Every finding on record at Gardens Health and Rehab, The

Based on observation and interview, the facility failed to maintain a safe, clean, sanitary, and comfortable environment by failing to maintain shower rooms in a safe and sanitary condition and failing to prevent persistent objectionable odors in the facility. These deficient practices had the ability to affect all residents. The facility census was 88. The facility did not provide a policy regarding environmental sanitation and maintenance. 1. Observation on 07/09/26 at 8:40 A.M. of shower room A-6 showed: - A facial tissue and plastic bag in the sink; - An opened one-gallon bottle of bodywash/shampoo sat on the shower room floor with no lid; - An approximate one inch by one inch gauze pad containing a brownish-red substance on the shower room floor; - An adhesive bandage containing a reddish substance on the shower room floor; - No handrail adjacent to the shower head. 2. Observation on 07/09/26 at 8:45 A.M. of shower room A-7 showed: - An opened one-gallon bottle of bodywash/shampoo sat on the shower room floor without a lid; - The shower head hanging downward because no wall hook was present to secure it; - A shower curtain missing two hooks. During an interview on 07/06/26 at 1:00 P.M., Resident #86 said he/she needed to hold onto the rail while showering and also needed the shower head on a hook on the wall, so he/she can hold onto the rail and not have to hold onto the shower head and try to shower. One shower room has handrails but the shower head dangles down and the other shower room has no handrails by the shower head, but the shower head is on a wall hook. He/She needs rails and for the shower head to be mounted on the wall to shower safely. He/She has been taking bed baths because he/she feels the shower rooms are unsafe. 3. Observation of Resident #68's room showed: - On 07/06/26 at 12:35 P.M., a strong urine odor was present; - On 07/07/26 at 5:30 P.M., and 07/08/26 at 11:30 A.M., a strong urine odor was present and food debris was scattered on the floor beside the bed; 4. Observation of 700 and 800 halls showed: - On 07/07/26 at 5:26 P.M., and 07/09/26 at 1:32 P.M., a strong urine odor was present throughout; - On 07/09/26 at 2:43 P.M., a strong urine odor was present throughout the unit. During an interview on 07/09/26 at 6:00 P.M., the Administrator said she would expect shower rooms to have curtains with no missing hooks, and for shower heads to be accessible and usable for all residents, meaning shower heads should be attached to the wall and not dangling, in case the residents need to hold the rail while showering. She also expects the shower rooms to be clean and free from dirty bandages or gauze bandage on the shower floor. The facility should also be free from urine and feces odors. During an interview on 07/17/26 at 10:34 A.M., the Maintenance Supervisor said the shower head hook to connect it on the wall has been broken for approximately one to one-and-a-half weeks. He had to wait until a new month to make a new order, but the parts are on order. He said when they were redoing the shower rooms, the handrail in front of the shower got broken and there are plans for it to be replaced, the part is not ordered yet. He is trying to get some bolts out of another piece to see if that rail can be used. During an interview on 07/17/26 at 10:38 A.M., the Housekeeping Supervisor said that rooms and shower rooms are cleaned every day. She said if there is an odor or a mess in a room staff will go back and clean again. She said she checks the shower curtains for missing hooks every couple of weeks, and she usually has hooks on hand to replace them. She said there should not be trash left in the sink or on the floor, and when it is found by housekeeping, they will throw away the trash and clean the area. Complaint #MO3064914

Based on interview and record review, the facility failed to ensure the required members attended Quality Assurance & Performance Improvement (QAPI) meetings at least quarterly. The facility's census was 87. The facility did not provide a policy. 1. Review of the monthly QAPI Meeting sign in sheets, dated August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, and February 2025, provided by the Administrator, showed the following required members attended each meeting: - Administrator; - Director of Nursing; - Infection Preventionist; - At least two other staff members; - No record of the Medical Director attending any meetings. During an interview on 03/12/25 at 4:36 P.M., the Director of Nursing (DON) said the Medical Director is invited, but he does not come to the meetings. During an interview on 03/12/25 at 4:30 P.M., the Administrator said the Medical Director should be coming to the meetings.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility's census was 87. Review of the facility's policy titled, Shower Room, undated, showed: - Maintaining a clean and sanitary shower room in skilled nursing facilities is crucial for infection control and resident safety; - Shower rooms should be cleaned and disinfected daily, with increased frequency based on usage and facility needs; - High-touch surfaces and any visibly soiled areas should be cleaned and disinfected immediately after each use; - Remove any waste or disposable items from the area; - Apply detergent to all surfaces, including walls, floors, fixtures, and equipment; - Scrub surfaces to remove dirt and biofilm. Observations on 03/10/25 between 10:05 A.M. and 10:48 A.M. showed: - The A wing shower room between hallway 200 and 300 had two, 2 inch (in.) diameter piles of fecal material about 1 in. near the shower drain and the caulking around the shower perimeter, where the wall meets the floor, was covered with a black substance; - The B wing B7 shower room: - Had the shower stall's caulking around the perimeter, where the wall meets the floor, was covered in a black substance; - Had 16, 1 in by 1 in. ceramic tiles missing to the entrance of the shower, exposing the floor beneath; - Had 1 foot (ft.) by 1 ft. section of floor tiles with a black substance between the 1-in. by 1-in. shower floor tiles; - The locked unit B6 shower room caulking around the perimeter, where the wall meets the floor, was covered in a black substance and three missing 4-in. by 4-in. ceramic wall tiles near the floor on the separation wall between the toilet and the sink. During an interview on 03/10/25 at 9:53 A.M., Resident #238 said the A wing shower room has a black substance in the floor. He/she would prefer the shower to look and feel clean. During an interview on 03/12/25 at 3:38 P.M., Resident #15 said the shower floor on B wing has a black substance and he/she would prefer it to look and feel clean. During an interview on 03/10/25 at 10:08 A.M., Housekeeper O said cleaning is done early every morning. He/she had cleaned this morning in the A wing shower room around 8:00 A.M. He/she also cleans the showers as needed, but usually it is only when someone tells him/her there is a problem. He/she wasn't told about any problems today in the A wing shower room. During an interview on 03/10/25 at 10:11 A.M., Housekeeper P said he/she usually cleans showers every morning. He/she has cleaned showers this morning. During an interview on 03/10/25 at 10:45 A.M., Housekeeper Q said he/she has scrubbed the black substance in the showers on the locked unit and on B wing but it doesn't come up. The former maintenance director was aware of the problem with the showers. It is unknown if the new maintenance director was told about the shower problems, including tile damage. During an interview on 03/12/25 at 12:50 P.M., the Administrator said the shower rooms should be kept clean and not have a black substance build up or feces in the floor. If the housekeepers can't remove the black substance, the caulk can be removed and replaced. Tiles should be kept intact on the floor and walls and the missing tiles will be replaced. During an interview on 03/12/25 at 2:16 P.M., the Maintenance Director said the showers should not have black build up in the corners, the caulk will be removed and replaced so housekeeping can scrub away black substance easily. The floor and wall tiles should be kept intact and the grout with black build up can be grinded out and replaced. Complaint #MO00250186

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for two residents (Residents #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on inspection of side rails. 1. Review of Resident #29's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/10/25 at 10:30 A.M., Resident lay in bed, grab bar up on left side of bed, right side of bed against the wall; - On 03/11/25 at 2:40 P.M., Resident out of room, grab bar up on left side of bed, right side of bed against the wall; - On 03/12/25 at 10:34 A.M., Resident lay in bed, grab bar up on left side of bed, right side of bed against the wall. During an interview on 03/12/25 at 5:00 P.M., the Maintenance Director said he had not done any inspections/assessments for side rails and grab bars. They are working on a policy for that. During an interview on 03/12/25 at 6:25 P.M., the Director of Nursing (DON) said she would expect the Maintenance Director to do side rail inspections. 46460

