Every finding on record at Golden Age Nursing Home

Based on observation and interview the facility failed to ensure staff served food to residents in a sanitary manner when Dietary Aide A served three residents their meals after touching unclean surfaces in the dining room with gloved hands without changing gloves or washing hands between each resident. This affected three of 12 sampled residents (Resident #22, #23 and #27). The facility census was 39.The facility did not provide the requested policy on sanitary handling of food served to the residents. 1.Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/18/25 showed:- Severe cognitive impairment;- Partial assistance for activities of daily living (ADL)s;- Partial assistance for eating;- Diagnoses included cancer, high blood pressure and heart failure.Review of the resident's care plan dated, 6/27/25 showed:-Assistance of one to two for ADLs;-Resident had a diagnosis of dementia.2. Review of Resident #23's admission MDS dated , 07/17/25 showed:- Severe cognitive impairment;- Dependent on staff for ADLs;- Partial assistance for eating;- Diagnosis included aphasia, high blood pressure and irregular heartbeat.Review of the resident's care plan dated, 07/27/25 showed:-The resident had a self-care deficit related to dementia;-The resident had issues with mobility;-The resident required assistance of one to two staff for ADLs.3. Review of Resident #27's quarterly MDS dated , 06/24/25 showed:- Severe cognitive impairment;- Dependent on staff for ADLs;- Dependent on staff for eating;- Diagnosis included high blood pressure, high cholesterol and thyroid disorder.Review of the resident's care plan dated, 7/25/25 showed:-The resident had a self-care deficit related to dementia;-The required assistance for eating;-The resident was dependent of staff for ADLs.Observation of the dining room on 09/02/2025 at 11:59 A.M., showed:-Resident #22 sat in a wheel chair in the dining room with his/her eyes closed;-Dietary Aide A entered the dining room wearing gloves;-Dietary Aide A picked up Resident #22's meal and sat it down on the table in front of the resident;-Dietary Aide A removed the cover of Resident #22's food and touched the inside of the plate containing the food with his/her gloved thumbs;-Dietary Aide A touched the top of the steam table with his/her gloved right hand then went to the cabinet and opened the cabinet with his/her gloved left hand and removed a cup;-Dietary Aide A added hot water to the cup and set it on the table that Resident #22 sat at;-Dietary Aide A wore the same gloves he/she had been wearing when he/she entered the dining room;-Dietary Aide A removed Resident #23's food from the steam table and sat it down on the in front of the resident;-Dietary Aide A removed the cover of Resident #23's food and touched the inside of the plate that contained the food with his/her gloved thumbs then went back to the steam table and touched the meal cards on top of the steam table;-Dietary Aide A then went back to the steam table and picked up Resident #27's meal and removed the cover;-Dietary Aide A removed the cover of Resident #27's food and touched the inside of the plate that contained the food with his/her thumbs;-Dietary Aide A did not change gloves before he/she served food to Residents #22, #23, and #27 after touching unclean surfaces;-Dietary Aide A did not change gloves between each resident.Observation of the dining room on 09/03/2025 at 12:12 P.M., showed:-Dietary Aide A brought a bed side table from the hall into the dining room;-Dietary Aide A had gloves on both hands as he/she entered the dining room;-Dietary Aide A touched the side and top of the bedside table as he/she rolled the table into the dining room;-No staff cleaned or sanitized the bedside table as it sat in the dining room by the steam table;-Dietary Aide A sat a container of sour cream packets and a container of butter packets on the bedside table next to the steam table;-Dietary Aide A touched the sides of a metal cart that a tray of drinks sat on;-Dietary Aide A walked behind the steam table and touched the wall with his/her gloved right hand and then touched the meal cards that sat on top of the steam table;-Dietary Aide A removed the cover form Resident #23's meal and rearranged the food on the resident's plate with his/her gloved hands;-The dietary manager entered the dining room;-Dietary Aide A walked by the Dietary Manger (DM) and touched the DM on the back with his/her gloved hands;-Dietary Aide A removed the cover from Resident #27's meal and used his/her gloved hands to rearrange the food on the resident's plate;-Dietary Aide A went back to the steam table and opened two packets of butter and placed the on Resident #22's plate with same gloves that had been worn since his/she entered the dining room;-Dietary Aide A served Resident #22 his/her meal;-Dietary Aide A touched unclean surfaces and served meals Residents #22, #23, and #27;-Dietary Aide A did not change gloves before he/she served food to Residents #22, #23, and #27 after touching unclean surfaces;-Dietary Aide A did not change gloves between each resident.During an interview on 9/3/25 at 1:22 P.M., Dietary Aide A said:-Gloves should be changed when clothing, face or other parts of the body;-Gloves that have touched unclean surfaces should be changed and clean gloves applied;-He/She did not realize he/she had touched the unclean surfaces;-Gloves that had touched unclean surfaces should be changed.During an interview on 9/3/25 at 02:52 P.M., the DM said:-Gloves should be changed when touching unclean surfaces;-Gloves should be changed when clothing, face or other parts of the body;-Gloves that have touched unclean surfaced should be changed and clean gloves applied;-Gloves should be changed between resident's, hands washed or sanitized between residents.During an interview on 9/3/25 at 03:01 P.M., the Registered Dietitian said:-Gloves should be changed when touching unclean surfaces;-Gloves should be changed when clothing, face or other parts of the body;-Gloves that have touched unclean surfaced should be changed and clean gloves applied;-Gloves should be changed between resident's, hands washed or sanitized between residents-He/She expected the DM to ensure the staff served the meals in a safe and sanitary manner.During an interview on 9/3/25 at 03:25 P.M., the Registered Dietitian said:-Gloves should be changed when touching unclean surfaces;-Gloves should be changed when clothing, face or other parts of the body;-Gloves that have touched unclean surfaced should be changed and clean gloves applied;-Gloves should be changed between resident's, hands washed or sanitized between residents;-He/She expected the DM to ensure the staff served the meals in a safe and sanitary manner.During an interview on 9/3/25 at 03:32 P.M., the Administrator said:-Gloves should be changed between resident's, hands washed or sanitized between residents;-He/She expected the DM to ensure the staff served the meals in a safe and sanitary manner.

Based on observation and interview the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections when the facility failed to ensure enhanced barrier precautions (EBP) were used for residents with wounds and/or an indwelling medical devices. This affected two residents (Resident #1, Resident #4) of 12 sampled residents. The facility census was 39.Review of facilities Enhanced Barrier Precautions policy, dated 10/2/2020, showed:-Enhanced Barrier Precautions apply to all residents with any of the following: wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy, or ventilator) regardless of MDRO (multidrug-resistance organisms) colonization status. Review of resident #4's Care Plan, undated showed:The resident had a foley catheter due to urinary retention with bladder obstruction;The resident was at risk for falls;The resident had a diagnosis of heart failure. Observation of the resident's room on 9/3/25 at 10:00 A.M., showed:There was no isolation signage posted to notify staff/visitors of the residents need for EBP;There was no isolation or supply cart that contained gown and gloves available for staff to use inside or near the residents room. 2. Review of Resident #1's Care Plan, undated., showed:The resident had a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of liquid nutritional formula) with a peg tube (a thin, flexible tube inserter directly into the stomach through a small incision in the abdominal wall); Observation of resident's room on 09/03/2025 at 9:16 A.M. showed: There was no signage posted to notify staff of the residents need for EBP;There was no cart that contained gown and gloves for staff to use inside or near the residents room. Observation on 09/04/2025 at 8:59 A.M. showed:LPN A did not wear a gown when disconnecting the residents feeding tube;CNA B and CNA C did not wear a gown when providing peri care to the resident.Please explain how they did not utilize EBP, what did they fail to do, and what did you see? During an interview on 09/04/2025 at 10:12 A.M. CMT A said he/she is not sure what EBP is or when it should be used. During an interview on 09/04/2025 at 10:49 A.M. CNA C said he/she is not sure what EBP is for or when it would be used. During an interview on 09/04/2025 at 12:46 P.M. LPN A said:He/She had infection control training when he/she was hired a month ago; He/she would not wear a gown when providing care for a resident with an IV, feeding tube, or catheter, unless the resident had an infection such as COVID or the flu. Why wouldn't he/she? During an interview on 09/04/2025 at 1:13 P.M. The DON said:EBP is to be worn with COVID, flu, blood born pathogens, and c-diff;Staff do not wear EBP when caring for residents with IVs, feeding tubes, or catheters. During an interview on 09/04/2025 at 4:01 P.M. The Assistant Administrator/Infection Preventionist said:Gowns and gloves are to be worn when a resident had an infection such as the flu, COVID, or C-diff;Staff do not need to wear a gown when caring for residents with IVs, feeding tubes, or catheters;She was unable to define what EBP was or was or when it should be used.

Based on interview and record review, the facility failed to complete a recapitulation (a detailed summary of the resident's stay at the facility) for three of 12 sampled residents (Resident #42, #43 and #44). The facility census was 39.Review of the facility's undated Discharge Summary policy showed:-The facility will communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of a discharge;-The discharging resident must have written discharge summary that includes a recapitulation of the resident's stay.1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/4/25 showed:- Moderate cognitive impairment;- Substantial assistance with toilet hygiene, dressing, toilet use and transfers;- Required set up with eating;- Diagnoses included high blood pressure, high cholesterol, and arthritis.Review of the resident's care plan dated 7/7/25, showed:-Assistance of two for activities of daily living (ADL)s;-Impaired hearing;-Diagnosis of high blood pressure.Review of the resident's medical record showed:- On 1/4/25 the resident was admitted to the facility;- On 7/15/25 the resident was discharged from the facility;- No recapitulation of the resident's stay was found.ar2. Review of Resident #43's Quarterly MDS, dated [DATE]., showed:- Severe cognitive impairment;- Dependent on staff with toilet hygiene, dressing, toilet use and transfers;- Diagnoses included high blood pressure, high cholesterol, and coronary artery disease.Review of the resident's care plan dated 6/5/25, showed:-Self care deficit related to dementia;-Assistance of two nursing staff for ADL's;-Diagnosis of high blood pressure, dementia and high cholesterol.Review of the resident's medical record showed:- On 11/12/24 the resident was admitted to the facility;- On 2/23/25 the resident was discharged from the facility;- No recapitulation of the resident's stay was found.3. Review of Resident #44's care plan, dated 1/23/25., showed:- Cognitive skills intact;- Assistance of two staff for personal hygiene, dressing, toilet use and transfers;- Assistance of one with eating;- Required set up and clean up with oral hygiene, showers, and personal hygiene;- Diagnoses included dysphagia, quadriplegia and chronic pain.No MDS information was found for the resident.Review of the resident's medical record showed:- On 5/11/23- the resident was admitted to the facility;- On 4/2/25- the resident was discharged from the facility;- No recapitulation of the resident's stay was found.4. During an interview on 9/4/25 at 11:32 A.M. the Director of Nursing said:-The facility did not do a recapitulation of the resident's stay;-The nurses document the resident is discharged and where they are being discharged to.During an interview on 09/4/25 at 12:12 P.M., the Administrator said:-There should be a recapitulation of the resident's stay in their medical record.

