after expiration, ready-to-eat foods were touched with bare hands, a thermometer was not properly cleaned, and frozen meat was not stored properly. The failed practice had the potential to affect 76 census residents consuming food in the kitchen. Review of the facility's procedure titled, Basics for Handling Food Safety, undated, showed the following: -Do not buy food past sell by, use-by, or other expiration dates; -Don't cross contaminate; -Keep raw meat, poultry, fish, and their juices away from other food; -Make sure thawing meat and poultry juices do not drip onto other food. Review of the facility's policy titled, Dietary Personnel Guidelines, dated ,d+[DATE], showed the following: -Hands and nails should be clean with no colored polish. Review of the facility's policy titled, Glove Use, dated ,d+[DATE], showed the following: -Utensils or tongs should be used to serve or handle foods, both raw and cooked. 1. Observation of the kitchen on [DATE], at 8:57 A.M., showed the following: -Raw chicken was stored in the walk-in refrigerator on the second to top shelf. The chicken was frozen, thawing in large clear plastic bags. The chicken was stored next to lettuce, cheese, and on a shelf above Almond milk containers. During an interview on [DATE], at 9:02 A.M., the Dietary Manager (DM) said the raw chicken needed to be stored on the lowest shelf. The chicken was pulled from the freezer the day before. 2. Observation of the kitchen on [DATE], at 8:57 A.M., showed the following: -Two crates of low-fat cottage cheese stored close to the floor, nearest the door; -One crate with three (five-pound) containers of low-fat cottage cheese had a date of [DATE]; -Four (five-pound) containers of low-fat cottage cheese had a date of [DATE]. During an interview on [DATE], at 9:02 A.M., the DM confirmed the food was expired and proceeded to take them out of the walk-in. 3. Observation and interview on [DATE], at 9:44 A.M., showed the following: -The Dietary Cook (DC) had dark nail polish on his/her fingernails; -He/she opened a bag of shredded lettuce and took out some of the lettuce with his/her bare right hand and placed the lettuce into a bowl; -He/she took out shredded cheese using his/her bare right hand and placed the cheese into two small bowls; -At 9:47 AM, the DC said the lettuce and cheese were for the residents' lunch meal. During an interview on [DATE], at 9:54 A.M., the DC said he/she had not been trained in how to handle ready-to-eat food. He/She had learned things from other jobs, restaurants. 4. Observation on [DATE], at 11:26 A.M., showed the following: -The DC took temperatures of the food items on the steam table; -He/She placed a thermometer into the gravy while pushing the dirty plastic portion into the gravy; -He/She cleaned the metal stem and did not clean the dirty plastic portion of the thermometer; -He/She placed the thermometer into the sweet potatoes with the plastic portion pushed into the liquid; -He/She cleaned the metal stem with an alcohol pad and did not clean the dirty plastic portion. During an interview on [DATE], at 11:47 A.M., the DC said he/she had never seen the plastic portion of the thermometer cleaned. He/She said he/she wiped it down sometimes. 5. During an observation on [DATE], at 12:23 P.M., the DC was observed pulling out two hot dog buns with his/her bare hands and placed them onto a plate. He/She opened the buns with his/her bare hands and placed hot dogs inside for a resident. 6. During an interview on [DATE], at 9:45 A.M., the DM said the following: -The DC had placed the chicken in the wrong place in the walk-in refrigerator; -Everyone was responsible for ensuring expired foods were not used; -She not noticed the DC wearing nail polish; -She had cleaned the plastic portion of the thermometer several times and it probably needed to be cleaned again.

Based on observations, interviews, and record review, the facility failed to ensure pureed food was prepared properly with appropriate texture in accordance with professional standards for seven residents receiving pureed texture. Review of the facility's procedure titled, Pureed, undated showed pureed food should have a smooth texture with no lumps. During an interview on 01/10/24, at 9:37 A.M., the Dietary Cook (DC) said they had seven residents who received the pureed texture. Review of the recipe for the pureed brown sugar glazed ham showed the following: -Prepare according to regular recipe with food thickener and water or stock and process until smooth. During an observation on 01/10/24, at 11:56 A.M., the DC prepared pureed ham. He/she placed plain boiled diced ham into the Robot Coupe (mechanical blender) and turned the machine on for processing. He/she added some liquid to the mixture which contained small undissolved pieces of beef broth. She placed the finished product directly onto the steam table. The pureed ham had the appearance of a mechanical texture. The DC did not add brown sugar glazed ham, or thickener, to the product per recipe instruction. During an interview on 01/10/24, at 11:56 A.M., the DC said she tried to ensure pudding thick texture for the food items. She said some of the food items were harder to puree than others. During a test tray observation with the Dietary Manager (DM) and interview on 01/10/24, at 12:39 P.M., showed the pureed ham had the appearance of mechanical texture. The DM confirmed the pureed ham looked more like mechanical texture and needed to be smoother. At 2:38 P.M., the DM confirmed it was the wrong texture. During an interview on 01/11/24 ,at 9:45 A.M., the DM said the puree texture needed to be of mashed potato or pudding consistency. The reason for a smooth texture was to ensure food was easier to swallow and the residents did not choke.

Based on observations, record reviews, and interviews, the facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature in accordance with professional standards for eight residents (Resident #18, #20, #25, #51, #8, #12, #7, and #73) of 20 sampled residents. Review of the facility's policy titled, Food Temperatures, dated 05/2015, revealed Hot food should be at least 120 degrees F [Fahrenheit] when served to the resident. 1. Review of Resident #18's Face Sheet, undated, in the electronic medical record (EMR) showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included vitamin deficiency. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 11/30/23, showed the resident was moderately cognitively impaired. During an interview on 01/08/24, at 11:09 A.M., the resident said the food was sometimes cold. The resident said the previous night had grilled cheese and it was cold, greasy, and nasty. He/She said the tomato soup was also cold. 2. Review of Resident #20's Face Sheet, undated, in the EMR, showed the following: -admitted [DATE]; -Diagnoses included severe protein calorie malnutrition. Review of the resident's quarterly MDS, with an ARD of 11/08/23, showed the resident was moderately cognitively impaired. During an interview on 01/08/24, at 12:31 PM, the resident said the food needed to be warmer. 3. During the resident group meeting on 01/09/24, at 1:55 P.M., showed the following: -Residents #25, #51, #8, #12, #7, #73, and #18), who were deemed cognitive intact and interviewable by the facility, were present; -The residents said the food was cold and undercooked; -The residents said some of the food looked like it was thrown on the plate; -The residents said some of the vegetables with excess liquid ran into other foods on the plate; -The residents said the food lacked seasoning and the food was just not good. 4. Review of the recipe for the buttered spinach showed the following: -Steam spinach; -Drain and add melted margarine, salt, and pepper. During an observation of the kitchen on 01/10/24, at 9:12 A.M., the Dietary Cook (DC) placed three cans of spinach into a large metal pan which contained the spinach and the liquid from the cans. The DC did not cook and drain before adding salt and butter to the spinach per recipe instruction. At 12:07 PM, the spinach was on the steam table and filled with excess liquid. During an observation in the dining room on 01/10/24, at 12:20 P.M., a resident poured his/her excess spinach liquid from his/her plate into her hot liquid beverage. During an observation and interview on 01/10/24, at 12:23 PM, the DC said they did their best on straining the spinach. The DC scooped spinach onto the plates with liquid from the spinach spreading throughout. During an interview on 01/11/24, at 9:45 A.M., the Dietary Manager (DM) said she had told dietary staff that if they were serving a juicy vegetable, then it needed to be in a bowl. She confirmed the spinach juice had spread across the plate. 5. During an observation on 01/11/24, at 11:35 A.M., the DC took temperatures of the food on the steam table. The spinach was 171 degrees Fahrenheit (F), the ham was 165 degrees F, and the sweet potatoes were 169 to 170 degrees F. The cook did not take temperatures of the pureed food items. During a test tray observation and interview with the DM on 01/10/24, at 12:39 P.M., the test tray was placed onto the cart. The cart left the kitchen at 12:44 P.M The staff started to pass trays on the hall at 12:45 P.M The last tray was passed at 12:52 P.M. Upon test tray evaluation, the pureed ham was 112 degrees F, the pureed spinach was 106 degrees F, the ham was 108 degrees F, the sweet potatoes were 118 degrees F, and the spinach was 118 degrees F. The DM said the temperature should have been at least 120 degrees F for the test tray. The DM confirmed residents had complained about food temperatures before and they told the residents that staff could reheat the food or get them a new plate. During an interview on 01/11/24, at 9:45 A.M., the DM said the pellet warmer only worked about half the time. They told the residents the staff could provide them with a fresh, hotter plate of food, or something different.