Based on interview and record review, the facility failed to provide the required annual competency training for dementia care (care of a resident with an impaired ability to remember, think, or make decisions) and/or have staff attend at least twelve hours of in-service education per year for two of three sampled Certified Nursing Assistants (CNAs). This deficient practice had the potential to affect all residents. The facility's census was 87. The facility did not provide a policy. 1. Review of CNA E's in-service record showed: - A hire date of 07/12/89; - A total of twelve hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. 2. Review of CNA F's in-service record showed: - A hire date of 03/28/23; - A total of four hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. During an interview on 03/12/25 at 3:50 P.M., the Director of Nursing (DON) said she provides some in-service videos on the staff's communication app. There are no written in-services on dementia care. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect in-services to be documented and include annual dementia care training and training on residents with cognitive impairments.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility's census was 87. Review of the facility's policy titled, Cleaning Rotation, dated 2011, showed: - Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; - Items cleaned daily: stove top, grill, exterior and large appliances, kitchen and dining room floors; - Items cleaned weekly: hoods, filters, storerooms. Review of the facility's policy titled, Steam Table Serving Temperatures for Hot and Cold Foods, dated 2011, showed: - Staff will follow the guidelines below when serving hot and cold beverages and food; - Foods will be served at the following temperatures to ensure a safe and appetizing dining experience; - Meat and casseroles at 135 degrees Fahrenheit (F) to 170 degrees F; - Dairy products 41 degrees F or below. 1. Observation on [DATE] at 9:58 A.M. and [DATE] at 12:40 P.M. of the kitchen showed: - No cleaning logs; - Scattered debris below the food preparation table; - Range with food debris on the floor beneath, black grime buildup and oily film on the griddle; - Range hood with an oily film build up on interior and exterior surfaces; - The dishwasher with a white build up on the interior surfaces; - Ice machine with a white build up on the exterior surfaces; - Two 12 inch (in.) ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers; - One light fixture without a plastic cover; - One light fixture with a damaged plastic cover. 2. Observation on [DATE] at 10:05 A.M. of the walk-in freezer showed: - The interior door frame near the ceiling with an approximately 1 in. by 3-foot (ft.) section of ice build up; - Door gasket with a black substance. 3. Observation on [DATE] at 10:15 A.M. of the walk-in refrigerator showed: - One cracked shell egg lay in an unlabeled, undated cardboard tray with 29 whole shell eggs; - One 12 in. by 12 in. foil topped metal container labeled brats, dated [DATE], with six cooked bratwurst sausages with onion bits; - One 12 in. by 12 in. metal container partially full and covered with foil, labeled sausage sauce, dated [DATE]; - One 12 in. by 12 in. metal container partially full of a yellow food, unlabeled and undated; - One 18 in. by 10 in. metal pan with white pureed food half full, unlabeled, dated [DATE]; - One 6 in. round plastic bowl with a brown food, unlabeled, dated [DATE]; - One 4 liter clear pitcher with a clear plastic package of undated, unlabeled liquid egg opened and partially full. 4. Observation on [DATE] at 10:20 A.M. and [DATE] at 12:35 P.M. of the dry food storage room showed: - An opened closet door with a 2 ft. by 1 ft. vent with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers; - Two 24 count boxes of 24 ounce (oz.) chocolate flavored syrup, dated best by [DATE]; - One 6 pound 5 oz. can of cut green beans stored in the floor of the dry storage beside the rack, dated received on [DATE]. 5. Observation of the dining room on [DATE] at 11:30 A.M. showed: - Beef tips in steam table bin at 190 degrees F; - Shepherd's pie in steam table bin at 200 degrees F; - Metal steam table bin container lay on the serving area counter with six bologna and cheese sandwiches at 55 degrees F, dated [DATE]. During an interview on [DATE] at 10:14 A.M., Dietary Aide (DA) L said liquid scrambled eggs are being served and new orders of shell eggs are on hold due to the egg shortage. He/she wasn't aware they had shell eggs and said they must be left over. The shell eggs should have been stored in a box with labels to indicate the expiration date and type of egg, and the cracked egg shouldn't have been in storage. During an interview on [DATE] at 10:42 A.M., the Assistant Dietary Manager (DM) said that food should not have been stored in the walk-in refrigerator without being properly labeled. The brown food wrapped in the round bowl should have been labeled and thrown out a long time ago since it was dated [DATE]. Leftover food should not be stored in those types of containers in the refrigerator. The eggs should have been in a box with labels to indicate the expiration date and type of egg. During an interview on [DATE] at 10:45 A.M., DA K said food should have been stored in a different type of container with a lid and labeled. The food in the small round bowl is unidentifiable, but smelled like it could be chili or taco meat. It should have been thrown out a long time ago since it has a label dated [DATE]. We should throw food out after three days if it isn't used. The eggs should have been in a box with labels to indicate the expiration date and type of egg, and we should not store cracked eggs. During an interview on [DATE] at 12:46 P.M., the DM said no shell eggs are served due to an egg shortage, and the eggs should not have been stored if they are cracked. Opened and leftover foods should be stored with dated labels and discarded after three days; expired foods should be thrown out. A company comes in to clean the vent hood, but staff wash the filters in the dishwasher weekly. The dishwasher should not have white build up inside. The stove and appliances should be cleaned, but there are no cleaning logs yet, as the DA crew is new. Canned food should not be stored in the floor in the dry storage. Vents should be clean, and lighting should be intact. Foods should be held for serving at appropriate temperatures according to facility policy. During an interview on [DATE] at 12:50 P.M., the Administrator said stored food should be labeled in the refrigerator and in the dry storage. The vents should be clean and light fixtures should be intact. Appliances should be kept clean, and the floors and walls should be cleaned underneath. There should be cleaning logs. The eggs should have been in a box with labels to indicate the expiration date and type of egg, and expired food should be thrown out. Foods should be held at safe temperatures and dietary staff should follow facility policy. During an interview on [DATE] at 2:16 P.M., the Maintenance Director said the walk-in freezer should not have ice build-up above the door. It may need a new gasket, and it should not have black build up. The vents in the kitchen ceiling should be clean and they will be repaired or replaced. The lighting should be intact, and it will be replaced in the kitchen. Repair parts and replacements get delayed due to shipping.