Based on interview and record review the facility failed to prioritize its improvement activities; measure the success of actions, track performance; regularly review, analyze, and act on data collected regarding the facilities performance improvement plan. This had the potential to effect all residents.The facility census was 39. Review of the facilities Quality Assurance Performance Improvement Program (QAPI) policy, dated 10/31/2024, showed:- Design of the QAPI program will:-gather quality concerns and issues from a variety of data sources;-establish methods to identify quality issues then to correct or show targeted improvement through scheduled monitoring;-develop and implement corrective action and performance improvement programs, and monitor and evaluate the effectiveness of the corrective action/performance improvement activities, revising as needed. Review of the facilities QAPI meeting minutes for 2025 showed: There was no tracking of performance improvement regarding the facilities PIP (Performance Improvement Plan) of handwashing. During an interview on 09/04/2025 at 2:13 PM The QAPI director/medical records clerk said:- The PIP for this year is handwashing, this began on 1/19/2025;- Signs have been posted around the building to educate staff regarding proper handwashing technique;- Additional hand sanitizer stations have been put up across the facility;- He/she is not sure how the facility would measure improvement with handwashing. During an interview on 09/04/2025 at 4:01 P.M. The Assistant Administrator/Infection Preventionist said:- There will be an in service regarding handwashing next month for all staff; - There has not been any performance improvement tracking for the handwashing PIP since it has been put in place at the beginning of this year;- There was no event that occurred to prompt the handwashing PIP, he/she thought it would be a good thing to go over with the staff.

Based on interview and record review, the facility failed to ensure on resident, Resident #1 was free from verbal and physical abuse when Certified Nursing Assistant (CNA A) grabbed the resident's arm, jerking him/her back into the wheelchair, while yelling and cursing at the resident. The facility census was 43. Review of the facility's Abuse and Neglect Policy, dated 2/19/2014 showed: -Upon hire, all staff will be trained on the abuse and neglect policy and through on going in-services. -Prevention: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -An employee of this facility shall not knowingly: b. Fail to report an incident or suspected incident of abuse. -Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes analysis of: The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care. -Identification: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing immediately. -Reporting: All employees of this facility must immediately report any incident or suspected incident of resident neglect, abuse, or misappropriation of resident property. Such incidents will be investigated and any findings of abuse will be reported to the state agency responsible for recording such data in the Abuse Registry. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment conducted by facility staff) dated 7/26/2024, showed: -The resident has minimal difficulty hearing, clear speech. He/she is usually able to make self understood and usually understands others. -The resident scores zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognition. -He/she wanders daily. -He/she requires substantial assistance with activities of daily living, including bathing, dressing, toileting and personal hygiene. Review of the resident's comprehensive care plan, dated 8/7/2024, showed he/she has a cognitive deficit related to the diagnosis of dementia without behaviors. Staff will talk calmly to the resident. Review of the facility's investigation showed: 7/25/24: Dietary staff were finishing serving dinner in the dining room at approximately 6:20 P.M. The Kitchen Supervisor observed Resident #1 standing up, leaning up against a chair by a table at the back of the dining room. The Kitchen Supervisor shouted Resident #1's name and asked him/her to sit down. Certified Nurses Assistant (CNA) A came into the dining room and said I can't run. The Kitchen Supervisor ran over to Resident #1 and took the resident's left hand to help keep him/her from falling. A few moments later, CNA A arrived at the resident's right side. CNA A grabbed the resident's right arm near his/her wrist and said Sit your ass down right now. CNA A then jerked the resident down into the wheelchair by his/her right arm. While being jerked into the wheelchair, the resident hit his/her right hip on the arm of the wheelchair. The resident cried out. CNA A then said That's it, you're going to bed right now. I've had enough. The Kitchen Supervisor observed the resident to be scared and shaken up. The Kitchen Supervisor said to CNA A that he/she was afraid the resident was hurt. CNA A responded No, I just scared the resident. You have to understand how he/she has been acting lately. CNA A then pushed the resident from the dining room. 7/27/24: At approximately 7:15 P.M., dietary staff were walking down the south hall to clean up. As the Dietary Aide A reached the nurses' desk, he/she observed Resident #1 standing up against a chair. Dietary Aide A assisted the Kitchen Supervisor to assist Resident #1 back into the wheelchair. Resident #1 said No, I don't want to. Don't do that, I don't want to. CNA A then approached the resident and dietary staff and said Don't worry, I got this. The Kitchen Supervisor returned to the kitchen and Dietary Aide A stayed on the hall. Dietary Aide A witnessed CNA A grab the resident by the wrist and say in an aggressive manner to sit back down in the wheelchair. CNA A then stated to Dietary Aide A that the resident never listens. Dietary Aide A then assisted CNA A to have the resident sit in the wheelchair and then returned to the kitchen. 7/29/24: At approximately 3:30 P.M., the Kitchen Supervisor approached the Assistant Administrator and expressed concerns that CNA A was rough, verbally and physically, with Resident #1. At 4:19 P.M., the Assistant Administrator interviewed CNA A regarding these allegations. CNA A stated that sometimes the resident just doesn't listen and has to be made to sit down. CNA A was suspended pending investigation. Review of the facility's Incident/Accident Report dated 7/29/24 showed the resident had been assessed, showing bruising to right forearm. During an interview on 8/7/24 at 2:17 P.M., the Kitchen Supervisor said: -He/she confirmed the information in the facility investigation. -He/she said that the resident was observed to be shaken up and fearful during the incident on 7/25/24, leaning away from CNA A and crying out. - She should have reported the incident immediately to the charge nurse or call administration. During an interview on 8/20/24 at 10:52 A.M., Dietary Aide A said: -During the evening of 7/27/24 between 7:00 P.M and 7:15 P.M., he/she was on the hall, picking up dishes from dinner. He/she witnessed Resident #1 standing up from his/her wheelchair. Dietary Aide A rushed over to the resident, as he/she is a fall risk. Dietary Aide A asked CNA A to come assist the resident. CNA A came to assist the resident and Dietary Aide A. Dietary Aide A witnessed CNA A grab the resident by the wrist and force the resident back into the wheelchair, while speaking to the resident in a harsh manner. -Dietary Aide A told the Kitchen Supervisor of the incident. -Dietary Aide A has received education about when to report possible incidents of abuse and who to report to. He/she knows to report immediately to anyone in a supervisor position, including the charge nurse or to call the administrator. He/she should have reported the incident immediately to a supervisor or administrator. The Administrator was not available for interview. During an interview on 8/7/24 at 2:31 P.M., the Assistant Administrator said: -CNA A's employment has been terminated. - There was no documentation in the employees file regarding the reason for termination. - He/she expects staff to treat residents with dignity and respect. -She expects staff keep residents safe and report possible incidents of abuse immediately. MO239935

Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. This had the potential to affect all of the residents. The sample was 19. The census was 43. Review of the facility's Matrix for Providers, dated 8/28/24, showed a census of 43 and the following resident characteristics: -26 residents with Dementia diagnosis -One resident fed via tube -No residents on dialysis -Three residents with indwelling catheter -11 residents with falls -6 residents on Hospice services During an interview on 8/28/24 at 1:22 P.M. the Administrator said: - She does not work in the facility on a full time basis. -She did not know anything about a facility assessment and does not have one. -She found information online and would write one but did not have a current assessment.