Based on record review and interview, the facility failed to ensure a PASSAR (Preadmission Screening and Resident Review) level one was retained in the resident's medical record and accessible for one resident (Resident #14) of six residents reviewed for PASSAR. 1. During an interview on 01/10/24, at 10:46 A.M., the Administrator said they did not have any specific policy related to PASSAR. Review of Resident #14's Face Sheet, undated, located in the electronic medical record (EMR) under the profile tab, showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included anxiety disorder, major depressive disorder, and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an Assessment Reference Date (ARD) of 11/18/23, showed the resident had moderately impaired cognition. Review of the resident's Nurse Practitioner Routine Visit note, located under the Resident Document tab of the EMR, dated 12/15/23, showed visit for schizoaffective disorder, increased crying and anxiety at times but improved, and for anxiety disorder, increased anxiety, crying at times but improved. Review of the resident's EMR showed no PASSAR level one available or accessible. During an interview on 01/09/24, at 12:19 P.M., the Director of Nursing (DON) said the PASSAR level one had gotten archived around 2014 to 2015. He stated he was the one who oversaw the PASSAR process, but had not audited the charts. He said he was not aware this resident did not have a PASSAR level one in the chart. He did not know what information was on the original PASSAR because it was not accessible. During an interview on 01/09/24, at 12:12 P.M., the Administrator said they did not have a physical copy of the PASSAR level one that was completed prior to admission. He said nothing had been in place since he had been at the facility since 2017.

Based on observations, interviews, and record review, the facility failed to ensure one resident (Resident # 41), of three residents reviewed for activities of daily living/restorative services, received services to maintain or improve walking ability when staff failed to offer to walk with the resident. This failure created a potential for further decline of the resident's lower body strength and walking ability. 1. Review of Resident #41's Profile tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included dementia, anxiety, unspecified abnormalities of gait and mobility, cognitive communication deficit, generalized muscle weakness, cellulitis (skin infection) of right lower limb, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), cerebrovascular disease, spinal stenosis (a narrowing of the spinal canal in the lower part of the back), weakness, and reduced mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), located in the resident's EMR under the Resident Assessment Instrument (RAI), with an assessment reference date (ARD) of 09/24/23, showed the following: -The resident was moderately cognitively impaired; -The resident did not exhibit any behavioral symptoms, including rejection of care; -The resident required supervision or touching assistance with walking. During an observation and interview on 01/08/24, at 9:27 A.M., the resident was observed sitting in his/her wheelchair in his room. A walker was noted in the resident's room. The resident said he/she walked with assistance from staff using the walker, but could not walk on his own, as he/she was unsteady and afraid of falling. The resident said he/she did not receive assistance to walk as often as he/she would like, and he/she did not ask the staff to help him/her walk because they were busy taking care of others. During an interview on 01/08/24, at 2:36 P.M., the resident said he/she liked to walk and that he/she walked with staff about every other week. The resident said he/she enjoyed walking and would like to walk more often, but reiterated he/she did not want to ask the staff to walk with him/her as they were busy. Review of the resident's PT (physical therapy) Discharge Summary, located in the resident's EMR under the Documents tab, electronically signed and dated on 09/21/23, showed the following: -Discharge recommendations of RNP (restorative nursing program) for exercise and ambulation. RNP for LE (lower extremity)/core exercises and ambulation with 2WW (two-wheeled walker) to resident tolerance. Review of the resident's Care Plan, initiated 08/23/23 and located in the RAI tab of the EMR, showed the following: -Resident has potential risk of falling related to impaired mobility and weakness; -Give verbal reminders not to ambulate/transfer without assistance. (Staff did not care plan the resident's recommended restorative program for exercises and ambulation.) Review of the resident's Point-of-Care (POC) tab of the EMR for Restorative Nursing showed the resident ambulated with the Restorative Aide (RA) on 10/25/23, 10/26/23, 11/03/23, 11/07/23, 11/08/23, 11/09/23, 11/22/23, and 11/30/23 for 10 to 15 minutes. Review of the resident's Restorative Daily Documentation and Program Note, dated 12/07/23, showed the following: -Resident refused to do any LE ex (lower extremity exercises). He/she only wanted to do is AMB (ambulate) 40' x 2 (twice for 40 feet), used fall (precautions) and gait belt tolerated well; -Further review of the same document on 01/04/24 showed resident discharged and is non-compliant. Resident says that he/she works out in his/her room; -Staff did not document any further attempts or refusals to participate in the exercise and walking program, and no indication the resident refused to walk with restorative staff. During an interview on 01/10/24, at 11:45 A.M., the Restorative Aide (RA) said the resident was discharged from exercise and ambulation with restorative due to non-compliance. The resident refused to exercise, but the resident enjoyed walking with assistance. The RA said he/she had no further documentation regarding any provision of restorative services or refusals to participate. The RA said he/she was aware the resident did not refuse to walk. During an interview on 01/11/24, at 9:45 A.M., the Physical Therapist (PT) said the resident was discharged from the restorative program due to non-compliance. The PT had met with the RA and was informed that the resident was refusing to exercise. Once a resident was discharged from restorative services, the certified nurse aides (CNAs) should provide range-of-motion exercises during their care. The PT said he/she was aware the resident did not refuse to walk and stated the CNAs should walk with him upon request.