Based on interview and record review, the facility failed to document pertinent education provided to the resident or the resident's representative regarding benefits, side effects, or warnings of the influenza (a viral respiratory infection) and/or the pneumococcal (an infectious lung disease) vaccine for two residents (Residents #36 and #47) out of five sampled residents. The facility's census was 87. The facility did not provide a policy regarding influenza or pneumococcal vaccination. 1. Review of Resident #36's medical record showed: - admitted [DATE]; - No documentation the facility provided information and education for influenza or pneumococcal vaccinations; - No documentation of consent or refusal; - No documentation the influenza or the pneumococcal vaccinations had been administered. 2. Review of Resident #47's medical record showed: - admitted [DATE]; - An incomplete Pneumococcal and Influenza Immunization consent form, signed by the representative on 06/17/24, that did not state whether or not the resident was to receive vaccinations; - No documentation that the influenza or pneumococcal vaccinations had been administered. During an interview on 03/12/25 at 2:09 P.M., the Minimum Data Set (MDS-a mandatory assessment tool to be filled out by facility staff) Coordinator said he/she could not find any more information for the residents that were missing vaccinations, but the facility does offer all vaccinations. During an interview on 03/12/25 at 4:03 P.M., the Director of Nursing (DON) said the facility is doing a complete audit of all vaccinations for all residents now.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #29) out of one sampled resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 87. Review of the facility's policy, Pain Assessment and Management, revised March 2015, showed: - The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; - The pain management program is based on a facility-wide commitment to resident comfort; - Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 1. Review of Resident #29's medical record showed: - admitted [DATE]; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints). Review of the resident's Physician's Order Sheet (POS), dated 03/11/25, showed: - Pain Scale twice daily every day and night shift for pain assessment, dated 11/15/24 and discontinued 12/28/24; - Pain Scale twice daily every day and night shift for pain assessment, dated 12/28/24; - Out of bed in chair daily, every shift, dated 11/15/24 and discontinued 12/01/24; - Out of bed in chair daily, every day shift, dated 12/01/24 and discontinued 01/22/25; - MS Contin Oral Tablet Extended Release (opioid pain medication) 30 mg, give 45 mg by mouth two times a day related to pain. Give with 15 mg tablet totaling 45 mg, dated 11/15/24 and discontinued 11/20/24; - MS Contin Oral Tablet Extended Release 15 mg, give 15 mg by mouth two times a day related to pain, dated 11/15/24 and discontinued 11/20/24; - MS Contin Oral Tablet Extended Release 15 mg, give 15 mg by mouth every morning and at bedtime related to pain, dated 11/21/24 and discontinued 02/26/25; - MS Contin Oral Tablet Extended Release 30 mg, give 45 mg by mouth every morning and at bedtime related to pain. Give with 15 mg tablet totaling 45 mg, dated 11/21/24 and discontinued 02/26/25; - MS Contin Oral Tablet Extended Release 15 mg, give 15 mg by mouth every morning and at bedtime related to pain, dated 02/26/25; - MS Contin Oral Tablet Extended Release 30 mg, give 45 mg by mouth every morning and at bedtime related to pain, dated 02/26/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 02/24/25, showed: - No cognitive impairment; - Total dependence on staff for bed mobility, sitting to lying, personal hygiene, upper and lower body dressing, chair/bed to chair transfer, toilet transfer and hygiene, tub/shower transfer, and showering/bathing; - Pressure reducing device for bed; - Almost constant pain that affects sleep frequently and affects day-to-day activities almost constantly. Review of the resident's care plan, revised 02/21/25, showed: - The resident has abdominal pain and right hip pain related to arthritis; - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects, and impact on function; - The resident will not have an interruption in normal activities due to pain through the review date; - The resident will not have discomfort related to side effects of analgesia through the review date. Review of the resident's Medication Administration Record (MAR), dated 11/15/24 through 03/12/25, showed: - In November, the resident missed five doses of MS Contin 15 mg out of 30 opportunities; - In November, the resident missed six doses of MS Contin 30 mg out of 30 opportunities; - In December, the resident missed three doses of MS Contin 15 mg out of 62 opportunities; - In December, the resident missed three doses of MS Contin 30 mg out of 62 opportunities; - In January, the resident missed four doses of MS Contin 15 mg out of 62 opportunities; - In January, the resident missed four doses of MS Contin 30 mg out of 6 opportunities; - In February, the resident missed 14 doses of MS Contin 15 mg out of 56 opportunities; - In February, the resident missed 10 doses of MS Contin 30 mg out of 56 opportunities; - In March, the resident missed three doses of MS Contin 15 mg out of 24 opportunities; - In March, the resident missed one dose of MS Contin 30 mg out of 24 opportunities. Review of the resident's progress notes showed: - On 11/17/24 at 5:44 P.M., medication (MS Contin 15 mg) not available; - On 11/29/24 at 9:02 A.M., awaiting medicine (MS Contin 30 mg) from pharmacy; - On 12/23/24 at 7:59 P.M., resident out of Morphine (MS Contin) 30 mg; - On 12/24/24 at 6:41 P.M., medication (MS Contin 30 mg) on order; - On 12/26/24 at 9:50 P.M., medication (MS Contin 15 mg) not available; - On 12/31/24 at 8:11 A.M., (MS Contin 30 mg) not available; - On 12/31/24 at 8:11 A.M., (MS Contin 15 mg) not available; - On 01/31/25 at 11:36 P.M., medication (MS Contin 30 mg) not available; - On 01/31/25 at 11:36 P.M., medication (MS Contin 15 mg) not available; - On 02/01/25 at 10:28 A.M., waiting for medication (MS Contin 30 mg) to be dispensed from the pharmacy. It is supposed to arrive today; - On 02/01/25 at 10:29 A.M., waiting for medication (MS Contin 15 mg) to be dispensed from the pharmacy. It is supposed to arrive today; - On 02/02/25 at 7:39 A.M., MS Contin 30 mg only given - 15 mg cap unavailable; - On 02/02/25 at 7:40 A.M., MS Contin 30 mg only given - 15 mg cap unavailable; - On 02/02/25 at 9:17 P.M., MS Contin 15 mg pill unavailable; - On 02/02/25 at 9:18 P.M., medication (MS Contin 15 mg) unavailable; - On 02/03/25 at 9:12 P.M., waiting for medication (MS Contin 15 mg) from pharmacy; - On 02/04/25 at 1:03 P.M., MS Contin 30 mg not available from pharmacy. Pharmacy called; - On 02/04/25 at 1:05 P.M., MS Contin 15 mg not available from pharmacy. Pharmacy called; - On 02/04/25 at 8:32 P.M., medication (MS Contin 15 mg) unavailable; - On 02/18/25 at 8:32 A.M., medication (MS Contin 30 mg) unavailable; - On 02/23/25 at 11:39 A.M., MS Contin 30 mg unavailable. Awaiting signed script; - On 02/23/25 at 7:43 P.M., MS Contin 30 mg not available; - On 02/24/25 at 8:00 P.M., resident requested hydrocodone-acetaminophen 10-325 mg. Resident out of morphine; - On 02/25/25 at 10:45 P.M., medication (MS Contin 15 mg) not available; - On 02/25/25 at 10:47 P.M., medication (MS Contin 30 mg) not available; - On 02/26/25 at 9:15 A.M., medication (MS Contin 15 mg) unavailable; - On 02/26/25 at 9:16 A.M., medication (MS Contin 30 mg) unavailable; - On 02/27/25 at 9:28 A.M., MS Contin 15 mg unavailable; - On 02/27/25 at 8:42 P.M., MS Contin 15 mg not available; - On 02/28/25 at 7:23 A.M., medication (MS Contin 15 mg) not available; - On 03/04/25 at 9:25 P.M., medication (MS Contin 15 mg) is on order; - On 03/05/25 at 9:20 A.M., medication (MS Contin 30 mg) is not available; - On 03/06/25 at 7:24 A.M., medication (MS Contin 15 mg) not available. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/12/25 at 2:45 P.M., up in his/her motorized scooter in the hall. During an interview on 03/09/25 at 12:54 P.M., the resident said he/she has a lot of pain and the facility has run out of his/her pain medication, MS Contin, a few times since he/she moved here in November. He/She is unable to give a pain rating that would be acceptable. His/Her goal is to get up in the motorized scooter three to four days a week. He/She can tolerate about an hour now. During an interview on 03/12/25 at 6:25 P.M., the Director of Nursing said she would expect residents to get their pain medication as ordered and for their pain to be managed at an acceptable level to the resident. During an interview on 03/20/25 at 2:20 P.M., the DON said one of the doctors was out sick and could not sign scripts, and the facility wasn't aware for about two to three weeks. They do have another doctor that covers. Staff would look at alternatives in the Emergency Kit (E-kit) and get approval from the doctor to give that if a medication was not available. They would try to get as close to the ordered medication as possible. There were days that the pharmacy could not make deliveries due to the winter weather. The facility just got a new pharmacy system in place this week, and it should make things go much more smoothly.

Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for five residents (Resident #29, #36, #57, #76, #83) out of 18 sampled residents and one resident (Resident #87) outside the sample. The facility's census was 87. Review of the facility's policy, Bed Holds and Returns, revised March 2017, showed: - Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy; - Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: the rights and limitations of the resident regarding bed holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and the details of the transfer (per the Notice of Transfer). 1. Review of Resident #29's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #36's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 3. Review of Resident #57's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 4. Review of Resident #76's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 01/28/25; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 5. Review of Resident #83's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 6. Review of Resident #87's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 03/12/25 at 8:25 A.M., the Director or Nursing (DON) said that family and responsible parties are notified verbally of transfers to the hospital. He/she was unaware bed holds had to be sent out on every hospital transfer, he/she thought they were only to be sent if the resident was in the hospital past midnight. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect bed hold policies to be given in writing to the resident and/or the resident's representative when discharging or transferring to the hospital.

Based on interview and record review, the facility failed to ensure the Covid-19 (an infectious disease caused by a virus that could cause some people to become seriously ill and require medical attention) vaccination was offered, administered, or refused by the resident and/or resident's representative for three residents (Resident #36, #47 and #56) out of five sampled residents. The facility's census was 87. Review of the facility's Immunization Policy, undated, showed: - The Centers for Medicare and Medicaid Services (CMS) mandates that all long term care facilities develop and implement policies to ensure that all staff are fully vaccinated against Covid-19. This includes educating residents and staff about benefits and potential side effects of the Covid-19 vaccine and offering the vaccine to them; - Facilities are expected to have processes in place to track and securely document the vaccination status of all staff and residents. 1. Review of Resident #36's medical record showed: - admitted [DATE]; - Diagnoses of schizoaffective disorder (a condition that includes delusions, hallucinations, depressed episodes and manic periods of high energy), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), borderline intellectual functioning (below average cognitive ability) and hypertension (high blood pressure); - No documentation the education of Covid-19 vaccination was provided; - No documentation the Covid-19 vaccination was provided or refused. 2. Review of Resident #47's medical record showed: - admitted [DATE]; - Diagnoses of morbid obesity, aphasia (a language disorder that affects a person's ability to communicate), functional quadriplegia (a condition where someone is unable to move limbs due to a medical condition, not spinal cord damage), post traumatic seizures (seizures that occur after a traumatic brain injury) and hypertension (high blood pressure); - No documentation the education of Covid-19 vaccination was provided; - No documentation the Covid-19 vaccination was provided or refused. 3. Review of Resident #56's medical record showed: - admitted [DATE]; - Diagnoses of rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in hands and feet), paraplegia (paralysis that affects all or parts of the trunk, legs and pelvic organs, Kienbocks disease (a rare, progressive bone disorder that disrupts blood flow to the small wrist bones) and pressure ulcer of the coccyx (tailbone); - No documentation the education of Covid-19 vaccination was provided; - No documentation the Covid-19 vaccination was provided or refused. During an interview on 03/12/25 at 2:09 P.M., the Minimum Data Set (MDS-a mandatory assessment tool to be filled out by facility staff) Coordinator said he/she could not find any more information for the residents that were missing vaccinations, but the facility offers all vaccinations. During an interview on 03/12/25 at 4:03 P.M., the Director of Nursing (DON) said the facility is doing a complete audit of all vaccinations for all residents now.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for ten residents (Resident #6, #14, #19, #37, #38, #57, #70, #72, #78, and #79) out of the 14 sampled residents. The facility's census was 87. Review of the facility's policy titled, Hand Hygiene Policy and Procedure, dated 2025, showed: - The purpose is to establish clear and standardized hand hygiene practices for all staff to prevent the spread of infections, maintain a safe environment, and comply with CMS (Centers for Medicare and Medicaid Services, CDC (Centers for Disease Control), and state infection control guidelines. This policy includes specific hand hygiene practices related to peri care (the cleaning of the the genitals and anal area) to minimize the risk of urinary tract infections (UTIs) and other infections; - This policy applies to all facility staff, including nurses, Certified Nurse Aides (CNAs), therapists, dietary staff, housekeeping, and any personnel with direct or indirect resident contact; - All staff must perform hand hygiene correctly and consistently before, during, and after resident care activities, including peri care, to prevent the transmission of infections; - Indications for hand hygiene-Staff must perform hand hygiene at the following times: Before and after direct contact with a resident, before performing an aseptic (being free from, or designed to prevent the presence of, disease-causing microorganisms) task, after contact with blood, body fluids, secretions, excretions, or contaminated surfaces, before and after wearing gloves; - Hand hygiene methods: Alcohol-based hand rub (preferred method), use alcohol-based hand rub with at least 60 percent (%) alcohol when hands are not visibly soiled; Hand washing with soap and water (required in certain circumstances); - Glove use and hand hygiene: Gloves do not replace hand hygiene, perform hand hygiene before putting on gloves and immediately after removing them. Change gloves when moving from a dirty to clean task, gloves become damaged or visibly contaminated, switching between different body areas. The facility did not provide a policy for Medication Administration. 1. Observation on 03/11/25 at 11:00 A.M. showed: - Certified Medication Technician (CMT) M administered medications to Resident #72; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration; - CMT M used a glucometer (a device used to check blood sugar level) to obtain a blood sugar level for Resident #72. CMT M did not wear gloves or wash/sanitize his/her hands prior to or after using the glucometer; - CMT M placed the glucometer on top of the medication cart without a barrier and without sanitizing the glucometer. 2. Observation on 03/11/25 at 11:05 A.M. showed: - CMT M administered medications to Resident #78; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 3. Observation on 03/11/25 at 11:13 A.M. showed: - CMT M administered medications to Resident #19; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 4. Observation on 03/11/25 at 11:15 A.M. showed: - CMT M administered medications to Resident #70; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 5. Observation on 03/11/25 at 11:20 A.M. showed: - CMT M administered medications to Resident #57; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 6. Observation on 03/11/15 at 11:25 A.M. showed: - CMT M administered medications to Resident #79; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 7. Observation on 03/11/25 at 11:32 A.M. showed: - CMT M administered medications to Resident #14; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 8. Observation on 03/11/25 at 11:35 A.M. showed: - CMT M administered medications to Resident #6; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 9. Observation on 03/11/25 at 11:45 A.M. showed: - CMT M administered medications to Resident #38; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 10. Observation on 03/11/25 at 11:48 A.M. showed: - CMT M administered medications to Resident #37; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. During an interview on 03/11/25 at 2:00 P.M., CMT M said that he/she should sanitize his/her hands between every resident when administering medications. He/She should wear gloves when administering ointments and when dealing with blood. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect CMTs to utilize proper hand sanitization and glove use while administering medications and obtaining blood sugar checks.