Based on interview and record review, the facility failed to employee a full time Licensed Nursing Home Administrator (LNHA) for the facility who was responsible for operation of the facility. In addition the LNHA was not available on a full time basis in the facility to provide oversight including development of a Facility Assessment or oversee the Quality Assurance program to ensure the residents receive appropriate nursing and medical care. The census was 43. Review of the facility's Assistant Administrator Job Description, dated 3/22/24, showed: -Golden Age Nursing Home requires Administration to maintain a courteous professional manner while interacting and communicating with residents, their families, co-workers, and visitors. This extends to telephone conversations, and written or digital forms of communication. -On request or on absence of the Administrator, the Assistant Administrator will function as the primary spokesperson for Golden Age Nursing Home and be the main representative for the facility to the public, community, and Golden Age Nursing Age District Board. -When requested by the Administrator, the Assistant Administrator management duties may include: guiding staff recruitment, hiring, employee orientation, job descriptions and performance evaluations, wage/salary changes, promotion, and if needed, disciplinary counseling or termination of any employee. -The Assistant Administrator will be guided by the Administrator in understanding of Nursing Home regulations to achieve compliance as required by existing Federal, Missouri and local regulations. When delegated by the Administrator, the Assistant will assume responsibility for interpreting Federal, state or local regulations to Department Heads, Managers, and the Golden Age Nursing Home board, and ensure the use of proper oversight to achieve compliance. Review of the facility's Administrator Job Description, dated 5/22/24, showed: -The Administrator is delegated the authority by the Golden Age Nursing Home board to: Assume overall administrative responsibility for the proper operation of Golden Age Nursing Home and care given to residents. -Must be an appropriately trained and qualified individual who is a licensed Nursing Home Administrator by the state of Missouri. Review of the minutes from the November 5, 2021 meeting of the Golden Age Nursing Home Board of Directors Meeting showed: -Discussion of Administrator: Assistant Administrator announced that her temporary license would expire on November 27, 2021. We must have an administrator by 11/27/21. Plans are to call the Medical Director to see if he/she knows of anyone that would help out until the Assistant Administrator gets her license. Put ads in the paper. Suggestion was made that the Administrator be asked to come back. All agreed that would be possible as long as the Assistant Administrator would still be assistant administrator and major decisions would be made by the Assistant Administrator. The Administrator can train in areas that did not get completed previously. He/she will have limited responsibilities. The Assistant Administrator will contact the Administrator and see if this is a possibility. Review of the minutes from the November 8, 2021 Golden Age Nursing Home Board of Directors meeting showed: -The Administrator agreed to accept the Administrator position while the Assistant Administrator is working towards his/her administrator requirements. He/she agreed to work 2-3 days a week. Review of the Administrator's employment record at the facility showed on 11/20/21 the Administrator is listed as the Administrator. Review of the Assistant Administrator's Temporary Emergency License showed the Temporary Emergency License #799 at Golden Age Nursing Home effective 7/30/2021 and expires 11/27/2021. Review of the Administrator's Nursing Home Administrators License showed Nursing Home Administrator License is valid through 6/30/2026. 1. Observation on 8/7/2024 and 8/27/24 showed: - No LNHA available to meet with the surveyors. - The Assistant Administrator is not a LNHA. - The Administrator works part time in the facility two days a week on Monday and Friday. - The Assistant Administrator said she is in charge however the Administrator can be available by phone when needed. During an interview on 8/27/24 at 1:54 P.M., Resident #39 said: -He/she believes the Assistant Administrator is the Administrator. That is who he/she goes to with all questions and concerns. During an interview on 8/27/24, Resident #1 said: -He/she believes the Assistant Administrator is the Administrator. The Assistant Administrator is here all the time. During an interview on 8/28/24 at 11:11 A.M., family member of Resident #38 said: -He/she believes the Assistant Administrator is the Administrator. -The Assistant Administrator is always at the facility and is who he/she takes concerns to regarding his/her family member. During an interview on 8/28/24 at 1:22 P.M., the Director of Nursing (DON) said the following: - The Assistant Administrator is not a LNHA. - She reports to the LNHA on a daily basis. - The Assistant Administrator makes decisions in the absence of the Administrator. During an interview on 8/28/24 at 2:25 P.M., the Administrator (ADM) and the Assistant Administrator (AADM) said the following: ADM: He/she works part time in the facility. - The Assistant Administrator is not a LNHA. -He/she has worked part time since approximately November 2021, and the Assistant Administrator has performed the duties of an Administrator in her absence. -He/she did not know anything about a facility assessment and the facility does not have a current one. The most recent facility assessment is dated 2022. -The Assistant Administrator finished the needed hours to be able to sit for the Administrator test at the end of July, 2024. The Assistant Administrator just need to send a letter and the Nursing Home Administrator Board will allow him/her to sit for the test. AADM: -He/she doesn't have a preceptor. The Administrator is his/her mentor. -He/she has worked three years, or about 2080 hours, to be able to sit for the Administrator test. -No one signs any documentation of the verification of hours the Assistant Administrator worked. -He/she usually attends QAA and QAPI meetings, as they normally occur on weekends and the Administrator doesn't work weekends. -Any concerns from staff, residents or families first come to the Assistant Administrator then he/she will pass them onto the Administrator as needed. -The Administrator works two days a week. The Assistant Administrator works Monday through Friday. 2. Review of the facility's Matrix for Providers, dated 8/28/24, showed a census of 43 and the following resident characteristics: -26 residents with Dementia diagnosis -One resident fed via tube -No residents on dialysis -Three residents with indwelling catheter -11 residents with falls -6 residents on Hospice services During an interview on 8/28/24 at 1:22 P.M. the Administrator said: - She does not work in the facility on a full time basis. -She did not know anything about a facility assessment and does not have one. -She found information online and would write one but did not have a current assessment. 3. Review of the facility policy QAPI Program dated 2/13/23 included the Board of Directors and Administration of the facility are responsible and accountable for the ongoing QAPI Program. Review of the facility QAPI meeting minutes for 2024 showed the Administrator did not attend the meetings on: -February 2nd -May 30th -June 21st -August 1st During an interview on 8/27/24 at 3:29 P.M. the Human Resources/QAPI Coordinator said: -Administration is not always at the meetings because of their availability. -The Administrator works 2 days a week. -The Assistant Administrator was in the facility daily. During an interview on 8/28/24 at 2:23P.M. the Assistant Administrator said: -She is not a licensed Administrator. -Typically she is in the facility Monday through Friday. -Usually she is available for meetings; but may not be at every one. - The Administrator works two days a week. -Generally she and the Administrator oversee the QAPI program. -The Administrator is the head over all the QAPI and Quality Assessment and Assurance (QAA) program. 4. Review of the facility provided policy Quality Assessment and Assurance (QAA) Committee dated 3/3/23 included the facility will maintain a QAA Committee consisting of the following representatives: -Administrator -Medical Director (licensed physician) -Director of Nursing -Infection Preventionist -Clerical staff -Staff members may be assigned for expertise and work perspective in the area under study Review of the facility provided QAA meeting notes showed only the Medical Director and Director of Nursing (DON) were present for meetings: -January 31, 2024 -Apirl 22, 2024 - No meeting in July 2024. -August 24, 2024 During an interview on 08/28/24 at 1:37 P.M. the DON said: -Usually she meets with the Medical Director on weekends. -The Medical Director typically comes to the facility on Saturdays. -The QAA Coordinator types everything from the monthly Quality Assurance and Performance Improvement (QAPI) meetings and she reviews them quarterly with the medical director as the QAA meetings. -There are not other staff at the meetings going over information with the Medical Director. -The meetings attendees are the DON and the medical director. - The Administrator works two days a week and does not attend the meetings.

Based on interview and record review, the facility failed to ensure that an effective training program for all new and existing staff was in place, when the facility failed to complete a facility assessment to include: Staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. Furthermore, the facility failed to track attendance and hours of training for staff members who required at least 12 hours of education yearly. This had the potential to effect all residents. The facility census was 43. The facility did not provide their Facility Assessment. The facility did not provide a policy on education of staff and competencies. Review of education records showed: - Quality Assurance and Performance Improvement education was completed 1/10/24; -Resident Rights, harassment, and professional communication was completed 1/25/24; -Resident transfers, lifts and use of restraints was completed 2/23/24; -Proper preparing of pureed food was completed 2/14/24 -Abuse and Neglect and Intimacy in the elderly was completed 3/25/24 -Standard precautions, and Activities of Daily Living was completed 4/25/24 -Incontinence and skin care was completed 5/25/24 -Elopement and use of a fire extinguisher was completed 6/27/24 -A table top emergency drill was completed 7/25/24 -Sensory communication, fall risk, and preventing abuse was completed 8/9/24. -There were no time frames for length of training to ensure 12 hours. -There was no education on Dementia care, Care of the cognitively impaired resident, or Restorative Nursing. Review of the employee files showed: -Nurse Aide (NA) A: -date of hire was 9/13/23 -No tracking of required training's -Certified Nurse Aide (CNA) A: -date of hire was 5/17/22 -No tracking of required training's -CNA B : -date of hire 9/14/17 -No tracking of required training's -CNA C: -date of hire 5/17/22 -No tracking of required training's -Certified Medication Technician (CMT) -date of hire 12/2/22 -No tracking of required training's During an interview on 08/29/24 01:21 PM the Director of Nursing said: -She and the Administrator create the yearly education calendar. -She observes staff performing care quarterly. -She has not documented the observation of cares. -When staff miss education they have to meet with her or the Administrator for the information. -Meetings are done on pay day to ensure staff attendance. -She does not have a tracking tool for hours of education and attendance at required training. -She is unsure if the Administrator changed Dementia care, or care of the cognitively impaired resident with another educational offering. During an interview on 08/28/24 at 1:22 P.M. the Administrator said: -The DON is in charge of education, tracking and the education calendar. -Staff must have required training's yearly. -The facility did not have a facility assessment.

Based on record review and interview the facility failed to have administrative oversight for the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to effect all residents. The facility census was 43. Review of the facility policy QAPI Program dated 2/13/23 showed: -The Board of Directors and Administration of the facility are responsible and accountable for the ongoing QAPI Program. Review of the facility QAPI meeting minutes for 2024 showed the Administrator did not attend the meetings on: -February 2nd -May 30th -June 21st -August 1st During an interview on 8/27/24 at 3:29 P.M. the Human Resources/QAPI Coordinator said: -Administration is not always at the meetings because of their availability. -The Administrator works 2 days a week. -The Assistant Administrator was in the facility daily. During an interview on 8/28/24 at 2:23P.M. the Assistant Administrator said: -She is not a licensed Administrator. -Typically she is in the facility Monday through Friday. -Usually she is available for meetings; but may not be at every one. - The Administrator works two days a week. -Generally she and the Administrator oversee the QAPI program. -The Administrator is the head over all the QAPI and Quality Assessment and Assurance (QAA) program.

Based on interview and record review, the facility failed to obtain a signature from the resident or or resident's legal representative on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms prior to discharging from Medicare services for two residents (Resident #4 and #11) out of three sampled residents. The facility census was 43. Review of form instructions skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) Form CMS-10055, dated 4/8/2014, showed: -Signature and date: The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The skilled nursing facility may fill in the date if the beneficiary needs help. The date should reflect the date the SNF gave therm notice to the beneficiary in-person or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for he beneficiary, write 'rep' or representative next to the signature. If the authorized representatives signature is not clearly legible, the authorized representative's name bust be printed. If the beneficiary refuses to choose an option and/or refuses to sign the SNFABN when required, the SNF should annotate the original copy of the SNFABN indicating the refusal to sign and may list a witness to the refusal. -Basic delivery requirements: -Who may sign: Beneficiary, Beneficiary's authorized representative, legally appointed representative or guardian of the beneficiary, in case of emergency, a disinterested third party/ -Delivery requirements: Must be signed to provide the correct forms. 1. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/5/24., showed: - Moderate Cognitive Impairment. - Total assist of all activities of daily living. -Diagnoses included: Heart failure, High blood pressure, and Parkinson's disease ( a chronic, debility neurological disorder that affects motor skills and movement). Review of the resident's electronic medical record, showed: - The resident admitted to skilled Medicare part A services on 3-1-24. - The last covered Medicare part A day was 4-26-24 - The facility did not obtain signatures on either CMS-10055 SNF/ABN form, or CMS 10123 NOMNC form from the facility staff member, the resident or the resident's representative. 2. Review of Resident #11's Quarterly MDS, completed on 7/1/24., showed: - Severe Cognitive Impairment; - Total assist of all activities of daily living. - Diagnoses included: Anxiety and Depression Review of the resident's electronic medical record, showed: - The resident admitted to skilled Medicare part A services on 2-22-24. - The last covered Medicare part A day was 3-31-24 - The facility did not obtain signatures on either CMS-10055 SNF/ABN form, or CMS 10123 NOMNC form from the facility staff member, the resident or the resident's representative. During an interview on 08/29/24 09:20 AM, the Social Services Director (SSD) said she was not aware that the documents did not have signatures, but that the documents should be signed to ensure they were received. During an interview on 8/29/24 at 2:20 P.M., the Administrator said: - The social service designee was responsible for the management of the SNF/ABN forms and the NOMNC forms. - She was not aware the forms had not been signed and should have been.