Based on interviews and record review, the facility failed to ensure two residents (Resident #41 and #65), of five residents reviewed for immunizations, received the pneumococcal vaccination series or had documented refusals. These failures had the potential to increase the spread of pneumonia among the unvaccinated residents. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 01/24/22 and accessed on 01/11/24 at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html showed the following: -For adults [AGE] years or older, who have not previously received any pneumococcal vaccine, the CDC recommends to give 1 dose of PCV [pneumococcal conjugate vaccine] 15 or PCV20; -If PCV15 is used, this should be followed by a dose of PPSV [pneumococcal polysccahride vaccine] 23 at least one year later; -If PCV20 is used, a dose of PPSV23 is not indicated; -For adults [AGE] years or older who have only received PPSV23, CDC recommends to give one dose of PCV15 or PCV20; -The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination; -Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it; -For adults [AGE] years or older who have only received PCV13, CDC recommends to give PPSV23 as previously recommended. Review of the facility's policy Immunization, undated, showed the following: -Pneumococcal: PCV 13 (PREVNAR 13) and PPSV23 (PNEUMOVAX23). Pneumococcal vaccination in persons ages 65 and older years, unless contraindicated, will be administered according to the following guidelines when determining the vaccination status: -If resident has not received either pneumococcal vaccine (PCV13 or PPSV23) or has unknown vaccination history, staff may administer PCV13, then wait one year and administer PPSV23; -If the resident has not received PCV13, but received PPSV23 at or after age [AGE] years, staff may administer PCV13 (at least one year after the most recent PPSV23); -If the resident had not received PCV13, but received one or more doses of PPSV23 at age 19 to 64, staff may administer PCVL3 (at least one year after the most recent PPSV23) and then administer PPSV23 (at least 1 year after PCV13 and at least 5 years after the most recent PPSV23); -If resident has received PCV13 at any age, but has not previously received PPSV23, staff may administer PPSV23 (at least one year after PCV13; -If resident has received PCV13 at any age and has received one or more doses of PPSV23 at age 16 to [AGE] years, staff may administer PPSV23 (at least one year after PCV13 and at least five years after the most receive PPSV23); -For any person who has received a dose of both pneumococcal vaccines at age greater than [AGE] years---revaccination is not indicated; -Contraindications to PCV13 (Prevnar13) include persons known to have severe allergic reactions (anaphylaxis) to any component of PCV13 or to any diphtheria toxoid-containing vaccine; -Requirements to administer the vaccination includes physician order, consent to receive signed by resident &/or legal representative, information sheet included with the consent to administer pneumococcal vaccine, includes general information, risks and side effects, and the resident will be monitored for fever for up to 72 hours. (The policy did not include any reference to the PCV15 or the PCV20.) 1. Review of Resident #41's Profile tab, of the electronic medical record (EMR), showed the following: -admitted [DATE]; -The resident was over [AGE] years old. Review of the resident's Immunizations tab, in the EMR, showed staff did not document information regarding offering or providing the pneumococcal vaccination series, or whether the vaccine had already been received. 2. Review of Resident #65's Profile tab, of the EMR, showed the following: -admitted [DATE]; -Resident was over [AGE] years old. Review of the resident's Immunizations tab, in the EMR, showed staff not document information regarding offering or providing the pneumococcal vaccination series, or whether the vaccine had already been received. 3. During an interview on 01/11/24, at 3:25 P.M., with the the Infection Preventionist (IP) and the Director of Nursing (DON) they said the following; -Both confirmed there was no other additional immunization information or documentation for the above residents, and they were unaware of the residents' pneumococcal immunization status; -They confirmed the facility's policy had not been updated to reflect the revised CDC guidance to offer PCV15 and PCV20; -The DON said pneumonia vaccinations had not been offered to the appropriate residents, as he had only been in the position for about a year and had not yet been able to audit pneumonia vaccinations to determine which residents required immunization; -The DON said the pneumonia vaccination should have been offered and administered, or a refusal documented, at or around the time of admission.

Based on interview and record review, the facility failed to report an allegation of possible abuse immediately to facility management and to the State Survey Agency (DHSS - Department of Health and Senior Services) within two hours when two staff failed to report one resident's (Resident #1) allegation of employee to resident physical abuse. The facility census was 81. Review of the facility's policy titled New Abuse/Neglect Report Regulations, dated 11/28/16, showed the following: -Immediately educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -The Administrator or designee must report to the State Survey Agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury; -Please ensure that the Administrator and Director of Nursing (DON) contact information is readily accessible to all staff for reporting purposes. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed an admitted [DATE]. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/25/23, showed the resident was moderately cognitively impaired. During an interview on 08/02/23, at 1:25 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she had walked into the resident's room around 6:40 A.M. and the resident was telling a certified nurse aide (CNA), that someone had hit him/her; -LPN A asked the resident, who hurt you? and the resident said you did; -The resident became agitated and then refused to take any medication; -LPN A decided to back off since the resident is confused with dementia and did not want to escalate the situation; -LPN A went back after giving the resident time to calm down and asked again who hurt him/her and this time the resident said, a big fat lady; -LPN A said he/she knows that any allegation of abuse needed to be reported immediately to a supervisor and that there is only two hours to report to state; -LPN A said he/she did not feel like it was a true report of abuse, because the resident is so confused and he/she knows they are confused. Review of resident's progress note dated 08/01/23, at 2:02 P.M., showed Licensed Practical Nurse (LPN) A documented the resident claimed someone on the night shift hit him/her (over six hours after the original allegation of abuse was made by the resident.) Review of the resident's progress note dated 08/01/23, at 5:00 P.M., showed the DON documented the following: -Completed self-report on allegation of staff member from night shift hitting resident; -Family members, Administrator, quality assurance (QA) nurse and physician were notified; -Investigation also initiated. (Staff noted the self-report over nine hours after the original allegation of abuse was made.) During an interview on 08/02/23, at 12:35 P.M., CNA B said the following: -He/she did not provide any information or report the allegation of abuse made by the resident prior to being asked; -He/she said if it were abuse, it should be reported right away; -He/she did not think of this as abuse due to the resident's confusion; -He/she said anything like this should be reported within 24 hours to the state. During an interview on 08/02/23, at 12:45 P.M., Certified Medication Technician (CMT) C said the following: -He/she would report any kind of abuse up to management; -Management should report it to DHSS; -Any allegation like this must be reported within two hours. During an interview on 08/02/23, at 12:55 P.M., CNA D said the following: -He/she would immediately report any allegations of abuse to the charge nurse and up to the DON and the Administrator; -This is the kind of incident that should be sent into the state; -Abuse allegations must be reported to state within two hours. During an interview on 08/02/23, at 1:05 P.M., the Housekeeping Supervisor said the following: -He/she would go to the charge nurse immediately if they saw or heard about this; -An allegation of someone hitting at a resident would require a report to the state; -The facility must report all allegations of abuse within two hours. During an interview on 08/02/23, at 1:15 P.M., CNA E said the following: -If he/she were to have a resident say they were hit, he/she would first help the resident to make sure they are okay and then go directly to the charge nurse; -They would then go to the DON and that must be reported to the state within two hours; -Any abuse allegation must be reported to state. During an interview on 08/02/23, at 2:45 P.M., the DON said the following: -Someone saying that someone else hurt them and not knowing any other information is definitely enough to make a report; -He/she did not see LPN A's note until 5:00 P.M., when someone else saw it and brought it to his/her attention. MO00222366