Based on interview and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, and reconciled for one resident (Resident #29) of 18 sampled residents and failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and end of each shift. The facility failed to document the total number of narcotic drug cards counted for two of three narcotic count books checked. The facility's census was 87. Review of the facility's policy titled, Controlled Substances, revised December 2012, showed: - The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; - Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services; - The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the Administrator a written report of such findings. 1. Observation of Resident #29's medication cards showed: - On 03/12/25 at 3:20 P.M., MS Contin (opioid pain medication) 30 milligram (mg) card showed one tablet in the card; - On 03/12/25 at 3:22 P.M., MS Contin 15 mg card showed 16 tablets in the card. Review of Resident #29's Controlled Substance Accountability Sheets showed: - On 03/12/25 at 3:20 P.M., MS Contin 30 mg with a count of two; - On 03/12/25 at 3:22 P.M., MS Contin 15 mg with a count of 15. During an interview on 03/12/25 at 3:20 P.M., Registered Nurse (RN) N said he/she gave the resident MS Contin 30 mg this morning and forgot to sign it out. He/She signed out MS Contin 15 mg and gave it to the resident this morning at 8:00 A.M., but he/she did not make the entry with no signature on the line just above it that showed on 03/11/25 at 8:00 A.M. that the count was 17 and one was given for an ending count of 16. He/She should sign medications out when they are given. 2. Review of the Nurses Controlled Substance Shift Change Record, dated 01/01/25 through 03/12/25, showed: - Signing indicates Package Quantity matches Package Log and Tablets remaining match Medication Administration Count Sheet; - A Hall oncoming and offgoing nurses missed a total of 103 out of 141 opportunities; - B Hall oncoming and offgoing nurses missed a total of 134 out of 147 opportunities. Review of the Certified Medication Technician (CMT) Controlled Substance Shift Change Record, dated 01/01/25 through 03/12/25, showed: - Signing indicates Package Quantity matches Package Log and Tablets remaining match Medication Administration Count Sheet; - 100/200 Hall oncoming and offgoing CMTs missed a total of 38 out of 57 opportunities in February with the facility unable to provide count sheets for January and March; - 300/400 Hall oncoming and offgoing CMTs missed a total of 18 out of 56 opportunities in February with the facility unable to provide count sheets for January and March; - B Hall oncoming and offgoing CMTs missed a total of 51 out of 62 opportunities with the facility unable to provide count sheets for February and March; - B Hall Unit oncoming and offgoing CMTs missed a total of 50 out of 62 opportunities with the facility unable to provide count sheets for February and March. During an interview on 03/12/25 at 3:47 P.M., Licensed Practical Nurse (LPN) G said he/she isn't sure why they don't count cards. Different facilities do different things. During an interview on 03/12/25 at 4:07 P.M., the Director of Nursing (DON) said offgoing and oncoming staff should be counting cards together with each shift change. Staff should sign out medications at the time they give them. During an interview on 03/20/25 at 2:20 P.M., the DON said the Shift Change Record indicates that both the oncoming and offgoing nurses have counted each resident's total number of pills on each narcotic card as well as total cards for each shift. The facility has two nurse narcotic carts and four CMT narcotic carts.

Based on interview and record review, the facility failed to ensure that three nursing assistants (NAs) completed a nursing assistant training program within four months of his/her employment at the facility. This deficient practice had the potential to affect all residents. The facility's census was 87. Review of the facility's policy, Nurse Aide Training Program, Purpose of, last revised December 2006, showed: - The primary purpose of the nurse aide training program is to prepare the individual for employment in a long-term care facility; - Provide each individual presently employed in the long-term care facility with an in-depth training program; - Provide each student with instructions on how to perform basic long-term care nursing procedures; - The policy did not address time frame in which NAs must become certified. 1. Review of Nursing Assistant H's personnel file and schedule showed: - Hire date of 09/11/24; - Not currently enrolled in a Certified Nursing Assistant (CNA) class; - Scheduled to work day shift on 03/01/25, 03/02/25, 03/05/35, 03/07/25, 03/10/25, 03/11/25, 03/12/25, 03/15/25, 03/16/25, 03/19/25, 03/21/25, 03/24/25, 03/25/24, 03/26/25, 03/29/25 and 03/30/25; - The facility failed to ensure the NA was certified within four months of his/her employment. 2. Review of Nursing Assistant I's personnel file and schedule showed: - Hire date of 10/24/23; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/12/25, 03/14/25, 03/17/25, 03/18/25, 03/19/25, 03/22/25, 03/23/25, 03/26/25, 03/28/25 and 03/31/25; - The facility failed to ensure the NA was certified within four months of his/her employment. 3. Review of Nursing Assistant J's personnel file and schedule showed: - Hire date of 08/23/24; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 03/01/25, 03/02/25, 03/04/25, 03/06/25, 03/08/25, 03/09/25, 03/11/25, 03/13/35, 03/15/25, 03/16/25, 03/18/25 and 03/20/25; - The facility failed to ensure the NA was certified within four months of his/her employment. During an interview on 03/12/25 at 4:30 P.M., the Director of Nursing (DON) said the facility is currently not able to have Certified Nursing Assistant (CNA) classes, but they were having them prior to getting a citation. All non-certified NAs are still working on the floor. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect NAs to be certified within four months of being hired and, if not certified within that time frame, the employee(s) should be moved to a department that doesn't have direct resident contact.

Based on observation, interview, and record review, the facility failed to appropriately assess residents for the use of side rails prior to installation or use, the facility failed to obtain informed consent from the resident or resident's representative, and the facility failed to provide on-going monitoring, supervision, and routine maintenance of the beds with side rails in use for two residents (Resident #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on side rails. 1. Review of Resident #29's medical record showed: - admitted [DATE]; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints); - On 11/16/24, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - An order for horse shoe rails for positioning, dated 11/27/24; - Resident was not assessed for risk of entrapment; - No signed informed consent that explained risks and benefits for side rail use. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment completed by the facility), dated 02/24/25, showed dependent on staff for bed mobility. Review of the resident's care plan, revised 02/24/25, did not address the use of side rails/grab bars. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed: - admitted on [DATE]; - Diagnoses of morbid obesity (excessive amount of body fat), aphasia (a language disorder that affects a person's ability to communicate, functional quadriplegia (a condition where someone is unable to move limbs due to a medical condition, not spinal cord damage), post traumatic seizures (seizures that occur after a traumatic brain injury) and hypertension (high blood pressure); - On 02/11/25, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - Resident was not assessed for risk of entrapment; - No order for side rails; - No signed informed consent that explained risks and benefits for side rail use. Review of the resident's quarterly MDS, dated [DATE], showed requires maximum assistance with bed mobility. Review of the resident's undated care plan did not address the use of side rails/grab bars. Observations of the resident showed: - On 03/10/25 at 10:30 A.M., resident lay in bed, grab bar up on left side of bed, right side of bed against the wall; - On 03/12/25 at 10:34 A.M., resident lay in bed, grab bar up on left side of bed, right side of bed against the wall. During an interview on 03/12/25 at 4:57 P.M., the Director of Nursing (DON) said if a resident assessment showed not indicated for side rails, he/she would not expect the resident to have them. If the resident wanted to use side rails as an enabler, another assessment should be completed. During an interview on 03/12/25 at 5:00 P.M., the Maintenance Director said he/she has not done any assessments for side rails/grab bars and they are working on a policy for that. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect residents to have a signed consent for the use of side rails and/or grab bars. They would also expect maintenance to complete a bed rail/entrapment assessment. 46460