Based on interview and record review the facility failed to ensure continued competence of nurse aides when they failed to perform competency evaluations, at least yearly, for 5 randomly sampled nursing staff (Nurse Aide A, Certified Nurse Aid A, B and C and Certified Medication Technician A). This had the potential to effect all residents. The facility census was 43. The facility did not provide a facility assessment or a policy on competency. Review of the employee files showed: -Nurse Aide (NA) A: -date of hire was 9/13/23 -No competency evaluation at the time of hire or within the last 12 months or since hire. -Certified Nurse Aide (CNA) A: -date of hire was 5/17/22 -No competency evaluation at the time of hire nor within the last 12 months -CNA B : -date of hire 9/14/17 -No competency evaluation at the time of hire nor within the last 12 months -CNA C: -date of hire 5/17/22 -No competency evaluation at the time of hire nor within the last 12 months -Certified Medication Technician (CMT) -date of hire 12/2/22 -No competency evaluation at the time of hire nor within the last 12 months During an interview on 8/28/24 at 1:22 P.M. the Administrator said the DON was responsible for staff training and competency. During an interview on 8/29/24 at 1:21 P.M. the Director of Nursing (DON) said: -She and the Administrator put in-services together a year at a time and as needed. -She and the Assistant DON go to the floor and watch different aides perform cares quarterly. -She does not document when staff are observed providing cares. -She is aware if something is not documented it is considered not done.

Based on record review and interviews the facility failed to ensure quarterly quality assessment committee (QAA) meetings were held with the required members. The facility census was 43. Review of the facility provided policy Quality Assessment and Assurance (QAA) Committee dated 3/3/23 showed: -The facility will maintain a QAA Committee consisting of the following representatives: -Administrator -Medical Director (licensed physician) -Director of Nursing -Infection Preventionist -Clerical staff -Staff members may be assigned for expertise and work perspective in the area under study Review of the facility provided QAA meeting notes showed only the Medical Director and Director of Nursing (DON) were present for meetings: -January 31, 2024 -Apirl 22, 2024 - No meeting in July 2024. -August 24, 2024 During an interview on 08/28/24 at 1:37 P.M. the DON said: -Usually she meets with the Medical Director on weekends. -The Medical Director typically comes to the facility on Saturdays. -The QAA Coordinator types everything from the monthly Quality Assurance and Performance Improvement (QAPI) meetings and she reviews them quarterly with the medical director as the QAA meetings. -There are not other staff at the meetings going over information with the Medical Director. -The meetings attendees are the DON and the medical director. - The Administrator works two days a week and does not attend the meetings.

Based on interview and record review, the facility failed to check the Family Care Safe Registry (FCSR) prior to employment to ensure all newly hired employees as well as checking the NA Registry to verify that new employees did not have a Federal Indicator (marker given to individuals who have committed abuse/neglect. This affected eight out of eight sampled employees hired since August, 2024. The facility census was 43. Review of the facility's Personnel Policy, dated January 2020., showed no information in regard to the requirement for staff to complete criminal background checks prior to employment. Review of the facility's undated Abuse and Neglect Policy., showed: -No information regarding Family Care Safe Registry verification. -No information regarding all staff to be verified through the NA Registry. Review of new employee hire records in the years 2023 and 2024., showed: -Staff #1, #2, #3, #4, #5, #6, #7, and #8 had no FCSR verification completed by the facility. -Staff #6 #7 had no verification through the NA registry completed by the facility During an interview on 8/29/24 at 3:30 P.M., the Business Office manager said: -She was unaware that all staff should be verified through the FCSR. -She was unaware that all staff should be verified through the NA registry. During an interview on 8/29/24 at 3:45 P.M., the Administrator said all verifications through the registries should be completed prior to new employees start date.

Based on observation, interview and record review, the facility failed to ensure five randomly sampled nursing staff (Nurse Aide A, Certified Nurse Aid A, B and C and Certified Medication Technician A)had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. The deficient practice potentially effected all residents. The facility census was 43. The facility did not provide a policy on competencies. Review of the employee files showed: -Nurse Aide (NA) A: -date of hire was 9/13/23 -No competency evaluation at the time of hire or within the last 12 months or since hire. -Certified Nurse Aide (CNA) A: -date of hire was 5/17/22 -No competency evaluation at the time of hire nor within the last 12 months -CNA B : -date of hire 9/14/17 -No competency evaluation at the time of hire nor within the last 12 months -CNA C: -date of hire 5/17/22 -No competency evaluation at the time of hire nor within the last 12 months -Certified Medication Technician (CMT) -date of hire 12/2/22 -No competency evaluation at the time of hire nor within the last 12 months During an interview on 8/28/24 at 1:22 P.M. the Administrator said the DON was responsible for training and competency. During an interview on 8/29/24 at 1:21 P.M. the Director of Nursing (DON) said: -She and the Administrator put in-services together a year at a time and as needed. -She and the Assistant DON go to the floor and watch different aides perform cares quarterly. -She does not document when staff are observed providing cares. -She is aware if something is not documented it is considered not done.

Based on interview and record review, the facility failed to ensure one nurse aide (NA) completed a nurse aide training program within four months of his/her employment in the facility. The census was 43. The facility did not provide a policy on use of Nurse Aides. Review of Nurse Aide (NA) A employee file showed: -Date of hire 9/13/23 -He/She completed an orientation module between 9/18/23 and 10/5/23. During an interview on 08/28/24 04:11 PM NA A said: -He/She began employment while he/she was in high school. -He/She did not attend a Vocational Technical School for Certified Nurse Aide (CNA) training. -He/She was not enrolled in CNA classes. -Administration had not discussed CNA classes with him/her. -He/She was not aware he/she needed to be certified within 4 months of hire. The administrator was not available for interview. During an interview the Director of Nursing said: -Nurse Aide A is not certified; -She is unsure why Nurse Aide A has not been in class.

Based on observation and interview, the facility failed to maintain the walls, hallways, ceilings and floors in a clean and homelike environment. Furthermore the facility failed to ensure furnishings were in good repair. The facility census was 43. The facility did not provide a policy for cleaning, maintenance of the facility and care of furnishings. Observations beginning on 08/28/24 at 11:06 A.M. showed on the 300 hall: -There was a gash in the sheet-rock between rooms [ROOM NUMBERS]; -There were multiple nicks and scratches in the sheet of the lower third of the hallway walls -Ceiling vent was rusted; -Multiple ceiling tiles had water stains; - Water stains on carpets in outpatient therapy room and room between the outpatient therapy and the exit door; -Multiple light fixtures had dead bugs and debris ; -There was water staining around vent outside room [ROOM NUMBER]; -Cobwebs were in the corners of the exit door, hallway and ceiling; -Dust, dirt and debris behind the fire doors in the floor corners. The nurse's station area showed: -Black non-skid matting on floor was peeling in multiple areas and secured in multiple areas with gray duct tape; -Black vinyl chairs cracked and peeling, exposing soft foam underneath; -Water fountain with crusty white debris at spigot and on the floor underneath; -Handrail from 300 hall into dining hall loose at one end; -Handrail outside soiled utility missing the end cap, exposed a rough edge; -Multiple gouges and scratches in lower third of the wall into the dining hall The 400 hall showed: -Multiple water stained ceiling tiles; -Dust, debris and dirt behind the fire door at the floor corners; -Ceiling vents had rust and water stains surrounding the vent; -Multiple gouges and nicks in lower third of the walls; -Multiple dead bugs and debris in ceiling light covers; -Cobwebs in the exit door and ceiling corners; -Rusted breaker box cover. The 200 hall showed: -Ceiling vents had dust, debris and rust; -Multiple nicks in lower third of the walls -General seating area blinds and window sills showed gray/white dust and debris; -Heat/air register had a black moldy substance and gray fuzzy debris on the grate; -Multiple light fixtures with debris and dead bugs. The conference room showed: -Cobwebs at the wall and ceiling corners; -Blinds had dust and debris. North dining room area showed: -Multiple bed frames; -Cobwebs in ceiling corners; -Multiple couches, chairs and tables in the room During an interview on 08/28/24 at 11:34 A.M. the Housekeeping supervisor said maintenance personnel are responsible for cleaning the hallways, dusting the hallways and cleaning of the light fixtures. The maintenance supervisor was unavailable for an interview. During an interview on 8/28/24 at 1:22 P.M. the Administrator said: -Maintenance cleans the hallways and the lights and completes repairs. -Housekeeping is responsible for the daily room cleanings. - The areas should be maintained, clean and homelike.