Based on interview and record review, the facility failed to protect all residents from potential abuse during an investigation of alleged employee-to-resident abuse when the accused employee continued to work unsupervised with other residents. The facility's censes was 87. Record review of the facility's Abuse Prohibition Protocol Manual-Protection, undated, included the following information: -It is the policy of this facility that the resident(s) will be protected from alleged abuse from the alleged offender(s); -Ensuring safety and wellbeing for the vulnerable individual are of utmost priority. Safety, security and support of the resident, their roommate if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be suspended without pay during the investigation process. The employee will be immediately removed from resident contact, asked to write a statement of the incident if applicable, allowed to finalize charting (supervised) and give report to the charge nurse or supervisor, and removed from the facility and will remain removed pending the results of a thorough investigation. 1. Record review Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, last reviewed 9/23/21 (during the care conference), showed the following information: -Always treat the resident with dignity and respect. Give his/her request appropriate attention and provide simple reasons why he/she could not have something he/she requested. Record review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/24/21, showed the following information: -Cognitively intact; -Required extensive assistance with bed mobility, transfers, dressing, and personal hygiene; -Functional limitation in range of motion: upper extremity and lower extremity on impairment on one side; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required a wheelchair for mobility. Record review of the facility's After Hours/Weekend Self-Report Form dated 10/9/21, at 5:28 P.M., showed Licensed Practical Nurse (LPN) A documented the following: -On 10/9/21, at 4:20 P.M., the resident claimed Certified Nurse Aide (CNA) B grabbed by arm and held down; -Action taken by facility as a result of the allegation: CNA B was not allowed back in the resident's room and two people (staff) in (the resident's) room at all times. Record review of LPN A's written statement dated 10/9/21, at 4:20 P.M., showed the following: -The resident was yelling and cussing in his/her room; -The LPN saw the aide (CNA B) enter the resident's room and asked the resident what was wrong and to assist the resident to the dining area; -Staff propelled the resident via wheelchair to the hall. The resident was kicking and screaming; -LPN A asked the resident what the problem was. The resident said CNA B grabbed his/her arm and held it down, that was abuse; -Staff propelled the resident to the dining room. Record review of the the resident's progress note dated 10/10/21, at 4: 48 A.M. (late entry for 10/9/21) showed LPN A documented the following: -Staff heard the resident yelling/cussing/throwing things in his/her room. An aide (CNA B) checked on the resident; -Staff propelled the resident in his/her wheelchair to the hall. The resident yelled staff (CNA B) abused him/her by grabbing his/her hand and holding it; -Asked the aides what happened and they confirmed the aide (CNA B) grabbed the resident's hand as he/she was in mid-swing to hit CNA B; -Staff propelled the resident to the dining room for dinner. -The nurse (LPN A) notified the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the administrator; reported to the state agency; and faxed the paperwork; -The nurse ensured that CNA B did not go back into the resident's room or make contact with the resident; -The LPN ensured that two staff members entered the resident's room at all times. The resident continued to try to have CNA B help him/her. Interviews conducted on 10/14/21, at 3:45 P.M., and om 10/23/21, at 8:15 P.M., CNA B said the following: -After he/she wheeled the resident into the hall, the resident yelled abuse. LPN A stood in the hall near the resident and said he/she would have to call the State Agency and complete paperwork on this (the allegation of abuse). The LPN walked to the nurses' station and CNA B then propelled the resident to the dining room; -LPN A told CNA B to stay away from the resident and to make sure two staff entered the resident's room at all times. He/she wanted two staff to assist the resident to protect staff from the resident making allegations against them and to protect the resident. The CNA could not remember if the LPN told him/her before or after he/she propelled the resident to the dining room; -After the resident made the abuse allegation, the CNA continued to work with other residents unaccompanied by other staff; -A few hours later, LPN A told the CNA he/she either had to leave or another staff member had to follow him/her around the facility. The CNA chose to leave; -The resident made the allegation of abuse against CNA B between 4:15 P.M. and 4:45 P.M. and CNA B clocked out and left the facility at 8:00 P.M. During an interview conducted on 10/14/21, at 4:18 P.M., LPN A said the following: -If he/she witnessed abuse or received an allegation of abuse against an employee, he/she would separate the two and make the employee leave the facility. He/she then would follow the chain of command with reporting, complete necessary paperwork and notify the state agency; -On 10/9/21, around dinner-time, the LPN heard the resident yelling, screaming and cursing. CNA B entered the resident's room to assist him/her to the dining room. The LPN heard items being thrown and the yelling got louder. He/she sent CNA C to assist CNA B. After LPN A heard something large fall onto the floor, CNA B wheeled the resident into the hallway, outside his/her room. The resident yelled abuse.; -After the CNA explained what happened, LPN A told CNA B not to go around the resident. CNA B then wheeled the resident to the dining room; -LPN A assigned another aide to assist the resident and told staff only to enter the resident's room with another staff member; -The LPN notified the Administrator of the allegation. The administrator told the LPN to ensure CNA B had no contact with the resident; -The LPN then completed the abuse reporting paperwork and faxed it to the abuse hotline; -A few hours later, he/she sent CNA B home. He/she sent him/her (CNA B) home because he/she (LPN A) did not have enough staff to follow CNA B around the facility; -The LPN had a lot going on that night and at first, he/she did not think about keeping other residents safe (from CNA B) because he/she never had an issue with CNA B; -The LPN said he/she did not know what the policy instructed staff to do after a resident made an allegation of abuse against an employee, but if he/she witnessed abuse, he/she would walk that employee to the time clock. During an interview conducted on 10/25/21, at 2:55 P.M., LPN E said if a resident alleged a staff member abused him/her, he/she would talk to the resident (if the allegation came from someone other than the resident), the accused staff member, and any witnesses. If the resident made a true allegation of abuse, he/she would notify the DON and start an investigation. He/she would also tell the employee to have no contact with the resident. The LPN would not assign another staff member to accompany the accused employee. In order to protect other residents, administration or the charge nurse should send the employee home after an allegation of abuse. During an interview conducted on 10/25/21, at 3:03 P.M., Registered Nurse (RN) D said if a resident made an allegation of abuse against an employee, the RN would separate the employee and the resident, and start an investigation. If the allegation were serious, he/she would send the accused employee home. A serious allegation included any obvious injury (red mark or bruising). Sending an employee home also depended on the number of staff working. If the facility had enough staff, he/she would send the employee home, if not he/she would send the employee to the opposite side of the facility to work. Another staff member would not need to accompany the accused employee while at the facility. During an interview conducted on 10/25/21, at 3:50 P.M., the DON said the following: -If a resident said an employee abused him/her, the charge nurse separated the resident and employee, notified her and/or the administrator of the allegation, and started an investigation. Depending on the