Based on observation, interview, and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions to meet the highest practicable physical, mental, and psychosocial well-being for four residents (Residents #29, #47, #49, and #79) out of 18 sampled residents and one resident (Resident #86) outside the sample. The facility's census was 87. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - admitted [DATE]; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints); - On 11/16/24, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - An order for horse shoe rails for positioning, dated 11/27/24; - An order for the audiologist to evaluate and treat, dated 2/27/25; - A quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility) assessment, dated 02/24/25, with B0200 marked for moderate difficulty with hearing; - Care plan did not address the use of side rails/grab bars or hearing difficulty. During an interview on 03/09/25 at 12:54 P.M., the resident said he/she has had hearing loss since living here. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed: - admitted [DATE]; - Diagnoses of morbid obesity, aphasia (a language disorder that affects a person's ability to communicate, functional quadriplegia (a condition where someone is unable to move limbs due to a medical condition, not spinal cord damage), post traumatic seizures (seizures that occur after a traumatic brain injury) and hypertension (high blood pressure); - Nurses Note, dated 6/21/24, showed the resident found on floor next to lowered bed, no injuries; - Side Rail assessment, dated 02/11/25, did not indicate need for bed rails; - Care plan did not address falls, grab bar, or fall mat. Observation on 03/10/25 at 10:30 A.M. showed the resident lay in a low rise bed with a floor mat and a grab bar on the left side of the bed. 3. Review of Resident #49's medical record showed: - admitted [DATE]; - Diagnoses of type 2 diabetes (a condition in which the body has trouble controlling blood sugar and using it for energy), pressure ulcer of the sacral region (area just above the buttocks and the base of the spine), and paraplegia (a condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body); -A Physician's order dated, 01/22/25, low concentrated sweets (LCS) diet, regular texture, regular/thin consistency; - Care plan did not address the use of cigarettes and supervised smoking status or the need for a LCS diet. During an interview on 03/09/25 at 11: 00 A.M., Resident #49 said he/she is a smoker and was unhappy that the facility changed the policy and now all residents are supervised smokers. 4. Review of Resident #79's medical record showed: - admitted [DATE]; - Diagnoses of spinal stenosis (spaces inside the bones of spine are too small and may cause, pain, tingling or weakness in an arm, hand, arm foot or leg) and chronic pain; - A smoking assessment, dated 10/16/24, showed safe to smoke without supervision; - Care plan did not address smoking. 5. Review of Resident #86's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), dementia, and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy); - admitted to hospice on 02/28/25; - Care plan did not address hospice. During an interview on 03/12/25 at 9:00 A.M., the MDS (Minimum Data Set, a mandatory assessment completed by the facility) Coordinator said that each department puts in their part of the care plan; it is a team effort. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect care plans to accurately reflect the condition of the residents and to be updated as needed. 46460 49754

Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Residents #138 and #289) out of 18 sampled residents. The facility's census was 87. Review of the facility's policy, Care Plans-Baseline, undated, showed: - A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; - The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medication, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs, including but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services; Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendations, if applicable; - The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; - The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: initial goals of the resident, a summary of the resident's medication and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan, as necessary. 1. Review of Resident #138's medical record showed: - An admitted [DATE]; - Diagnoses of fractured (broken) right humerus (the long bone in upper arm), epilepsy (a disorder that causes seizures) and depression; - No baseline care plan. Observation on 03/10/25 at 2:36 P.M. showed the resident with a sling on his/her right arm, hand was swollen and resting on leg. 2. Review of Resident #289's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (a decline in cognitive function that cannot be attributed to a specific known cause), cirrhosis of the liver (a condition in which the liver is scarred but the specific cause of the scarring is unknown), constipation, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), essential primary hypertension (a chronic cardiovascular disease that causes abnormally high blood pressure for unknown reasons), and chronic viral hepatitis C (a liver infection caused by the hepatitis C virus (HCV) that persists more than six months); - A baseline care plan, dated 03/10/25, three days after being admitted to the facility. During an interview on 03/12/25 at 9:00 A.M., the MDS (Minimum Data Set) Coordinator said the admitting nurse should fill out a baseline care plan on newly admitted residents upon arrival. He/She will be doing them from now on. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect baseline care plans to be completed within the required time frame. 49754

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #52) out of 18 sampled residents and one resident (Resident #86) outside the sample. The facility's census was 87. Review of the facility's policy, Certifying Accuracy of the Resident Assessment, revised December 2009, showed all personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; - Section A1805: Enter the two-digit code that best describes the setting the resident was in immediately preceding this admission/entry or reentry; - Section A1805: Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was admitted from a hospital that is contracted with Medicare to provide acute inpatient care and accepts a predetermined rate as payment in full. 1. Review of Resident #52's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), alcoholic cirrhosis of the liver (a chronic liver disease caused by long-term excessive alcohol consumption), insomnia (persistent problems falling and staying asleep), and pain; - admitted to hospice on 10/27/24; - A significant change MDS assessment with an ARD of 01/14/25 with Section O0110K1 marked no for hospice care. 2. Review of Resident #86's medical record showed: - An admitted [DATE]; - Diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), dementia, and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy); - A progress note dated 02/28/25. Resident readmitted to the facility after a hospital stay. Hospital stay dates 02/23/25-02/28/25; - A Death in Facility MDS tracking record dated 03/03/25, with Section A1805 marked entered from a nursing home (long-term care facility). During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing said they would expect MDS assessments to be coded accurately.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility) within the required time frames for seven residents (Resident #29, #31, #36, #49, #52, #68, and #83) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on completion of MDS assessments. Record review of the Resident Assessment Instrument (RAI) Manual showed: - For the Admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; - For the Admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later than than 13 days after the Entry Date (A1600); - For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). 1. Review of Resident #29's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 12/12/24, and MDS completion date of 12/12/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 2. Review of Resident #31's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 03/29/24, and MDS completion date of 03/29/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 3. Review of Resident #36's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 03/17/24, and MDS completion date of 03/17/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 4. Review of Resident #49's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 12/18/24, and MDS completion date of 12/18/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 5. Review of Resident #52's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 11/01/24, and MDS completion date of 11/01/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 6. Review of Resident #68's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 07/10/24, and MDS completion date of 07/10/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 7. Review of Resident #83's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 01/14/25, and MDS completion date of 01/14/25; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect MDS assessments to be completed in a timely manner per the RAI manual.

Based on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for four residents (Resident #29, #57, #76, #83) out of 18 sampled residents and one resident (Resident #87) outside the sample. The facility's census was 87. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer; - Hospital transfer on 01/30/25 not included on the monthly list sent to the ombudsman. 2. Review of Resident #57's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 3. Review of Resident #76's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer; - Hospital transfer on 01/28/25 not included on the monthly list sent to the ombudsman. 4. Review of Resident #83's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 5. Review of Resident #87's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 03/12/25 at 10:54 A.M., the Social Services Designee said she sends the list to the ombudsman monthly. She does not send them if residents go out and come right back in the same day. She will add them to the list if they are a true discharge, meaning out overnight. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect transfer notifications to be given in writing to the resident and/or resident's representative upon discharge or transfer. They would also expect all transfers, including emergent transfers, to be included on the monthly list sent to the Ombudsman.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two residents (Resident #52 and #56) out of 18 sampled residents and one resident (Resident #33) outside the sample. The facility's census was 87. The facility did not provide a policy that addressed the timely completion of significant change MDS assessments. Review of the Resident Assessment Instrument (RAI) Manual, revised October 2024, showed: - A significant change in status (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident; - A SCSA is required to be completed by the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). 1. Review of Resident #33's medical record showed: - A quarterly MDS assessment with an ARD of 10/10/24 and a completion date of 10/15/24; - An opened, but incomplete significant change MDS assessment with an ARD of 01/11/25; - The facility failed to complete a significant change assessment within 14 days. 2. Review of Resident #52's medical record showed: - An admitted [DATE] to hospice services; - A significant change MDS assessment with an ARD of 01/14/25 and a completion date of 02/05/25; - The facility failed to complete a significant change MDS assessment within 14 days of hospice admission. 3. Review of Resident #56's medical record showed: - An admitted [DATE] to hospice services; - A significant change MDS assessment with an ARD of 12/04/24 and a completion date of 12/30/24; - The facility failed to complete a significant change MDS assessment within 14 days of hospice admission. During an interview on 03/12/25 at 5:56 P.M., the MDS Coordinator said he/she would expect a significant change assessment to be completed for a resident admitted to hospice, or any other thing that would warrant a significant change, within 14 days. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect a significant change MDS to be completed per the RAI Manual. 46460