Based on interview and record review, the facilty failed to follow their abuse and neglect policy when staff failed to immediately intervene and report witnessing two separate incidents of staff to resident physical and verbal abuse to facility administration. The facility census was 43. Review of the facility's Abuse and Neglect Policy, dated 2/19/2014 showed: -Upon hire, all staff will be trained on the abuse and neglect policy and through on going in-services. -Prevention: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -An employee of this facility shall not knowingly: b. Fail to report an incident or suspected incident of abuse. -Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes analysis of: The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care. -Identification: Our facilty will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing immediately. -Reporting: All employees of this facilty must immediately report any incident or suspected incident of resident neglect, abuse, or misappropriation of resident property. Such incidents will be investigated and any findings of abuse will be reported to the state agency responsible for recording such data in the Abuse Registry. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment conducted by facility staff) dated 7/26/2024, showed: -The resident has minimal difficulty hearing, clear speech. He/she is usually able to make self understood and usually understands others. -The resident scores zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognition. -He/she wanders daily. -He/she requires substantial assistance with activities of daily living, including bathing, dressing, toileting and personal hygiene. Review of the resident's comprehensive care plan, dated 8/7/2024, showed he/she has a cognitive deficit related to the diagnosis of dementia without behaviors. Staff will talk calmly to the resident. Review of the facility's abuse investigation showed: On 7/25/24 Dietary staff were finishing serving dinner in the dining room at approximately 6:20 P.M. The Kitchen Supervisor observed Resident #1 standing up, leaning up against a chair by a table at the back of the dining room. The Kitchen Supervisor shouted Resident #1's name and asked him/her to sit down. Certified Nurses Assistant (CNA) A came into the dining room and said I can't run. The Kitchen Supervisor ran over to Resident #1 and took the resident's left hand to help keep him/her from falling. A few moments later, CNA A arrived at the resident's right side. CNA A grabbed the resident's right arm near his/her wrist and said Sit your ass down right now. CNA A then jerked the resident down into the wheelchair by his/her right arm. While being jerked into the wheelchair, the resident hit his/her right hip on the arm of the wheelchair. The resident cried out. CNA A then said That's it, you're going to bed right now. I've had enough. The Kitchen Supervisor observed the resident to be scared and shaken up. The Kitchen Supervisor said to CNA A that he/she was afraid the resident was hurt. CNA A responded No, I just scared the resident. You have to understand how he/she has been acting lately. CNA A then pushed the resident from the dining room. On 7/27/24 at approximately 7:15 P.M., dietary staff were walking down the south hall to clean up. As the Dietary Aide A reached the nurses' desk, he/she observed Resident #1 standing up against a chair. Dietary Aide A assisted the Kitchen Supervisor to assist Resident #1 back into the wheelchair. Resident #1 said No, I don't want to. Don't do that, I don't want to. CNA A then approached the resident and dietary staff and said Don't worry, I got this. The Kitchen Supervisor returned to the kitchen and Dietary Aide A stayed on the hall. Dietary Aide A witnessed CNA A grab the resident by the wrist and say in an aggressive manner to sit back down in the wheelchair. CNA A then stated to Dietary Aide A that the resident never listens. Dietary Aide A then assisted CNA A to have the resident sit in the wheelchair and then returned to the kitchen. On 7/29/24 at approximately 3:30 P.M., the Kitchen Supervisor approached the Assistant Administrator and expressed concerns of abuse to the Assistant Administrator that CNA A was rough, verbally and physically, with Resident #1. At 4:19 P.M., the Assistant Administrator interviewed CNA A regarding these allegations. CNA A stated that sometimes Resident #1 just doesn't listen and has to be made to sit down. CNA A was suspended pending investigation. Review of the facility's Incident/Accident Report dated 7/29/24 showed the resident had been assessed, showing bruising to right forearm. During an interview on 8/7/24 at 2:17 P.M., the Kitchen Supervisor said: -He/she confirmed the information in the facility investigation. -He/she said that the resident was observed to be shaken up and fearful during the incident on 7/25/24, leaning away from CNA A and crying out. -He/she has received training on Abuse and Neglect reporting. -He/she was very busy on 7/25/24 and should have reported the incident immediately but lost track of time, then forgetting to report the incident to the charge nurse or administrator. -He/she then observed a bruise on the resident's right forearm on 7/27/24 and recalled the incident on 7/25/24. He/she would have reported the incident then, but there was no one in the administrative offices, so he/she waited until 7/29/24 when the Assistant Administrator was working to report the incident. During an interview on 8/7/24 at 2:31 P.M., the Assistant Administrator said: -CNA A's employment has been terminated. -He/she expects staff to treat residents with dignity and respect. -He/she expects staff to report allegations of abuse or neglect immediately to supervisory staff on duty. If the administrator, assistant administrator or director of nursing are not in the facility, staff can report to the nursing supervisor, charge nurse or any other supervisors in the building. MO239935

Based on interview and record review, the facility failed to keep one cognitively impaired resident (Resident #1) safe from verbal and physical abuse when Certified Nursing Assistant (CNA A) grabbed the resident's arm, jerking him/her back into the wheelchair, while yelling and cursing at the resident. The facility census was 43. Review of the facility's Abuse and Neglect Policy, dated 2/19/2014 showed: -Upon hire, all staff will be trained on the abuse and neglect policy and through on going in-services. -Prevention: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -An employee of this facility shall not knowingly: b. Fail to report an incident or suspected incident of abuse. -Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes analysis of: The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care. -Identification: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing immediately. -Reporting: All employees of this facility must immediately report any incident or suspected incident of resident neglect, abuse, or misappropriation of resident property. Such incidents will be investigated and any findings of abuse will be reported to the state agency responsible for recording such data in the Abuse Registry. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment conducted by facility staff) dated 7/26/2024, showed: -The resident has minimal difficulty hearing, clear speech. He/she is usually able to make self understood and usually understands others. -The resident scores zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognition. -He/she wanders daily. -He/she requires substantial assistance with activities of daily living, including bathing, dressing, toileting and personal hygiene. Review of the resident's comprehensive care plan, dated 8/7/2024, showed he/she has a cognitive deficit related to the diagnosis of dementia without behaviors. Staff will talk calmly to the resident. Review of the facility's investigation showed: 7/25/24: Dietary staff were finishing serving dinner in the dining room at approximately 6:20 P.M. The Kitchen Supervisor observed Resident #1 standing up, leaning up against a chair by a table at the back of the dining room. The Kitchen Supervisor shouted Resident #1's name and asked him/her to sit down. Certified Nurses Assistant (CNA) A came into the dining room and said I can't run. The Kitchen Supervisor ran over to Resident #1 and took the resident's left hand to help keep him/her from falling. A few moments later, CNA A arrived at the resident's right side. CNA A grabbed the resident's right arm near his/her wrist and said Sit your ass down right now. CNA A then jerked the resident down into the wheelchair by his/her right arm. While being jerked into the wheelchair, the resident hit his/her right hip on the arm of the wheelchair. The resident cried out. CNA A then said That's it, you're going to bed right now. I've had enough. The Kitchen Supervisor observed the resident to be scared and shaken up. The Kitchen Supervisor said to CNA A that he/she was afraid the resident was hurt. CNA A responded No, I just scared the resident. You have to understand how he/she has been acting lately. CNA A then pushed the resident from the dining room. 7/27/24: At approximately 7:15 P.M., dietary staff were walking down the south hall to clean up. As the Dietary Aide A reached the nurses' desk, he/she observed Resident #1 standing up against a chair. Dietary Aide A assisted the Kitchen Supervisor to assist Resident #1 back into the wheelchair. Resident #1 said No, I don't want to. Don't do that, I don't want to. CNA A then approached the resident and dietary staff and said Don't worry, I got this. The Kitchen Supervisor returned to the kitchen and Dietary Aide A stayed on the hall. Dietary Aide A witnessed CNA A grab the resident by the wrist and say in an aggressive manner to sit back down in the wheelchair. CNA A then stated to Dietary Aide A that the resident never listens. Dietary Aide A then assisted CNA A to have the resident sit in the wheelchair and then returned to the kitchen. 7/29/24: At approximately 3:30 P.M., the Kitchen Supervisor approached the Assistant Administrator and expressed concerns that CNA A was rough, verbally and physically, with Resident #1. At 4:19 P.M., the Assistant Administrator interviewed CNA A regarding these allegations. CNA A stated that sometimes the resident just doesn't listen and has to be made to sit down. CNA A was suspended pending investigation. Review of the facility's Incident/Accident Report dated 7/29/24 showed the resident had been assessed, showing bruising to right forearm. During an interview on 8/7/24 at 2:17 P.M., the Kitchen Supervisor said: -He/she confirmed the information in the facility investigation. -He/she said that the resident was observed to be shaken up and fearful during the incident on 7/25/24, leaning away from CNA A and crying out. - She should have reported the incident immediately to the charge nurse or called the administration. During an interview on 8/20/24 at 10:52 A.M., Dietary Aide A said: -During the evening of 7/27/24 between 7:00 P.M and 7:15 P.M., he/she was on the hall, picking up dishes from dinner. He/she witnessed Resident #1 standing up from his/her wheelchair. Dietary Aide A rushed over to the resident, as he/she is a fall risk. Dietary Aide A asked CNA A to come assist the resident. CNA A came to assist the resident and Dietary Aide A. Dietary Aide A witnessed CNA A grab the resident by the wrist and force the resident back into the wheelchair, while speaking to the resident in a harsh manner. -Dietary Aide A told the Kitchen Supervisor of the incident. -Dietary Aide A has received education about when to report possible incidents of abuse and who to report to. -He/she knows to report immediately to anyone in a supervisor position, including the charge nurse or to call the administrator. - He/she should have reported the incident to a supervisor. The administrator was not available for interview. During an interview on 8/7/24 at 2:31 P.M., the Assistant Administrator said: -CNA A's employment has been terminated. -He/she expects staff to treat residents with dignity and respect. - He/she said that it is her expectation that staff keep residents safe and report possible incidents of abuse immediately. MO239935

Based on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia and failed to review it annually. The facility also failed to ensure facility staff were informed of the facility's Water Management Plan. The facility census was 43. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: -Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. -The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit. 1. Review of the facility's undated Water Management Plan included the following: - The Water Management Committee included the Maintenance Director, Director of Nursing and Administrator; - Preventive Maintenance and Control Measures included the following: o System flushing- Flush all drain outlets (both hot and cold) that are used less than once per week. Purging should be approximately three minutes or until temperature stabilizes-weekly; o Hot water storage tank flushing- Flush bottom drain valve on hot water tanks for five minutes at full flow- quarterly; o Hot water tank inspection- Inspect, clean, disinfect, and descale hot water storage tankes- Annually; o Ice machine inspection- Inspect and disinfect ice machines-Monthly; o Temperature of storage tanks- Measuring temperature in storage tanks as well in the hot water distribution system- weekly; o Disinfection levels- Residual chlorine should be checked to ensure proper disinfection is available- Monthly; o Visual inspection- Biofilm, corrosion, and organic debris provide areas optimal for growth- Ice machines, strainers and shower heards should be inspected regularly during maintenance- quarterly; o Environmental sampling- IDEXX Legiolert screening tests should be conducted to test for Legionella bacteria. Sample sites should encompass the entire water system to provide verification that control measures are effective. Three to four locations per floor (sinks/showers). Hot water tanks- semi-annually. Observation on 1/11/23 at 8:05 A.M. showed the following: - The facility had chillers outside the facility; - There was stagnant water observed in the commode room. Review of the facility's water management records on 1/11/23 showed - Last test performed 7/25/22 with no findings. During an interview on 1/11/23 at 1:00 P.M., the Maintenance Director said: - He was not on a committee to review the facility's water management plan annually; - The only thing he does for water management was take water samples annually and send them to be tested ; - He monitored the ice machines every two months, but he was not aware there was more he should be doing. During an interview on 1/11/23 3:00 P.M., the Infection Preventionist/Director of Nursing said: - There had been no cases of Legionellosis since the last survey; - She was not familiar with the water management plan, or what to do if there was a positive case; - She was not part of the water management committee. During an interview on 1/11/23 at 3:05 P.M., the Administrator said: - She paid a company to develop the water management plan; - It had not been reviewed annually; - If there was a case of Legionellosis she would call the company who developed the plan.