severity, the charge nurse would either tell the employee to leave or to work on the opposite side of the building. Severe allegations that would prompt employee suspension included sexual abuse allegations and if the alleged abuse caused injury like red marks. If the allegation was not severe, the accused employee could work on a different hall, away from the accusing resident; -After the resident made the allegation of abuse against CNA B, LPN A moved him/her to another hall to work then later, suspended the CNA. The DON did not know the specifics of the investigation as she was out of town at the time. During an interview conducted on 10/25/21, at 5:00 P.M., the administrator said the following: -If a resident made an allegation of abuse against and employee, the charge nurse removes the employee from the situation and notifies him immediately. Prior to the Covid-19 pandemic, the facility would immediately send the accused employee home pending a complete investigation. After the pandemic began, the facility no longer could just send staff home. The facility had to ensure there was enough staff in the facility to meet fire code before the facility could send an employee home. If the facility had enough staff for fire code, the facility would send that employee home, if not, the facility would send the accused employee to the other side of the facility and institute the buddy system. The accused employee could not enter a resident's room without the direct supervision of the nurse. This direct supervision remained until the employee's shift ended or another employee came in to replace the accused employee. If the nurse reported witnessed abuse, they would send the employee home regardless of staffing numbers; -Residents were protected from potential abuse as long as another staff member directly monitored the accused employee. Any time the charge nurse called him regarding an allegation against an employee, and he did not immediately send the employee home, he always instructed nurse to begin the buddy system. He observed this in action multiple times. Usually, after staff reported an allegation of abuse, he went to the facility to start the investigation; -On 10/9/21, around dinnertime, LPN A called the Administrator to report the resident's allegation of abuse against CNA B. At that time, the Administrator asked the nurse their staffing numbers. He asked the nurse if they met fire code. The nurse said he/she did not think so. The Administrator told the nurse to move CNA B to another hall and partner the CNA with the nurse working on that side of the facility. The Administrator told the nurse to call him with the specific staffing numbers after he/she completed the required paperwork and reporting to the State agency. It took the nurse a while to get back to the Administrator. He tried calling the nurse, to discuss sending the CNA home, but he/she was on the phone. After he/she finished that phone call, he/she called the administrator to report he/she was sending CNA B home During an interview conducted on 10/25/21, at approximately 5:50 P.M., the Administrator said he reviewed CNA B's time sheet which showed he/she clocked off his/her shift on 10/9/21 at 8:04 P.M. MO 991

Based on record review and interview, the facility failed to treat one resident (Resident #1) in a manner that promoted dignity and respect when staff did not speak to the resident in a respectful manner and did not honor the resident's wishes regarding dining location. The facility's censes was 87. 1. Record review Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, last reviewed 9/23/21 (during the care conference), showed the following information: -Always treat the resident with dignity and respect. Give his/her request appropriate attention and provide simple reasons why he/she could not have something he/she requested. Record review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/24/21, showed the following information: -Cognitively intact; -Required extensive assistance with bed mobility, transfers, dressing, and personal hygiene; -Functional limitation in range of motion: upper extremity and lower extremity on impairment on one side; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required a wheelchair for mobility. Record review of the resident's progress note dated 10/10/21, at 4:48 A.M. (late entry for 10/9/21), showed Licensed Practical Nurse (LPN) A documented the following: -Staff heard the resident yelling, cussing, and throwing things in his/her room; -An aide checked on the resident. The resident continued to yell and threw things at the aide. The nurse sent another aide to observe; -Staff propelled the resident in his/her wheelchair to the hall. The resident yelled Certified Nurse Aide (CNA) B abused him/her by grabbing his/her hand and holding it. The nurse asked the aides what happened and they confirmed the CNA B grabbed the resident's hand as he/she was in mid-swing to hit CNA B. Record review of the resident's written statement (documented by Certified Medication Technician (CMT) G) dated 10/9/21, at 4:20 P.M., and signed by the resident on 10/9/21, showed the following: -The resident started screaming because his/her (bedside) table fell over and he/she was not strong enough to pick it up; -CNA B and CNA C entered the resident's room and the resident placed his/her foot against the wall so CNA (B) could not move him/her; -The resident told LPN A, CNA B grabbed his/her arm and LPN A blamed the resident and said he/she had to call the State on him/her three times. During an interview conducted on 10/4/21, at approximately 4:45 P.M., CMT G said the following: -On 10/9/21, the CMT saw the resident in the hall outside his/her room. The resident told LPN A, CNA B abused him/her. LPN A said, to the resident in an irritated voice, this was the third time he/she (LPN A) had to call the State and complete the (abuse) paperwork.; -The CMT assisted the resident with a statement about the incident that occurred before dinner. The resident was tearful when the CMT talked to him/her; -The resident told CMT G he/she placed his/her foot against the wall to keep CNA B from taking him/her to the dining room; -Sometimes, the resident ate his/her meals in the dining room, sometimes he/she did not. During an interview conducted on 10/10/21, at 2:35 P.M., the resident said the following: -LPN A yelled and cursed at him/her. He/she would yell, get back to your room; -The resident had anxiety and eating (in the dining room) around 80 plus people made him/her nervous. He/she ate most of his/her meals in his/her room; -On 10/9/21, he/she wanted to eat his/her dinner in his/her room, but CNA B said he/she (the resident) could not eat in his/her room and attempted to take him/her to the dining room. The resident said no, you will not and placed his/her foot on the wardrobe/closet door (to brace himself/herself). CNA B then placed his/her hand on the resident's upper arm and tried to pull him/her out of his/her room; -After the CNA wheeled the resident into the hallway, the LPN asked the resident what happened. The resident told LPN A, CNA B abused him/her. LPN A then said, in an irritated voice, this was the third time he/she had to complete the (abuse investigation) paperwork; -LPN A and CNA B would not let the resident eat in his/her room on 10/9/21; -The incident caused the resident to be very upset, he/she cried through dinner because he/she felt bad; -CNA B said he/she could not eat in his/her room and he/she put his/her hands on him/her (the resident). Record review of CNA B's written statement dated 10/9/21, at 4:20 P.M., showed the following information: -The resident was screaming in his/her room. The (bedside) table was flipped over and everything was on the floor; -The CNA moved the resident, sitting in his/her wheelchair, to the side and picked up the table. The resident was still screaming and cussing; -The CNA positioned himself/herself behind the resident to bring him/her to the dining room; -The resident was still screaming and cussing and tried swinging at the CNA. The resident started grabbing stuff off his/her dresser and still tried to swing. The resident then saw CNA C and started yelling at him/her. -CNA B finished moving the resident out in the hall to the nurse (LPN A). During interviews conducted on 10/4/21, at 3:45 P.M., and on 10/23/21, at 8:15 P.M., CNA B said the following: -Residents decided if they ate in their room or in the dining room. If the resident was at risk for choking, the resident ate his/her meals in the dining room. If the resident refused, the CNA reported to the nurse and followed the nurse's instructions; -On 10/9/21, before dinner, the CNA heard the resident screaming and cursing in his/her room. LPN A told CNA B to take care of the resident and take him/her to the dining room; -LPN A wanted all residents to eat in the dining room. The CNA did not know why; -CNA B entered the resident's room and, without saying anything to the