Based on observation, record review and interview, the facility failed to provide care in a sterile manner for one resident (Resident #4) of 11 sampled residents and did not assess or notify the physician when the peripherally inserted central catheter (PICC), (a long, flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart, used to deliver fluids, blood transfusions, medications, and nutrition intravenously, and to draw blood samples) line was cut during a dressing treatment and subsequently removed without a physician's order, placing the resident at risk for possible complication of a catheter-related bloodstream infection (CRBSI), which can occur when bacteria enter the bloodstream through the catheter site due to improper sterile technique, potentially leading to serious systemic infection. The facility census was 88. The Administrator was notified on 12/17/24 at 4:50 P.M. of an Immediate Jeopardy (IJ) which began on 12/17/24. The IJ was removed on 12/17/24 as confirmed by surveyor onsite verification. Record review of the facility policy dated August 2014 Guidelines for Preventing Intravenous Catheter Related Infections, directed staff to: - Use either sterile gauze or sterile transparent, semi-permeable membrane to cover central or peripheral (a device used to draw blood and give treatments, including intravenous fluids (IV), drugs, or blood transfusions. A thin, flexible tube is inserted into a vein, usually in the back of the hand, the lower part of the arm, or the foot) catheter sites; - Removal of a midline or any central line is to be performed upon the order of a Physician or authorized prescriber in accordance with State Nurse Practice Act. Review of the following sources, Infusion Nursing: An Evidence-Based Approach, Third Edition edited by [NAME], [NAME], [NAME], [NAME], and [NAME]. 3. INS (Infusion Nurses Society) Policies and Procedures for Infusion Nursing, 3rd Edition and the Infusion Nursing Standards of Practice - Revised 2016; Journal of Infusion Nursing, Supplement to January/February 2016, Volume 39, Number 1S, showed upon removal of an infusion apparatus, appropriate staff should: - Verify physician order; - Measure the catheter and inspect the tip; - Use caution in the removal of a midline/PICC catheter, including precautions and interventions to prevent air embolism (blockage in an artery) and increase the likelihood of clot formation. Petroleum-based ointment and a sterile dressing may be applied to the access site to seal the skin-to-vein tract and decrease the risk of air embolus; - Position the patient so that the IV insertion site is at or below the level of the heart to reduce the risk of air embolus; - Apply a tourniquet to the upper arm by the shoulder if the catheter breaks during removal and a suspected fragment remains in the patient; - Not occlude arterial flow; - Notify the physician immediately and access emergency response system, as appropriate; - Stay with the patient and continue to monitor; - Document procedure, including catheter length, outcome and patient's response on the Midline/PICC progress record or other form as applicable. Review of Resident #4's medical record showed: - Admission to facility on 03/09/22 with last re-admission to the facility on [DATE]; - Cognition intact, own responsible party; - Able to make needs known; - Diagnoses of chronic obstructive pulmonary disease (a common lung disease that causes breathing problems by restricting airflow), osteomyelitis right hip abscess (a painful bone infection that can occur when bacteria or other germs spread to the bone), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and hypertensive heart disease with heart failure (a group of conditions that can occur when high blood pressure (hypertension) goes unmanaged); - No PICC catheter monitoring sheet. Review of the resident's care plan showed no mention of the placement or care of a PICC line. Record review of the December 2024 Physician Order Sheet (POS), showed: - An order dated 11/28/24 change PICC line dressing weekly on Fridays for infection control; - An order dated 11/28/24 flush PICC line with normal saline (a sterile solution of water and salt), Heparin (an anticoagulant (blood thinner) that stops your blood from forming blood clots or making them bigger) 5 milliliters (ml) every shift for line patency; - An order dated 11/28/24 monitor PICC line insertion for bleeding and or signs and symptoms of infection every shift; - An order dated 11/28/24 Daptomycin (antibiotic) intravenous solution reconstituted, 800 milligrams (mg) intravenously one time a day for bone infection; - No orders to remove the PICC line. Review of the hospital discharge summary, dated 11/27/24 showed the PICC line was inserted on 10/31/24 with 55 centimeters (cm) of line inserted. Observation and interview on 12/17/2024 at 11:35 A.M., showed: - Resident #4 sat in his/her wheelchair in his/her room; - No PICC line and or dressing to the resident's upper left arm; - The resident said Registered Nurse (RN) A tried to change the dressing over the PICC line and accidentally removed the line from his/her arm. The RN pulled the entire thing out of his/her arm, then left. He/She had not seen the nurse since. During an interview on 12/17/24 at 11:40 A.M., RN A said: - Licensed Practical Nurse (LPN) B informed him/her of difficulty with Resident #4's PICC line infusing the IV antibiotic this A.M.; - He/she went to assess the situation and attempted to access the PICC line dressing to make an observation; - The PICC line was covered with a transparent dressing so viewing the PICC line was not difficult; - It appeared that maybe a sterile gauze lying under the line may have been causing problems with the infusion; - The dressing was taped around the site too much, making it difficult to access the site; - He/she used his/her un-sterile scissors from his/her pocket and cut through the dressing, cutting the PICC line as well; - He/she pulled the rest of the PICC line out at that time and applied pressure to the site; - He/She threw the entire PICC line and dressing away in the waste container; - He/She did not make measurements or an observation of the condition of the PICC line after it was pulled out; - He/She had not contacted the physician or the Director of Nursing (DON) regarding cutting the line or removing the entire device; - He/She had not been back into Resident #4's room since the PICC line was removed. No assessment had been made of Resident #4 since the event occurred and RN A was unsure what signs and symptoms to observe for; - He/She did not know if the facility had a policy in place for care of PICC line; - He/She was aware all dressing changes and treatments to a PICC line needed to be completed with sterile technique; - He/She was aware scissors from his/her pocket were not sterile. During an interview on 12/17/24 at 11:50 A.M., LPN B said: - The resident's PICC line flushed (the process of cleaning and rinsing the tube with a solution to prevent clotting and keep it clear) easily prior to administering the IV (intravenous fluids) antibiotics during the morning administration; - The antibiotic was running slowly and he/she was only able to administer approximately half the dosage; - After removing the IV antibiotic, the PICC line flushed easily again; - He/She immediately reported the antibiotic infusion issue to RN A; - RN A and LPN B assessed the site on Resident #4, when RN A attempted to remove the transparent dressing covering the PICC line site; - RN A took scissors from his/her pocket and cut the dressing, also cutting through the PICC line tubing; - RN A then pulled the remaining line from the resident's arm and disposed of it in the trash container; - RN A said he/she would notify the physician; - He/She was unsure if the facility had a policy on the care of a PICC line; - Any access or dressing changes with PICC lines is a sterile procedure; - He/She was unsure if an RN can pull a PICC line without a physician order; - He/She said no one had been in to assess or monitor Resident #4 since the PICC line was removed. During an interview on 12/17/24 at 11:55 P.M., the Assistant Director of Nursing (ADON) said: - RN A had just made him/her aware of the PICC line being cut while attempting to access the site this morning; - Any treatments to a PICC line are to be sterile, RN A should not have used scissors from his/her pocket to cut the dressing. This is not a safe practice. RN A should have not have used scissors at all around a PICC line. That is not a safe practice; - RN A should have immediately notified the him/her, the DON and the physician of cutting the line, and certainly after removing the PICC line. RN A should have assessed and monitored the resident for any further changes in condition and document the incident in the medical record. Observations on 12/17/24 at 12:00 P.M., showed: - RN A brought a black trash bag containing the PICC line and dressing into the ADON's office; - The ADON laid the PICC line out on the desk and measured from the entry point of the line to the cut end showing a measurement of 13 centimeters (cm), the second part of the line measured 51. 5 cm; - PICC line insertion point was cut straight across with no jagged edges. During an interview on 12/17/24 at 12:17 P.M., RN A said he/she had not been in contact with the physician. No assessment of the resident had been performed. During an interview on 12/17/24 at 12:27 P.M., LPN B said he/she had not seen the resident or assessed his/her condition. During an interview on 12/17/24 at 2:00 P.M., the resident's physician said: - He/she was just informed by the DON of Resident #4's PICC line being cut and removed this morning; - The nurse should have notified him/her immediately of the removal due to the PICC line could have been torn or broken off, which places the resident in immediate danger of complications; - He/She has a nurse specifically assigned to the facility in the office to take calls from the facility and to reach him/her immediately. - The PICC line should have been inspected for any damages prior to being thrown away; - The resident should be assessed and sent to the emergency room for evaluation and possible replacement of the PICC line. During an interview on 12/17/24 at 1:25 P.M., the DON said she would have expected the RN and or LPN to notify the physician immediately after the PICC line had been cut and removed, assessments started, and observation for signs of bleeding, shortness of breath and vital signs taken and or call an ambulance. RN A should have known not to use any sharp object to access the PICC line or any other type of IV line. The DON is unsure if a facility policy is in place specifically related to PICC line care. During an interview on 12/17/24 at 1:35 P.M., the Administrator said he is not a nurse, but would have expected the nurse to call the DON and or physician for further guidance immediately. MO245912 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to ensure safety for three residents (Resident #2, #5, and #9) of 22 sampled residents, two residents (Resident #26, and #34) outside of the sample, and 39 residents for hot water temperatures. The facility census was 78. 