Based on record review and interviews, the facility failed to ensure they maintained a Department of Health and Senior Services (DHSS) approved surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 43. The facility did not have a policy for surety bonds. Review of the facilities approved surety bond, approved on 12/23/2011 showed an approved amount of $15,000.00. Review of the RTF worksheet on 01/12/2023 showed: -The average monthly balance for the facility's interest bearing account of $18,934.23; -The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $28,500. During an interview on 01/12/23 at 10:20 A.M. the Business Office staff member said: -He/she doesn't do anything with the surety bond. During an interview on 01/12/23 at 10:25 A.M. the Business Office Manager (BOM) said: -He/she doesn't do anything with the bond. -The Administrator reviews the bond. -He/she didn't know if the Assistant Administrator had reviewed the bond also or not. -He/she has only been in the BOM position since September/October. During an interview on 01/12/23 at 10:35 A.M. the Assistant Administrator said: -He/she doesn't do anything with the bond yet; -He/she hasn't been shown the bond yet. -The administrator is responsible for the bond. During an interview on 01/12/23 at 12:06 P.M. the Administrator said and showed: -He/she knew the surety bond needed to be between $30,000 and $40,0000. -He/she reviewed it recently and they called their insurance company about September or October to have it increased. -The bond paper still showed current bond amount was $15,000. During a follow up interview on 01/12/23 at 12:51 P.M. the Administrator said: -He/she called the insurance company, and there was record that the increase was initiated in July 2022 but the insurance company had emailed the business office back for additional information and nothing had been done or followed up on since. -He/she was not aware the email hadn't been addressed.

Based on observation, record review and interviews, the facility failed to provide appropriate treatment and services for one of 13 sampled residents (Resident #11) who had [DIAGNOSES REDACTED]. Staff knew the resident put large items in his/her mouth, but did not ensure he/she sat in a location in the dining room to allow staff to monitor him/her during meals. As a result, the resident put a golf-ball sized cooked beet in his/her mouth and choked on the beet. Even after the choking incident, staff failed to move the resident to a position where he/she could be monitored closely during meals. The facility's census was 30. Review of the facility's Behavior Monitoring Policy, dated (MONTH) (YEAR), showed: - Staff will monitor resident's behaviors at admission. - Residents exhibiting behaviors or that are taking antipsychotic medications (are often used in combination with other medications to treat [MEDICAL CONDITION], dementia, and mental illness) will be monitored each shift and documented on the behaviors section on the electronic Medication Administration Record [REDACTED] - Residents with behaviors that are a threat to their safety or others safety will be monitored by 1-1 staffing until the behaviors resolve. 1. Review of Resident #11's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 8/31/18, showed staff assessed the resident as follows: - Barely/never understood, with moderate cognitive impairment; - Totally dependent on staff for activities of daily living (ADLs); - No identified behaviors; - [DIAGNOSES REDACTED]. Review of the resident's Speech Therapy Initial Assessment, dated 9/17/18, showed: - [DIAGNOSES REDACTED]. - Referred for evaluation due to decreased consumption and refusal of ground meat items; - Would benefit from skilled dysphagia therapy intervention to address oropharyngeal dysphagia related to inappropriate diet texture leading to decreased consumption and risk for poor nutrition/hydration. - Precautions aspiration (breathing a foreign substance into your airways is called lung, or [MEDICAL CONDITION], aspiration. The substance could be food, liquid, medicine, mucus, or saliva. Aspiration can cause choking. It can also cause a problem called aspiration pneumonia, which is a serious infection in the lungs). - Recommendations: upgrade diet to regular entree cut into bites no bigger than 1/2 inch, mechanical (foods that are soft, and easy to chew and swallow) soft items; - No further speech therapy treatments at this time. Review of the resident's care plan, last updated on 9/6/18, showed: - Impaired verbal communication related to [MEDICAL CONDITION] and dysphagia; - Staff will monitor for signs and symptoms of depression and monitor for adverse drug reactions related to his/her daily antidepressant medication; - The care plan did not direct staff to monitor for adverse drug reactions related to his/her daily antipsychotic medication; - No interventions for the behaviors. Review of the resident's physician's orders [REDACTED]. - Regular entree cut no larger than 1/2 inch pieces, mechanical soft side items; start date 9/10/18, [DIAGNOSES REDACTED].>- [MEDICATION NAME] (antipsychotic medication) 5 milligrams (mg) orally twice daily start date of 9/19/18, discontinued on 11/11/18, and increased to [MEDICATION NAME] 10 mg twice daily for a [DIAGNOSES REDACTED]. Review of the nurses' notes, dated 11/11/18, showed: - New order received to increase the resident's [MEDICATION NAME] 5 mg twice daily to [MEDICATION NAME] 10 mg twice daily, due to the resident frequently yelling out, hitting the geri-chair, making loud grunting noises, and trying to get up and out of the geri-chair after snacks. Review of the resident's Behavior Monitoring Log for the month of (MONTH) (YEAR), showed: -11/1/18 thru 11/3/18: staff charted no behaviors; -11/4/18, at 2:11 P.M.: description of behavior agitated, intervention left blank, note [MEDICATION NAME] given; -11/5/18 thru 11/8/18: staff charted no behaviors; -11/9/18, at 9:22 P.M.: description of behavior yelling, intervention left blank, note left blank; -11/10/18 at 8:53 P.M.: description of behavior restless, intervention left blank, note pushing the call light every 10 minutes and yelling at the beginning of the shift; -11/12/18: staff charted no behaviors. Observation of the dining room on 11/12/18, at 12:02 P.M., showed: - Resident #11 sat alone at the table in a geri-chair with the back of his/her geri-chair facing the assist dining tables, eating his/her meal; - The plate contained a several ping pong ball sized whole beets, green beans, mashed potatoes and gravy, and fried chicken, on the bone, not cut into 1/2 inch pieces; - There were approximately six staff in the dining room; two dietary staff and four nursing staff; - Three nursing staff were seated at the assist tables, assisting other residents with eating their noon meal; - One dietary staff was preparing the trays from the steam table and the other dietary staff passed the trays to the residents as they were prepared. Observation of the dining room on 11/12/18, at 12:15 P.M. showed: - Resident #11's arms flailing with his/her eyes and mouth wide open with a facial expression that appeared as the resident was in distress; - The resident's lips and nail beds were bluish (discoloration of the skin may signal lack of oxygen in the blood. Blue lips may indicate a type of cyanosis caused by lower levels of oxygen in the red blood cells) in color and he/she was gasping for air with an audible wheezing (a high-pitched [MEDICATION NAME] sound caused by narrowing of the [MEDICATION NAME] tubes) sound noted; - Registered Nurse (RN) A, who was sitting at one of the assist tables said the resident has [MEDICAL CONDITION] and the surveyor replied to him/her the resident is choking; - RN A immediately got up and from the assist table and performed the [MEDICATION NAME] maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) four times as the resident sat in the geri-chair; - As staff moved the resident away from the table, he/she reached for a package of crackers and attempted to put the crackers in his/her mouth; - RN A did not stand the resident up to perform the [MEDICATION NAME] maneuver in an attempt to dislodge the object; - Staff pushed the resident down the hall to his/her room; the resident's lips and nail beds continued to be bluish in color; the audible wheezing sound was louder than before and sounded moist or wet; - At 12:38 P.M., the resident sat in his/her geri-chair in his/her room and he/she coughed up a whole beet the size of a ping pong ball; - Then he/she immediately vomited a moderate amount of undigested food; - Immediately, the bluish color to the resident's lips and nail beds returned to a normal color. - RN A used a pulse oximeter (device to measure oxygen levels of the blood) which indicate a heart rate of 112 (normal resting heart rate for adults ranges from 60 to 100 beats per minute ) and oxygen saturation of 87 percent (%, normal blood oxygen levels in humans are considered 95-100 %). - Staff then administered a breathing treatment. Review of the nurse's note, dated 11/12/18, at 1:53 P.M., showed: - Resident became choked in the dining room with classic sign noted; resident given four [MEDICATION NAME] thrusts then taken to room and was able to cough out the whole beet; given a breathing treatment. - Physician called and received an order to give [MEDICATION NAME] 40 milligrams (mg) orally daily for two days. - Vitals stable at this time; no difficulty with breathing denies and complaints of pain or discomfort. - Resident did vomit just after getting out the object. No aspiration noted of the emesis (vomiting) at this time. - Message left for the resident's spouse; will continue to monitor. - The documentation did not show the nurse did a head to assessment or that he/she auscultated the resident's lungs before or after the breathing treatment. - RN A did not document the resident's vitals as an oxygen saturation of 87% or a heart rate of 112. - RN A did not document the bluish color noted to the resident's lips and nail beds. Review of the resident's vital signs charted on 11/12/18 showed: - At 12:30 P.M. -1:00 P.M.: temperature 95.9 Fahrenheit (F, normal range from 97 F to 99 F, heart rate 110 respirations 24, blood pressure 190/104 (more than 120 over 80 and less than 140 over 90 (120/80-140/90). - The medical record did not show RN A charted the oxygen saturation of 87%. Observation of the dining room on 11/13/18, at 12:17 P.M., showed: - Resident #11 sat alone at the table in a geri-chair with the back of his/her geri-chair facing the assist tables, eating his/her meal; - He/she ate beef and noodles with large pieces of hamburger, peas, ice cream, and a biscuit; - Several staff were in the dining room assisting other residents with their meal; however, from 12:17 P.M. to 12:31 P.M., the resident fed his/herself and was not thoroughly chewing the food before he/she quickly took another bite of the beef and noodles; - No facility staff observed the resident feed him/herself and/or the resident's facial expressions for a total of 14 minutes. Observation of the dining room on 11/14/18, at 12:15 P.M., showed: - Resident #11 sat alone at the table in a geri-chair with the back of his/her geri-chair facing the assist tables, eating his/her meal; - Staff served him/her a shredded corn beef casserole sandwich on white bread, not grilled or toasted and cut in 1/2. - Staff did not cut the resident's entree into 1/2 inch pieces. - Several staff were in the dining room assisting other residents with their meal; however, from 12:15 P.M. to 12:25 P.M., the resident ate his/her meal with no staff in that section of the dining room observing the resident eat his/her meal. - No facility staff were observing the resident feed him/herself and/or the resident's facial expressions for a total of 10 minutes. - At 12:25 P.M., a staff member walked past the resident to deliver a tray at another resident at a different table. During an interview on 11/13/18, at 4:30 P.M., RN A said: - He/she used the [MEDICATION NAME] maneuver on Resident #11 on 11/12/18, because he/she choked on a whole beet and he/she is at risk for choking; - Resident #11 frequently has behaviors and requires staff interventions; his/her behaviors often are related to food. - Yesterday (11/12/18) after he/she choked on the beet, the resident put approximately six pieces of chewing gum in his/her mouth at once. - He/she had to be monitored closely; - After he/she provided the abdominal thrust, the resident even attempted to put crackers in his/her mouth while he/she was actively choking; - He/she can be resistive to care and will say no, no when staff attempt to proved care and yells and he/she will grunt; - He/she administered a breathing treatment following the choking incident as the resident was wheezing; - He/she did not chart the resident's lung sounds before and/or after the breathing treatment but should have; - He/she did not chart the resident's oxygen saturation of 87% because 15 minutes later it was up to 94%; - He/she did not chart the bluish colored lips or nail beds because he/she did not observe this as he/she was behind the resident providing abdominal thrusts; - A nurse did report to him/her that the resident's lips appeared gray and looking back he/she thinks he/she should have charted additional information. - An assessment should be done when there is a change in a resident's condition and the documentation does not indicate this was done. - Resident #11's nurse's note, dated 11/12/18, should have included a head to assessment. During an interview on 11/14/18, at 12:35 P.M., the Dietary Manager (DM) said: - Residents' diet should be followed; - On on 11/12/18, staff did not follow Resident #11's diet and should not have served the resident whole beets. - He/she should have received mechanical soft food items as he/she is at risk for choking; - The entree today was a Reuben casserole sandwich made with corned beef. - Today, staff did not follow the resident's diet as the resident's entree should be cut into 1/2 inch pieces and his/her sandwich was only cut in half. - All the residents on mechanical soft diets received untoasted white bread today on their sandwiches, instead of the toasted rye bread. - He/she was unsure why the residents receiving mechanical soft diets were not served the grilled or toasted rye bread. During an interview on 11/15/18, at 5:30 P.M., the Director of Nursing (DON) said: - On 11/12/18, staff did not follow the resident's diet and should not have served whole beets. - On 11/14/18, staff did not follow the resident's diet and should have cut the entree into 1/2 inch squares. - The resident does have known behaviors and appropriate interventions should have been implemented. - RN A should have done the [MEDICATION NAME] maneuver with Resident #11 in a standing position to facilitate clearing the the airway. - Documentation should present a clear picture of what happened and the documentation was vague. - RN A informed him/her that he/she was sure a foreign body was in the airway when he/she preformed the [MEDICATION NAME] maneuver and he/she should have done the abdominal thrust with the resident in a standing position to facilitate clearing the the airway.