resident, started to untangle the resident's wheelchair footrests from the bedside table that laid sideways on the floor. When the aide stood upright, the resident tried to hit him/her. The CNA positioned himself/herself behind the resident's wheelchair and started propelling the resident out of his/her room. The resident asked the CNA where he/she was going. The CNA said to the dining room, it was time for dinner. The resident started screaming again, and tried to hit him/her. The resident also took items off his/her dresser and threw them. The CNA did not know why the resident started to yell and throw things; -Normally, if a resident tried to hit him/her, he/she walked away to give the resident time to calm down. The CNA did not walk away from this situation because he/she was doing what LPN A told him/her to do (taking the resident to the dining room for dinner); -The CNA did not ask the resident if he/she wanted to go to the dining room or why he/she was yelling; -After the CNA wheeled the resident into the hall, the resident said CNA B abused him/her. LPN A said, in an irritated voice, now he/she had to call the State Agency and complete the paperwork. The LPN then walked to the nurses' station; -LPN A's tone of voice was not nice. Some residents took offense to how he/she talked to them; -CNA B did not tell the Director of Nursing (DON) or Administrator of LPN A's disrespectful tone or attitude towards residents. CNA B thought other staff reported the LPN's tone; -If CNA B heard LPN A talk hateful to a resident, he/she would report it to the DON or Assistant Director of Nursing (ADON). Record review of LPN A's written statement dated 10/9/21, at 4:20 P.M., showed the following: -The resident was yelling and cussing in his/her room; -The LPN saw the aide (CNA B) enter the resident's room and asked the resident what was wrong and to assist the resident to the dining area; -Staff propelled the resident via wheelchair to the hall. The resident was kicking and screaming; -LPN A went to the resident and asked him/her what the problem was; -The resident said CNA B grabbed his/her arm and held it down, that was abuse; -The LPN asked CNA B what happened and he/she said he/she grabbed the resident's arm because he/she was hitting and throwing things at him/her; -The resident tried to grab LPN A's arm, in anger, and the LPN said do not put your hands on me, I will not let you try to abuse me. During an interview conducted on 10/4/21, at 4:18 P.M., LPN A said the following: -On 10/9/21, around dinner-time, the LPN heard the resident yelling, screaming and cursing, which he/she did all of the time; -CNA B entered the resident's room to assist him/her to the dining room. The LPN heard items being thrown and the yelling got louder; -After CNA B wheeled the resident into the hallway, outside his/her room, the resident yelled abuse. The LPN asked the resident what happened. The resident said CNA B grabbed him/her and held him/her down then lifted his/her arm to show the LPN where CNA B grabbed him/her. The LPN quickly looked at the resident's arm then told the resident it was time to go to the dining room and walked away; -During the interaction, the LPN did not ask any the resident any further questions and stood far enough away that the resident could not reach him/her. The resident was very angry and the LPN did not want the resident to accuse him/her of abuse; -The resident ate some meals in his/her room, but that evening the resident needed to eat in the dining room because he/she was upset in his/her room; -He/she did not say now he/she (LPN A) had to complete abuse paperwork and call the state agency directly to the resident, but he/she might have said it away from the resident. Record review of CNA C's written statement dated 10/9/21, at 4:20 P.M., showed the following: -LPN A asked CNA C to go into the resident's room; -CNA C saw CNA B moving the resident's table to take the resident to dinner; -The resident tried to hit CNA B and tried throwing things. The resident tried shutting the door in CNA C's face so he/she (CNA C) held it (the door) open while CNA B proceeded to push (in his/her wheelchair) the resident out (of his/her room); -CNA B asked LPN A to talk to the resident. During an interview conducted on 10/25/21, at 2:04 P.M., CNA C said the following: -On 10/9/21, LPN A told CNA C to go to the resident's room to be a witness for CNA B. The resident was yelling and CNA B needed to take the resident to the dining room for dinner. LPN A told CNA B the resident had to go to the dining room, regardless; -After CNA B untangled the resident's bedside table from his/her wheelchair foot rests, he/she started to take the resident out of his/her room, the resident asked where they were going. CNA B told the resident he/she was taking him/her to the dining room. At that point, the resident yelled, cursed and tried to hit CNA B. The resident planted his/her feet on the floor trying to prevent CNA B from wheeling him/her out of his/her room; -CNA C did not know why LPN A did not want the resident to eat in his/her room. CNA B did what LPN A told him/her to do; -After CNA B wheeled the resident into the hall, the resident told LPN A that CNA B abused him/her. LPN A, in an irritated tone, said to the resident, now, he/she had to [OBSCENITY] ing call the State and complete the (abuse allegation) paperwork. The resident stopped talking and started to cry. CNA B took the resident to the dining room; -LPN A could be rude and disrespectful to residents, and cursed in front of residents; -LPN A talked rudely, in a sharp tone, to the resident; -If someone talked to him/her, the way LPN A talked to the resident, CNA C would be mad too; -CNA C told the ADON the incident that occurred on 10/9/21 was LPN A's fault because LPN A said the resident had to go to the dining room for dinner. During an interview conducted on 10/10/21, at 5:35 P.M., CNA F said the following: -LPN A was bossy and would sometimes speak to residents in a rude or sharp tone of voice, especially when he/she felt overwhelmed by his/her work duties; -Although CNA F did not witness the incident that occurred between the resident, CNA B and LPN A, when he/she assisted the resident to bed that night, the resident said staff was mean because LPN A told CNA B the resident had to eat in the dining room. The resident told the CNA he/she (the resident) was in trouble because the State would be at the facility again. The CNA assured the resident he/she was not in trouble; -CNA F did not know why LPN A did not want the resident to eat in his/her room that night. The resident, at times, ate meals in his/her room. During an interview conducted on 10/25/21, at 2:55 P.M., LPN E said the following: -LPN A did not really understand that when a resident refused, he/she refused. LPN E talked to LPN A about resident rights. He/she also talked to the ADON and DON. When LPN A felt stressed and anxious, he/she did not think well; -LPN A and the resident had an issue. LPN C thought their personalities clashed. If the resident did not want to go to the dining room, LPN A said the resident had to go to the dining room and could not stay in his/her room. During an interview conducted on 10/25/21, at 3:03 P.M., the ADON said LPN A was rough around the edges. The ADON thought the resident's and LPN's personalities clashed. During an interview conducted on 10/25/21, at 3:50 P.M., the DON said the following: -On 10/9/21, when the incident occurred between the resident and CNA B, she was out of town. Staff completed the investigation before she returned to work. She thought a staff member might have told her that LPN A made the resident go to the dining room. The resident usually ate his/her meals in his/her room. The DON did not know why the LPN would require the resident to eat in the dining room. The only reason that made sense to her, was that LPN A wanted to monitor the resident because he/she threw items in his/her room; -The DON could not say the resident and LPN A got along well. They had personality differences. The resident exhibited behaviors (yelling, cursing), but she did not know if the resident's behaviors were truly behaviors since LPN A was often the one who witnessed and documented the resident's behaviors; -LPN A was rough around the edges. The DON thought how the LPN sounded (tone) or came across (perception) was just his/her personality. She did not think the LPN acted maliciously nor did he/she punish residents. His/her tone could be difficult for people to interpret and some residents did not know how to take him/her; -Staff should not make residents to go to the dining room for meals. -Staff should not curse in front of residents. During an interview conducted on 10/25/21, at 5:00 P.M., the Administrator said the following: -On 10/9/21, LPN A told CNA B to take the resident to the dining room for observation; -The Administrator thought taking the resident into the dining room to sit amongst other residents made the situation more uncomfortable for the resident; -LPN A could be abrasive to staff but he never heard him/her speak that way to any residents; -Staff should not make a resident eat in the dining room if he/she did not want to; -Staff should not curse to or around residents. MO 483 and MO 991