1. Record review of Resident #2's face sheet showed: - [DIAGNOSES REDACTED]. - History of falls; - Resided on the locked, Special Care Unit (SCU). Review of the fall risk assessment, dated 5/21/15, showed staff did not identify the resident at high risk for falls. On 8/22/15 and 8/25/15, staff identified the resident at high risk for falls. Review of the care plan, dated 5/29/15, showed: - The resident had a history of [REDACTED]. - an order written [REDACTED]. - an order written [REDACTED]. Review of a nurse's note, dated 8/23/15 at 8:30 A.M., showed staff found the resident on the floor in the hall. He/she had no apparent injuries. Staff noted the resident continued to wander in other residents' rooms. Review of the care plan, updated 8/23/15, showed staff identified the resident had a fall. The care plan directed staff to provide standby assistance when possible. The care plan did not identify causative factors contributing to the fall or further identify interventions to reduce the risk of falls. Review of nurses' notes, dated 8/24/15 at 10:10 A.M., showed staff found the resident lying on his/her back with a large amount of blood under his/her head. The nurse noted the resident's left ear was cut in half. The resident was transported to the hospital for treatment. Review of the facility's fall investigation, dated 8/24/15 at 10:30 A.M., showed staff found the resident in another resident's room lying with blood beneath his/her head. The resident had one-half of his/her left ear cut off midway up the ear. Staff noted that they were unable to determine how, where or why the fall occurred due to the resident's [DIAGNOSES REDACTED]. Staff did not develop interventions to reduce the risk of further falls. Review of nurses' notes, dated 9/3/15, showed at 2:10 P.M., the resident fell in the hallway. Review of the facility's fall investigation, dated 9/3/15, showed the resident resisted wearing skid resistant socks numerous times during the day. Staff witnessed the fall. He/she did not experience injuries. Review of the care plan, updated 9/3/15, showed staff identified the resident fell . The care plan did not identify causative factors contributing to the fall or identify interventions to reduce the risk of further falls other than to encourage proper foot wear. Review of a nurse's note, dated 9/26/15, showed staff found the resident lying on the floor in the hall with a moderate amount of bright red blood under his/her head and facial area. The resident had a 2 centimeter (cm) laceration to the left eye/eyebrow area, a 2 cm hematoma to the left forehead and a 3 cm laceration to the left side of the head with a 4 cm hematoma. The resident was transported to the hospital. Review of the facility's fall investigation, dated 9/26/15, showed staff found the resident lying in the hallway with lacerations to the head. Staff did not identify causative factors contributing to the fall or identity interventions to reduce there risk of further falls other than to notify physician and provide comfort measures. Record review of nurses' notes, dated 10/5/15, showed the resident fell forward from a recliner and hit his/her head on the floor. Staff noted the resident had no new injuries. Review of the transfer sheet, dated 10/5/15, showed the facility sent the resident to the hospital for evaluation with a laceration on the left eyebrow and knot on top of it. During an interview on 10/7/15 at 3:15 P.M., Director of Nursing (DON) A said she was not aware of all of Resident #2's falls. DON A identified the resident as ambulatory with an unsteady gait, confused and having dementia. During an interview on 10/7/15 at 3:40 P.M., DON A and Licensed Practical Nurse (LPN) A said Resident #2 had [DIAGNOSES REDACTED] and depth perception issues which may have contributed to the falls. Interventions to reduce fall risk included encouraging the resident to wear a helmet and staying close to him/her. Observation on 10/7/15 at 3:50 P.M., showed Resident #2 ambulated with Certified Nurse Aide (CNA) O. Resident #2 had fading bruised and reddened areas above and below the right eye and two knots on the left and top of his/her head. Resident #2 did not wear a helmet or hip protectors. Observation on 10/8/15 at 10:00 A.M., Resident #2 ambulated without assistance. He/she had a slow, shuffling gait. The resident's right eye remained bruised and red and the knots on the resident's head were bleeding. The resident did not wear a helmet or hip protectors. During an interview on 10/8/15 at 10:40 A.M., DON A said she knew all of the responsibility for the resident's falls fell on her. DON A said she did not know who was responsible for monitoring falls. During an interview on 10/8/15 at 10:45 A.M., Administrator A said Resident #2 began experiencing falls in July, 2015. Therapy and nursing assessed the resident and it was thought that an Exelon patch (used for the treatment of [REDACTED]. During an interview on 10/8/15 at 11:35 A.M., the ADON said staff did not fully address the cause of Resident #2's falls or investigate possible interventions to reduce the risk of falls and injury. During an interview on 10/15/15 at 4:00 P.M., CNA I said he/she worked nights as the only CNA for multiple units. When Resident #2 fell , CNA I was not on the locked, secured unit. Another resident told CNA I that a resident was bleeding. CNA I said that if the resident had not notified him/her, it would have been another 20 minutes before he/she found Resident #2. Review of the facility's fall policy and protocol, dated 2/12/09, showed the policy directed staff to review any risk factors identified and complete a fall risk assessment after each fall. The DON or designee's responsibility included maintaining and updating a list of residents identified as being at high risk. The policy directed staff to complete weekly reviews for progress, interventions and care plan revisions. 2. Record review of Resident #5's annual MDS, dated [DATE], showed: - Extensive physical assistance of two staff for transfers; - Not steady and only able to stabilize with human assistance during transfers between the bed and wheelchair; - Functional limitations in range of motion of upper and lower extremities on both sides. Observation on 10/14/15 at 3:20 P.M. showed: - The resident lay in bed; - CNA I placed a gait belt (device used to assist with transfers and walking) around the resident's waist; - CNA E and CNA I each placed one hand on the gait belt and lifted the resident under the arms; - The resident's legs crossed over each other and he/she could not bear weight; - The resident's feet dragged across the floor from the bed to his/her Broda chair (a specialized wheelchair for positioning). 3. Observation on 10/14/15 at 12:21 P.M. showed: - Resident #26 sat in a recliner on the SCU; - CNA M placed a gait belt around his/her waist; - CNA E and CNA M each placed one hand on the gait belt and lifted the resident under the arms; - The resident could not bear weight, his/her feet dragged across the floor from the recliner to the wheelchair, and he/she yelled Ooohh. Observation on 10/14/15 at 1:22 P.M. showed: - Resident #26 sat in his/her wheelchair in the SCU dining room; - The resident's legs straight out in front of him/her; - CNA M pulled the resident's wheelchair backward down the hallway to his/her room with no foot pedals and the resident's feet dragging on the floor; - CNA M placed a gait belt around his/her waist; - CNA E and CNA M each placed one hand on the gait belt and lifted the resident under the arms; - The resident could not bear weight, his/her feet dragged across the floor from the wheelchair to the bed, and he/she yelled Ooohh; - The bed was not locked and it rolled toward the window. During an interview on 10/14/15 at 1:30 P.M., CNA M said the resident has been very stiff ever since returning from the hospital. He/she was independent prior to going to the hospital with pneumonia. He/she walked and transferred independently and toileted himself/herself. The therapy department evaluates the residents and determines how they transfer. We haven't been told how to transfer him/her, but it takes two staff now to care for him/her. During an interview on 10/16/15 at 9:55 A.M., the Speech Therapist (ST) said the resident was evaluated by the Physical Therapist (PT), Occupational Therapist (OT), and herself after returning from the hospital for treatment of [REDACTED]. Prior to his/her hospital stay, the resident required stand by assist for bed mobility, transfers, walking, dressing, personal hygiene, toileting, and eating. Since returning from the hospital, he/she requires moderate to total assist for all ADLs. 4. Observation on 10/15/15 at 6:35 P.M. showed: - Resident #9 assisted to his/her bed from the dining room; - CNA K on the resident's left side with one hand on the gait belt around the resident's waist; - CNA L on the resident's right side with one hand pulling on his/her pants. 5. Observation on 10/16/15 at 6:20 A.M. showed: - CNA P pushing Resident #34 down the hallway in his/her wheelchair with no foot pedals; - The resident's left foot caught on the floor under the wheelchair and he/she yelled Ow, my foot!; - CNA P asked the resident What did you do that for? Hold your feet up. During an interview on 10/16/15 at 11:15 A.M., DON B said she would expect staff to use a gait belt when transferring a resident and not to pull on a resident's pants. She would expect foot pedals to be placed on the wheelchair before transporting a resident. She would not expect a gait belt to be used for a resident who can not bear weight. She would expect the therapy department to reassess these residents to determine whether they require a mechanical lift. Record review of the facility's policy, Gait Belt Transfers, dated 2/1/11, showed: - Place gait belt around resident's waist, snug but not tight; - Assistants stand on either side of resident, facing each other if two person transfer is required; - Staying close to the resident, the assistants rock back and forth, synchronizing movements and weight shifting from one leg to the other while maintaining a backward pelvic tilt. Hips and knees are bent, and on the count of three, the resident is lifted up with use of the gait belt and assisted to the chair, bed, commode, or other appliances or furniture. 10. Observations on 10/13/15 during two minute hot water tests using a digital stem type thermometer showed: - At 10:30 A.M., the sink in resident room 307 had a hot water temperature measuring 122.6 degrees Fahrenheit (F); - At 10:36 A.M., the sink in resident room 408 had a hot water temperature measuring 123.0 F; - At 10:42 A.M., the bathroom for staff near the nursing office by 100 and 200 halls had a sink hot water temperature measuring 123.8 F. Observations on 10/14/15 during two minute hot water tests using a digital stem type thermometer showed: - At 12:57 P.M., the shower room sink (located between 200 and 300 halls) had a hot water temperature measuring 124.9 F, and began to go down in temperature slowly from there; - At 2:10 P.M., the Maintenance Supervisor used his thermometer to measure the hot water temperature in the shower room (located between 300 and 400 halls) at the sink at 122.0 F. During an interview on 10/14/15 at 2:12 P.M., the Maintenance Supervisor said he spends the greatest part of his time with water heaters and ensuring good hot water temperatures. He said he would turn the temperature down immediately and run some water out to get it down. He said the same water heater serves the A wing of the building. Record review of hot water temperatures for three months showed the temperatures within the range of 105 to 120 F and checked at least weekly. Record review of the hot water temperature policy and procedure showed: - Maintenance Director will monitor hot water temperatures in randomly selected locations throughout the facility on a weekly basis to ensure water temperatures are maintained at or below 125 degrees; - In the event a water temperature is noted to be at 125 degrees or above, the Maintenance Director will adjust the water temperature immediately and recheck to ensure that the water temperature is at the correct level; - The Maintenance Director will inform the Administrator of the incorrect temperature and the corrective actions taken.