Based on observation, interview and record review, the facility failed to ensure staff completed thorough investigations of resident falls and failed to adequately assess and develop individualized care plans to prevent falls for one additional resident (Resident #11) after the resident rolled off of a bed with a low air loss mattress twice during separate care episodes. The resident sustained [REDACTED]. This also affected two (Residents #1 and #6) of nine sampled residents who sustained falls in the facility. Facility staff also failed to maintain the temperature of hot water at resident accessible sinks, on two of three resident corridors, at or below the maximum allowed temperature of 120? (degrees) Fahrenheit (F). Hot water temperatures on the 300 and 400 corridors measured more than 120? F. The facility census was 37. 1. Review of the facility's policy, "Reporting/Investigating Resident Accidents/Incidents," showed: -Persons witnessing an accident or incident involving a resident must promptly report such information to their department supervisor. -An Accident/Incident Report must be completed on the shift in which the accident/incident occurred. A copy of this report is to be provided to the administrator within 24 hours of such incident. -All accidents or incidents involving residents must be thoroughly documented in the resident's medical record. Such documentation, at a minimum, must include: a) A description of what happened, including witness accounts; b) A description of the action taken; c) A description of the medical treatment administered, if any; d) A description of the resident's response to the treatment, if any; e) A description of the resident's progress; f) A description of preventive measures implemented to try to prevent such accident/incident from recurring; g) The date and time the resident's representative (sponsor) and attending physician were notified; and h) Other information that may be pertinent or relative to the accident/incident. -Management will thoroughly investigate all accidents/incidents involving residents and will document the findings of such investigation in appropriate locations. Review of the facility's policy, "Care Plans-Comprehensive," dated April 2006, showed: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. -Each resident's comprehensive care plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect treatment goals and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and enhance the optimal functioning of the resident by focusing on a rehabilitative program. -Care plans are revised as changes in the resident's condition dictate. 2. Review of Resident #11's Fall Risk Assessment, last reviewed on 6/3/12, showed: -Total score of 13; -Total score of 10 or above represents high risk for falls; -No falls in the past three months. Review of the resident's comprehensive care plan, dated 6/20/12, showed: -Assist of two staff for transfers using a Hoyer Lift (a device used to lift and transfer incapacitated residents). -Assist of one to two staff for some activities of daily living (ADL's); -Handwritten addition, dated 8/7/12, indicated staff added a bed alarm to the resident's bed; -Resident requested 1/2 bed rails up for security. Review of the resident's Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/18/12, showed: -[DIAGNOSES REDACTED]. -Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact; - Total dependence for bed mobility with two+ person assistance; -Pressure reducing mattress on bed; -Hypnotic (medications used to induce sleep) medications received seven out of last seven days. Review of Incident /Accident Report, dated 9/24/12, at 5:30 A.M., showed: -Resident rolled out of bed during A.M. care; -No apparent injuries; -Resident was alert; -Employee(s) involved section not filled out; -Charge nurse notified of incident; -Physician and family notified 9/24/12; -Steps taken to prevent reoccurrence section not filled in; -Reviewed and signed by the Director of Nursing (DON) and Registered Nurse (RN) B. During an interview on 12/5/12, at 3:15 P.M., related to the resident's 9/24/12, fall, Certified Nurse Aide (CNA) B said: -He/she turned the resident while another CNA placed a clean brief on the resident; -The resident's side rail was up on CNA B's side of the bed; -As the other CNA attempted to place the brief, the resident grasped the side rail and pulled him/herself up and over more; -The resident's feet slid off the mattress, the rest of his/her body followed, and the resident fell to the floor; -The resident slid off on CNA B's side of the bed; -The other CNA stayed with the resident while CNA B notified the nurse, RN B; -The nurse came in less than 5 minutes, assessed the resident, found no obvious injuries, and they returned the resident to bed with the use of a Hoyer lift; -The resident did not complain of pain; -The DON in-serviced CNA B to position him/herself more in the middle of the bed, bend his/her legs for a better stance, and to not let the resident help so much. Review of Incident/Accident Report, dated 11/4/12, at 7:15 A.M., showed: -CNA A attempted to put a lift pad under the resident, and when the resident was turned to his/her side, his/her feet slid off the edge of the bed causing him/her to fall to the floor; -Two skin tears identified on the right and left arms; -Physician notified at 8:00 A.M.; -Family notified at 5:45 P.M.; -Steps taken to prevent reoccurrence section not completed. Review of RN A's nurses' notes, dated 10/4/12, (incident report indicates 11/4/12) at 7:15 A.M., showed: -CNA A attempted to place a lift pad under the resident; -CNA A started to turn Resident #11 to his/her right side, the resident's feet started to slide off the bed and the resident slid to the floor between the bed and the wall; - Resident able to move all extremities and denied pain at the time; -Resident lifted back to bed using a Hoyer lift; -Resident observed by staff to have two skin tears, one on the left upper arm measuring 12 centimeters by four centimeters, and one on the right upper arm measuring six centimeters by two centimeters; -Skin tears cleansed and covered with dressings; -RN A notified the DON and the physician. Review of RN A's nurse's notes, dated 10/4/12, (incident report indicated 11/4/12) at 1:00 P.M., said: -Resident complaint of tenderness to his/her right rib cage; -Dark purple bruising noted below the right arm pit; -Resident was unable to rate his/her pain; -Tylenol given for pain. Review of LPN (Licensed Practical nurse) A's nurse's notes, dated 11/5/12, at 8:45 A.M., showed: -Resident complaint of pain in right rib cage; -Physician notified of resident's condition; -physician's orders [REDACTED]. Review of LPN B's nurse's notes, dated 11/5/12, at 5:00 P.M., showed: -Physician notified of x-ray results; -physician's orders [REDACTED]. Review of Resident #11's x-ray results, dated 11/5/12, showed: -Fractures (age undetermined) of the right 5th, 6th, and 7th ribs. Review of LPN A's nurse's notes, dated 11/16/12, at 11:00 A.M., showed: -Resident complaint of pain in the right ribs; -Pain medications continue to be given. During an interview on 12/5/12, at 12:15 P.M., Resident #11's family said: - On 11/4/12, the nurse's aide let the resident roll out of bed on to the floor while trying to turn him/her to the side causing he/she to crack some ribs and have two skin tears. - The same type of incident happened on 9/24/12, but the resident did not sustain any injuries. During an interview on 12/5/12, at 1:25 P.M., RN A said: - Staff did not initiate a fall care plan following the fall on 9/24/12, or 11/4/12; - Staff use two CNA's for cares and turning of the resident following the fall on 11/4/12. During a phone interview on 12/5/12, at 3:00 P.M., related to Resident #11's fall on 11/4/12, CNA A said: -He/she attempted to place a lift pad under the resident by him/herself; -He/she had the side rails in the up position instead of down (on this bed, when the side rails were up-perpendicular to the bed, the rail was a quarter or cane rail, and when down-parallel to the bed, became a half rail); -The mattress was slick; -The resident's feet fell off of the bed when the CNA rolled the resident to his/her side; -The resident continued to roll fell off the bed, landed in a sitting position on the floor, and had a skin tear on each arm; -He/she notified the nurse right away and the nurse assessed the resident; -He/she knew two staff should turn any resident who required two staff to transfer, but was in a hurry so tried to do it alone; -He/she never turned the resident alone before this incident; -When hired, he/she received instruction that residents who required two staff to transfer them also required two staff to turn them; -After the incident, the DON in-serviced him/her and the other staff related to the need for two staff to turn residents who required two staff to transfer; -He/she learned a lot from this incident, and would never do that again. During an interview on 12/5/12, at 1:25 P.M., the DON said: -Resident #11's first fall occurred on 9/24/12, during morning care when two staff turned him/her, the resident's feel fell off the bed, and the resident rolled out of the bed onto the floor. -The second fall occurred 11/4/12, when one staff turned the resident to place a lift pad, the resident's feet fell off the bed, and the resident rolled out of bed to the floor. -She always instructed all staff to have two staff turn or position any resident who required two staff for transfers. -She in-serviced staff individually between 11/5/12, and 11/16/12, and had them sign to show they received instruction related to two staff needed to turn or position residents who require two staff for transfers. -She agreed with the MDS coordinator (MDSC) related to the presence of the low air loss mattress (LALM) as a contributing factor in both falls for Resident #11. -The resident had no previous falls even though the resident used the LALM since admission. -She didn't know what else to do to decrease any fall risk factor related to the LALM. 3. Review of Resident #1's Fall Risk Assessment, dated 6/2/12, showed: -Intermittent confusion; -Ambulatory/Incontinent; -Required use of assistive devices (i.e., cane, w/c, walker, furniture); -Took one to two medications within the past seven days that could have contributed to fall risk factors; -Total score was 11 with a score of 10 or more representative of HIGH RISK; -No Fall Risk Assessment after 6/2/12. Review of the resident's quarterly MDS, dated [DATE], showed: -A BIMS score of 11 which indicated moderate cognitive impairment; -Supervisory set-up help for transfers; -Ambulated independently with a cane or crutch; -Occasional urinary incontinence; -No falls; -On a daily diuretic. Review of the resident's Incident/Accident Report for 6/9/12, at 8:30 A.M., showed: -The resident was confused and disoriented