Based on observation, interview, and record review, the facility staff failed to ensure one resident (Resident #1) had appropriate orders for an urinary catheter and failed to provide appropriate catheter care for the resident. The facility failed to obtain physician orders for catheter care and failed to monitor and assess to ensure appropriate cather care for one resident (Resident #12) who admitted to the facility with a urinary catheter for [MEDICAL CONDITION]. A sample of 14 residents was selected for review in this facility with a census of 84. 1. Record review of the facility policy titled, "Admission of the Resident", dated April 2006, showed that facility staff are to obtain orders upon admission for a resident with a catheter. The catheter orders must include the type of catheter, including the catheter size and the bulb size for indwelling catheters and orders for the frequency of the catheter change. 2. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated comprehensive tool completed by facility staff, dated 3/5/2012, showed the following information: - The resident requires extensive assistance with toileting and personal hygiene; -The resident has an indwelling catheter. Record review of the care plan, last reviewed on 12/14/11, showed the following: -The resident required an indwelling urinary catheter related to the history of urinary obstruction; - The care plan directed staff to provide catheter care every shift, and as needed; -The care plan did not direct staff when to change the catheter; -The resident was at risk for urinary tract infections related to the indwelling urinary catheter; -The care plan directed staff to ensure meticulous personal hygiene. Record review of the resident's November 2011 nurses' notes showed the following: -On 11/20/11 at 12:10 A.M., facility staff documented they sent the resident to the hospital for scrotal swelling; -On 11/20/11 at 5:20 A.M., staff documented the resident returned from the hospital with a Foley catheter (a urine collection bag connected to an indwelling urinary catheter) until the scrotal swelling resolved; -On 11/21/11 at 3:00 P.M., staff sent the resident to the hospital for increased [MEDICAL CONDITION] and pain; -On 11/23/11 at 2:00 P.M., staff documented the resident returned from the hospital with a Foley catheter; -On 11/28/11, staff documented the resident is complaining of abdominal pain and has minimum output in the Foley catheter. The staff notified the physician and received orders to irrigate the catheter and to change if necessary. The staff changed the Foley catheter. The staff did not document the size of the Foley catheter. The staff documented that upon insertion of the catheter, many blood clots entered the urine collection bag with urine. The resident stated "I feel much better" after 1500cc of bloody urine was recorded and drained from the urine collection bag; -On 11/29/11 at 10:00 A.M., staff documented the physician ordered a urinalysis with culture and sensitivity. Record review of the resident's November 2011 physician order sheet (POS) showed the following: -No physician orders for the Foley catheter for the resident's return from the hospital on [DATE]; - No physician orders for the Foley catheter for the resident's return from the hospital on [DATE]; -A hand written order on 11/28/11 to irrigate the Foley catheter or replace the Foley catheter if unable to irrigate. The POS showed no documented orders for size of Foley catheter. The POS did not direct staff when to provide catheter care or change the catheter, next. Record review of the resident's medical record showed a progress note, dated 11/29/11. The physician documented his/her examination of the resident. The physician found the resident's Foley catheter to be draining bloody urine. The physician ordered a urinalysis with culture and sensitivity. The physician documented to allow further medication changes by the resident's primary physician. Record review of the resident's urinalysis lab report showed the following: -The specimen was collected on 11/29/11; -The specimen colony count was greater than 100,000 CFU/mL; -The culture report on 12/2/11 showed the specimen grew proteus mirabilis. Record review of the resident's December 2011 nurse notes showed the following: -On 12/22/11, staff documented the resident is complaining of abdominal cramping and abdominal distention. The staff document the resident's Foley catheter has no urine output. The staff attempted to flush the catheter with no success. The physician instructed staff to change the catheter. The staff documented they removed an intact 18 french catheter and replaced with an 18 french catheter without difficulty. The staff documented after insertion the catheter drained 800mL of clear yellow urine into the urine collection bag. Record review of the resident's December 2011 physician order sheet showed the following: -On 12/2/11 the physician ordered [MEDICATION NAME] 500 mg by mouth twice a day for seven days for the treatment of [REDACTED]. - The POS showed no documentation the physician gave orders for when to change the catheter or what size catheter or bulb to use; -The POS did not direct staff to provide catheter care every shift for the resident during December. Record review of the resident's December 2011 treatment administration record showed facility staff failed to document any catheter care or catheter change. Record review of the resident's December 2011 progress notes showed the physician documented the resident had a catheter in place on 12/5/11 and 12/12/11. The physician did not document orders or plan of care for the catheter. Record review of the resident's January 2012 nurses' notes showed the following: -On 1/25/12 at 7:00 P.M., staff documented the resident had a temperature of 100 degrees and not feeling well. The staff notified the physician and received new orders for labs, a chest x-ray and antibiotics to be started; - On 1/25/12 at 9:00 P.M., staff documented the resident started antibiotics and showed no signs or symptoms of adverse drug reactions; -On 1/26/12 at 11:00 A.M., staff documented the resident received a chest x-ray; -On 1/26/12 at 8:00 P.M., staff documented the resident, nurse practitioner and resident's daughter notified of lab and x-ray results. The resident's daughter does not want the resident sent to the hospital at this time; -On 1/26/12 at 11:45- 11:50 P.M., staff documented the resident's temperature of 102.1 degrees with confusion and difficulty swallowing. Notified the nurse practitioner and received orders to send the resident to the emergency room for evaluations and treatment; -On 1/26/12 at 11:52 P.M., staff documented the resident's daughter was notified regarding the resident's status and order to send to emergency room ; -On 1/27/12 at 12:20 A.M., staff documented the resident left the facility. Record review of the January 2012 physician order sheet showed the following; - The POS showed no documentation the physician gave orders for when to change the catheter or what size catheter or bulb to use; -The POS did not direct staff to provide catheter care every shift. Record review of the resident's January 2012 treatment administration record showed facility staff failed to document any catheter care or catheter change to the Foley catheter. Record Review of the resident's hospital records, with an admission date of [DATE]; showed the resident admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] is likely secondary to the urinary tract infection. Record review of the resident's nurse notes showed on 2/3/12 at 5:00 P.M., staff documented the resident returned to the facility with a Foley catheter draining cloudy yellow urine. Record review of the February 2012 physician order sheet showed the following; - The POS showed no documentation the physician gave orders for when to change the catheter or what size catheter or bulb to use; -The POS did direct staff to provide catheter care every shift; -On 2/13/12 a hand written order to perform a urinalysis with culture and sensitivity; Record review of the resident's urinalysis lab report showed the following: -The specimen was collected on 2/13/12; -The specimen colony count was greater than 100,000 CFU/mL; -The culture report on 2/16/12 showed the specimen grew proteus mirabilis; -The sensitivity report showed the bacteria are sensitive to [MEDICATION NAME]/clav. ([MEDICATION NAME]). Record review of the February 2012 physician order sheet showed on 2/16/12 the physician ordered [MEDICATION NAME] 875mg, by mouth twice a day, for 10 days. Record review of the facility form titled, "24 hour shift report" dated 2/19/12, showed at 10:45 A.M. the resident's