Based on observation, interview and record review the facility failed to seek treatment in a timely manner for two (Residents #1 and #3) of ten sampled residents. This practice potentially could affect all residents. The facility census was 72. 1. Review of Resident #3's Physician order [REDACTED]. The POS listed an order for [REDACTED]. Review of the nurses' notes, dated 7/8/15, showed the following: - At 11:45 A.M., Licensed Practical Nurse (LPN) G documented the resident had increased weakness and did not respond to questions. Resident #3 had an 86% oxygen saturation reading with poor air exchange throughout the lungs and exhibited diaphragmatic breathing (breathing that only utilized the diaphragm). Staff placed the resident in bed and applied an O2 mask with the O2 running at 5 liters/minute. The nurse placed a call to the physician and a message was left. - At 2:00 P.M., the physician's office returned the call and told the nurse to send the resident out to the emergency room . - At 2:40 P.M., LPN G left a message for the physician to cancel the order to send the resident to the ER and instead order a chest x-ray and antibiotics as the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Registered Nurse (RN) B felt the resident could be treated in house. - At 3:00 P.M., LPN H documented the physician had not returned the call and at 3:10 P.M., Resident #3 left for the hospital. - At 4:25 P.M., the hospital reported the resident had to be intubated and flown out to St. Louis with a [DIAGNOSES REDACTED]. Review of the facility's Administrative Investigative Form, dated 7/8/15 showed Resident #3's transfer to the emergency room had been delayed an hour (2:00 P.M. until 3:10 P.M.) due to a staff disagreement on the need to actually send the resident out or treat in house as the resident's condition had improved since the initial phone call to the doctor. Interviews conducted on 7/22/15 showed the following: - At 10:05 A.M., the DON said LPN G got an order to send Resident #3 to the ER at 2:00 P.M. LPN G and LPN H wanted to send the resident to the emergency room , but ADON and RN B felt he/she could be treated at the facility. Staff were bickering among themselves. The DON said he/she told them if you have an order to send Resident #3 out, then follow it and send him/her out. He/she was made aware of the order to send the resident out when it was received. - At 10:30 A.M., the ADON said he/she walked to the resident's room approximately 2:00 P.M. The resident had on oxygen and showed no signs of distress. The ADON denied having a discussion with other staff regarding sending Resident #3 out or treating in the facility. - At 12:00 P.M., LPN G said he/she would have had the resident out in 30 minutes LPN G said if a doctor gives an order you have to carry them out. LPN G said he/she felt forced to go against his/her better judgement when he/she made the second call to the physician. During an interview on 7/28/15 at 12:42 P.M., LPN H said the resident's oxygen saturation was low, in the mid 60's when they got to his/her room. He/she put the mask on the resident and turned the oxygen up to 5 liters. RN B said they needed to titrate the oxygen down. After RN B titrated it, the oxygen saturation went down to 62%. LPN H replaced the mask and turned the oxygen back up to 5L. At approximately 3:00 P.M. resident started sternal breathing and LPN H said he/she was sending him/her out. During an interview on 7/28/15 at 2:17 P.M., RN B said LPN G told him she received an order from the doctor to send the resident out at approximately 1:45 P.M. RN B said since LPN G was the one that got the order, then LPN G needed to be the one to send Resident #3 out. RN B denied ever saying keep the resident at the facility. During a telephone interview on 8/26/15 at 3:32 P.M., with Physician U said he/she absolutely expected nursing staff to follow his/her orders to send Resident #3 to the emergency room . Physician U said his/her initial response was delayed because the facility had left a message with his office and not contacted him/her on his/her cell phone, or he/she would have called sooner. Physician U said he/she called the order to send Resident #3 out at 1:46 P.M. He/she later received a call from LPN G regarding not sending Resident #3 out. The physician said he/she called back and told staff to send the resident out immediately. If the resident was in distress, there would have been no problem with them sending the resident without a doctor's order. Review of the Emergency Department Report, dated 7/8/15 at 3:35 P.M., showed the following: - Hospital staff placed Resident #3 on O2 at 6 liters by nasal cannula with a saturation of 100%. - A history of acute and chronic [MEDICAL CONDITION]. - A urinalysis showed a urine infection present, along with several other critical labs. - Hospital staff intubated the resident at 5:08 P.M. and diagnosed him/her with acute [MEDICAL CONDITION] and pneumonia. - An ambulance transported the resident to a larger hospital in St. Louis at 5:38 P.M. Review of the Change in a Resident's Condition or Status Policy, dated 2/1/11, showed: - When a resident has a serious change of condition, the nurse supervisor/charge nurse will immediately notify the resident's attending physician and/or 911, the DON, and the Administrator. 2. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/15/15, showed: -Cognitively severely impaired, with inattention, disorganized thoughts, and delusions; -Ambulated with supervision; -Since admission or prior assessment had 2 or more falls without injury, 2 or more falls with minor injury, and one fall with major injury; -[DIAGNOSES REDACTED]. Review of the nurse's notes dated 7/9/15 at 8:15 A.M., showed Resident #1 found on the dining room floor on his/her left side with the left leg bent at the knee. Staff assisted the resident up and the resident complained of pain in the left leg. Staff placed the resident in a chair and notified the doctor. The resident transferred to the emergency room at 8:55 A.M. and at 10:45 A.M. returned to the facility with a [DIAGNOSES REDACTED]. Review of the nurse's notes dated 7/10/15 at 10:00 A.M., showed Licensed Practical Nurse (LPN) A documented bruising to the resident's left ankle and foot. The resident expressed foot pain when palpated or he/she bore weight. At 10:30 A.M., the LPN noted left ankle with [MEDICAL CONDITION] and resident voiced discomfort upon touch. Review of the nurse's note dated 7/13/15 at 1:00 P.M., showed LPN A documented Family Member (FM) P requested an x-ray of the resident's foot due to bruising, light gray in color, and pain on palpation. Staff contacted the physician and an order received to x-ray the left foot and ankle. The x-ray company informed facility staff that they could not be there until the next day. The x-ray completed on 7/14/15 had a negative result. Staff informed the physician and no new orders were given. Observation on 7/21/15 at 10:25 A.M., showed the resident's foot and ankle had bruising from the top of the foot and ankle, down to the arch of the left foot and heel and continued to be tender to the touch. During an interview on 7/21/15 at 10:30 A.M., FM P said when he/she told the nurse about the bruising LPN A called for an x-ray. FM P heard LPN A tell them it was alright if it wasn't that night, that it was several days old. FM P said Resident #1 continued to tread lighter on the left side. During an interview on 7/21/15 at 11:00 A.M., LPN A said he/she saw the bruise when the resident's sock was removed. LPN A received an order for [REDACTED]. The resident had continued to ambulate and would not sit in a wheelchair. The resident received pain medication but the area was not iced, wrapped, or elevated. During an interview on 7/22/15 at 10:30 A.M., Assistant Director of Nursing (ADON) C said he/she would have expected the nurse to call the doctor regarding the pain and bruising to the ankle on the first day seen, not four days after. Review of the facility's policy, Change in a Resident's Condition or Status, dated 2/1/11, showed the charge nurse will contact the resident's attending physician or on-call physician when there has been an accident or injury involving the resident, a discovery of injuries from an unknown source, or instructions to notify the physician of changes in the resident's condition. MO# 8