before the incident; -The resident said he/she was washing his/her hands and when he/she turned around got his/her feet tangled and sat down on the floor on his/her butt; -Assessment included: Rotation ok-moved all extremities. Temperature 96.8, pulse 64, respirations 16 and blood pressure 89/65. Complained of right hip hurting. -A diagram showed marks across the middle right buttock and upper right buttock as areas of injury. -Sent by ambulance to the hospital on [DATE], at 10:20 A.M.; -Staff notified the physician at 9:45 A.M., no date indicated. -Staff notified a family member at 9:55 A.M., no date indicated. -The staff member who prepared the report signed it, no date indicated. -The DON and administrator signed the report, no date indicated. -Nothing documented in the section for additional comments and/or steps taken to prevent recurrence. Review of the resident's pelvis radiology report, dated 6/9/12, showed: -Indication: Fall, right hip pain; -Superior pubic ramus fracture (bone that forms part of the pelvis front); -Arthritis of both hips without hip fracture. Review of the resident's physician telephone order sheets showed: -6/9/12-x-ray right hip (send out), Tylenol 325 milligrams (mg) one to two tablets every four hours as needed for pain (PRN) and ice pack PRN to right hip; -6/11/12-Vicodin 5/500 mg one to two tablets every four hours PRN pain, bed rest for three days and physical therapy to evaluate and treat after three days of bed rest; -6/12/12-Insert Foley catheter (sterile tube inserted into the bladder to drain urine) while on bed rest. Review of the resident's undated care plan with review signatures for 6/5/12, and 9/13/12, showed: -Problem: Needs supervision and assistance daily with ADL's; -Goal: To be clean and have good appearance daily; -Interventions included: Assist of one staff with ambulation, transfers, and toileting; -No problem or interventions related to fall risks or an actual fall; -No evidence of a care plan update to reflect fall prevention interventions after the 6/29/12 fall. 4. Review of Resident #6's Fall Risk Assessment, dated 5/5/12, showed: -Disoriented to person, place, and time at all times; -No falls in the past three months; -Chair bound and/or assist with elimination; -Balance problem while standing and walking; -Poor vision with or without glasses; -Took three to four medications within the last seven days that may have contributed to risk factors; -Had one to two disease conditions that may have contributed to risk factors; -Total score of 14 with 10 or above representative of HIGH RISK. Review of the resident's annual MDS, dated [DATE], showed: -Required extensive assistance of two staff for transfers; -Did not ambulate; -Used a wheelchair for mobility; -Required extensive assistance of one staff for eating, hygiene and bathing; -Received antipsychotic medication; -Occasionally incontinent -No falls; -[DIAGNOSES REDACTED]. Review of the resident's Incident/Accident Report for 6/29/12, at 7:30 A.M., showed: -Resident's condition before the incident was normal; -Occurred in resident's room; -Description-Heard resident hollering, entered room, observed resident sitting on floor wedged between foot pedals on wheelchair. No reddened or bruised areas noted. Able to flex and extend all extremities without difficulty; -Vital signs taken; -Physician notified by fax at 8:00 P.M., no date indicated; -Family notified at 9:00 P.M., no date indicated; -Signed by person who prepared report, no date indicated; -Signed by the DON on 7/2/12; -Signed by the administrator, no date indicated; -Nothing documented in the section for additional comments and/or steps taken to prevent recurrence; -No care plan update with interventions to prevent similar falls in the future. Review of the resident's Fall Risk Assessment, dated 8/24/12, showed: -Disoriented to person, place, and time at all times; -No falls in the past three months (even though the resident fell on [DATE]); -Chair bound and/or assist with elimination; -Balance problem while standing and walking; -Poor vision with or without glasses; -Took three to four medications within the last seven days that may have contributed to risk factors; -Had one to two disease conditions that may have contributed to risk factors; -Total score of 14 with 10 or above representative of HIGH RISK. Review of the resident's Incident/Accident Report for 9/2/12, at 10:20 A.M., showed: -Resident's condition before the incident was confused, disoriented and sedated-Neurontin (anti-seizure medication), valproic (anti-seizure medication) and Trazadone (anti-depressant medication) given at 8:00 A.M.; -Equipment involved-wheelchair; -Description-Pushing resident in hall to meal, put foot down off pedals and fell out of wheelchair, went on hands and knees and rolled over on left side. Small reddish area under right eye. No other red areas. Using all extremities. No complaint of pain; -Vital signs taken; -Diagram showed a mark under the resident's left eye and small red area under left eye written under type of injury; -Physician notified at 3:30 (no A.M. or P.M. marked), date not indicated; -Family member notified at 10:45 A.M., no date indicated; -Signed by staff who prepared report, no date indicated; -Signed by DON and administrator, no date indicated. -Nothing documented in the section for additional comments and/or steps taken to prevent recurrence; -No care plan update with interventions to prevent similar falls in the future. Review of the resident's Fall Risk Assessment, dated 11/18/12, showed: -Disoriented to person, place, and time at all times; -No falls in the past three months (even though the resident fell on [DATE]); -Chair bound and/or assist with elimination; -Standing/Walking-Not able to perform; -Poor vision with or without glasses; -Took three to four medications within the last seven days that may have contributed to risk factors; -Had one to two disease conditions that may have contributed to risk factors; -Total score of 14 with 10 or above representative of HIGH RISK. Review of the resident's quarterly MDS, dated [DATE], showed: -Required extensive assistance of two staff for transfers; -Did not ambulate; -Used a wheelchair for mobility; -Required extensive assistance of one staff for eating, hygiene and bathing; -Received antipsychotic medication; -Always incontinent; -Had one fall; -[DIAGNOSES REDACTED]. Review of the resident's undated care plan, reviewed by staff on 11/29/12, showed: -Problem: At risk for falls due to unsteady gait; -Goal: Will have no injuries as a result of a fall; -Interventions included: Requires assist of two with transfers, no longer ambulates, and resident uses a wheelchair and assist of one for ambulation; -No interventions specific to the resident's two falls out of a wheelchair; 5. During an interview on 12/4/12, at 3:10 P.M., the DON said she did not know she needed to complete a more thorough fall investigation. She thought the incident report was enough. She wasn't aware she needed to document investigation for factors that might contribute to falls and show interventions to prevent future occurrences on the incident/accident form. During an interview on 12/5/12, at 1:25 P.M., the MDSC said: -The DON notified her about accidents and falls, and gave her the Incident Reports which she initialed to show she saw the reports and entered them in the computer. -Staff evaluated residents' fall risks on admission and quarterly; -She talked with direct care staff and DON, and also used her observations to gather information for care plan development and problem interventions. -She thought the fact that Resident #1 was on a low air loss mattress was a factor both times the resident rolled out of bed. -She didn't know what else to do to reduce the fall risk factor related to the presence of the LALM. -She didn't always initiate a fall care plan when a resident had a fall and was not sure why. 6. Observation, interview, and record review, on the following dates and times, showed the temperature of hot water exceeded 120? F in resident rooms on the 300 and 400 corridors when measured by the surveyor using a stem-digital indicating thermometer: 12/3/12 - At 5:19 P.M., at the hand sink in room #402, measured 121.3? F at one minute, 125.1? F at one minute and 20 seconds, then dropped to 123.4? F within a few seconds where it remained steady to the two minute mark. - At 5:25 P.M., at the hand sink in room #405, measured 121.4? F at one minute then dropped to 120? F and held steady for the next 30 seconds. - At 5:36 P.M., at the hand sink on the east side of the main dining room, measured 119.2? F at one minute and 121.4? F at two minutes. 12/4/12 - At 10:12 A.M., observation of the 300 & 400 hall mechanical room with the maintenance supervisor (MS), showed two 91 gallon LP gas-fired water heaters with two mixing valves, installed in tandem, a larger valve over a smaller valve. The MS said installers told him the arrangement allowed for the larger valve to handle periods of higher demand and the smaller valve normal demand. He said it was hard to set the controls because they could change depending on use when set. He said maintenance workers (MW) monitored hot water temperatures weekly and did keep a log. - At 10:53 A.M., at the hand sink in room #304 with the maintenance supervisor (MS) , measured 120.0? F in 30 seconds, 123.2? F steady for one minute, and 125.0? F at two minutes. During an interview, the MS said the system of mixing valves installed on the south unit water heaters made it hard to set and maintain the hot water temperature because the valves were effected by demand-that the valves functioned differently during high demand than low. - At 11:01 A.M., at the hand sink in room #311, measured 120.0? F in 45 seconds, held steady at 121.2? F for one minute and measured 122.4? F at two minutes. - At 12:43 P.M., at the hand sink in room #407, measured 115? to 116? F at one minute and 126.2? F at two minutes. During an interview, Resident #1 said he/she did use the hot water at the sink, but generally only used the cold and did not have any problems. - At 12:47 P.M., in room #413, during an interview, Resident # 12 said he/she used the sink to wash his/her face and hands every morning and had all the hot water he/she needed and was never too hot. 12/5/12 - At 8:10 A.M., during an interview, MWs A and B said they measured hot water temperatures in resident rooms weekly, usually during the afternoon. They said they chose different rooms each time and kept a log. Review of their log showed a worksheet that included the laundry, kitchen and service areas with designated space for three rooms on each of three resident corridors. Review over the previous month showed temperatures measured each week with averages in resident rooms/central baths of 114? to 116? F on the 300 and 400 corridors and an occasional measurement of 118? to 119? F.