catheter pulled out, penile bleeding noted. Record review of the resident's February 2012 treatment administration record showed facility staff documented catheter care to the Foley catheter every shift. Observations on 3/8/12 at 10:45 A.M., showed the following: -CNA A entered the room, donned gloves and applied the gait belt to the resident's waist; -CNA A assisted the resident to stand and pivot to the bedside; -CNA A moved the urine collection bag from the wheelchair to the bed. The dignity bag was drenched with urine; -CNA A changed gloves and assisted the resident to remove his pants to below his/her knees and removed incontinent brief; -The resident's penis was retracted and extremely red and excoriated with a small sore on a skin fold over the head of the penis; -CNA A, using a wet cloth, cleaned down the right side of the resident's groin and down the left side of the resident's groin folding the wet cloth over between each side; -CNA A obtained a second wet cloth and cleaned the catheter tubing going back and forth on the tubing to and from the insertion site; -CNA A failed to clean the head of the penis at the insertion site of the catheter; -CNA A assisted the resident to roll onto his/her right side and performed incontinent care on the resident's buttock. Record review, interview and observation on 3/12/12 at 9:30 A.M. showed the following: -Record review of the resident's medical record showed facility staff failed to obtain orders for the resident's catheter; -LPN B said someone should have written orders for the catheter on Friday, 3/9/12; -LPN B wrote a telephone order sheet to obtain orders for when to change the catheter, when to perform catheter care and the size of catheter to be used. During an interview on 3/8/12 at 10:45 A.M., Resident #1 said he did not like the catheter. The resident said he has had a few urinary tract infections and the catheter is bothersome. During an interview on 3/8/12 at 11:25 A.M., LPN B said the penile area on the resident is sometimes red. LPN B said the resident complains about the catheter on some days. LPN B expected staff to provide catheter care by first cleaning the head of the penis starting at the insertion site and moving in a circular motion outward. The staff should clean the catheter tubing by moving away from the insertion site and not in a back and forth motion. During an interview on 3/8/12 at 11:38 A.M., CNA A said staff are expected to provide catheter care by first cleaning the head of the penis at the insertion site and moving away from the insertion site . CNA A said then staff clean the catheter tubing by cleaning away from the insertion site toward the urinary collection bag. 3. During an interview on 3/9/12 at 12:05 P.M., LPN B said the following: -When a resident returns from the hospital with a catheter the admitting nurse should obtain orders for when to change the catheter, what size of catheter should be used, when to change the urine collection bag and when staff should provide catheter care; -The admitting nurse should document the reason or [DIAGNOSES REDACTED]. -If the expected time ends, staff should attempt bladder retraining or document reason for keeping the catheter; -Resident #1 should have orders for his catheter starting in November when he returned to the facility with a catheter; -LPN B said she changed the Foley catheter in February because the catheter was pulled out. LPN B is unsure of how the catheter was pulled out. 4. During an interview on 3/9/12 at 1:35 P.M., the Assistant Director of Nursing (ADON) said the following: -When a resident returns to the facility with a catheter, the admitting nurse should notify the physician and obtain orders for catheter care every shift and as needed, to change the catheter monthly and as needed and document the reason for the catheter and how long the physician expects the resident to keep the catheter; -Resident #1 has had a catheter off and on for some time now. At one time the catheter was stitched in. The staff has difficulty changing his catheter due to his retracted penis and the facility has sent the resident out for the catheter change on prior occasions; -Resident #1 should have orders in the chart every time he returned from the hospital with the catheter; -The ADON expects staff to perform catheter care on every shift and as needed. If the resident is experiencing irritation or sores around the insertions site the staff should inform the charge nurse to notify the physician. The staff should clean at the insertion site of the catheter in a circular motion moving away from the insertion site. She expects staff to clean catheter tubing by cleaning away from the insertion site toward the urinary collection bag, not in a back and forth motion; -At 3:30 P.M., The ADON said she had searched Resident #1's current and closed medical record and was unable to find any orders relating to the catheter for any of the readmitted s. 5. During an interview on 3/12/12 at 10:50 A.M., the Director of Nursing (DON) said she expected the admitting nurse to obtain orders for the catheter upon the resident's return to the facility. The resident returns to the facility with a transfer to long term care sheet that has all the orders from the hospital for the resident's primary physician to decide to keep or change. The orders should include to change the catheter monthly, and as needed, and to provide catheter care every shift, and as needed. 6. Record review of Resident #12's Resident-Data Collection showed staff admitted the resident to the facility on [DATE]. Staff identified the resident could transfer independently and had a urinary catheter. Record review of the interim plan of care (undated) showed staff identified the resident had an indwelling urinary catheter. Staff were to empty the resident's catheter. The plan of care did not include instructions for staff to provide catheter care, monitor the resident for appropriate catheter care, or when the catheter should be changed. Record review of the physician order sheet (POS) dated February, 2012, showed a handwritten order dated 2/21/12, for staff to change the resident's catheter monthly using a size 16 french (the size of the diameter of the catheter) catheter. The POS did not direct staff to provide catheter care. Record review of the nurses' notes dated 2/22/12, showed staff changed the urinary catheter leg bag due to leakage. The nurses' notes showed no further documentation regarding the resident since 2/22/12. Record review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff dated 2/29/12, showed the following information: -Able to correctly answer nine out of 15 questions during a brief interview for mental status; -Independent with transfers and ambulation in his/her room; -Limited assistance with personal hygiene and bathing; -Had an indwelling urinary catheter; -Continent of bowel; -[DIAGNOSES REDACTED]. Record review of the Care Area Assessment Summary dated 2/29/12, showed urinary incontinence and indwelling catheter triggered as a care area and would be addressed in the care plan. Record review of the care plan dated 3/2/12, showed staff identified the resident required an indwelling urinary catheter related to [MEDICAL CONDITION]. Interventions included (in part) to provide supervision and assistance, when indicated, for catheter care every shift and as needed and change the catheter per the physician orders. Record Review of the POS [REDACTED]. During an interview on 3/9/12, at 1:30 P.M., the resident said he/she wore a leg bag for the catheter. The resident said he/she took care of the catheter and cleaned it him/herself. During an interview on 3/9/12, at 1:47 P.M., Nursing Assistant (NA) G said the resident took care of him/herself. NA G was not aware the resident had a urinary catheter. Record review of treatment record on 3/12/12, at 9:40 A.M., showed no treatment orders for the resident. During an interview on 3/12/12, at 9:40 A.M., LPN B said said the resident came to the facility from home. LPN B looked in the treatment book and said there was not a treatment record for catheter care or changing the catheter monthly. When a resident admitted with a catheter staff should make a treatment sheet for the catheter care and changing the catheter. Staff should be assessing to make sure catheter care gets done and whether the resident was capable of doing his/her catheter care. LPN B thought the resident was probably able to do his/her own catheter care. If staff wrote orders on the right side of the POS, they should also write them in the boxes on the left side of the POS. If the orders were not written in the boxes on the left side the order would not get carried over to the next month. During an interview on 3/12/12, at 9:55 A.M., CNA H said the resident wore a catheter leg bag. The resident emptied the catheter him/herself. CNA H said sometimes the resident did his/her catheter care and sometimes staff did it. CNA H said catheter care should be done daily.