Every finding on record at Granby House

Based on observation, interview, and record review, the facility failed to ensure food was protected at all times from possible contamination when the ceiling in the walk-in cooler had a water leak during rain. The facility census was 52. Review of the facility policy titled, Maintenance Service, dated 2001, showed the following:-Maintenance service shall be provided to all areas of the building, grounds, and equipment;-The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times;-Functions of the maintenance personnel include maintaining the building in good repair and free from hazards and establishing priorities in providing repair service. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. 1. During observation and interview on 05/19/26, at 6:07 A.M., of the kitchen showed the following:-The walk-in cooler had a substantial leak coming from the ceiling and dripping down to the floor requiring a towel to be put down on the floor in front of the walk-in cooler;-Dietary [NAME] (DC) H said the walk-in cooler had been leaking for 15 years. During an interview on 05/22/26, at 10:08 A.M., Dietary Aide (DA) G said the following:-The walk-in cooler had been leaking for the one and a half years he/she has worked at the facility;-The water runs to the floor;-Management was aware of the leak. During an interview on 05/22/26, at 10:12 A.M., DC H said the leak in the walk-in cooler sometimes got the boxes of eggs wet. Maintenance has worked on the issue. During an interview on 05/21/26, at 10:27 A.M., the Maintenance Supervisor said the walk-in cooler had been leaking for the two years he has worked at the facility. He has tarred the roof, but this did not stop the leak. During an interview on 05/22/26, at 10:25 A.M., the Dietary Manager (DM) said the following:-The walk-in cooler had been leaking for a long time;-Maintenance tried to tar the roof;-The water does leak on the egg boxes. They try to keep everything covered;-She was concerned about sanitation;-Management was aware of the leak. During an interview on 05/27/26, at 9:06 A.M. the Registered Dietician (RD) said there should not be a leak in the roof of the walk-in cooler for food safety, and it should be repaired. During an interview on 05/22/26, at 3:06 P.M., the Administrator said there should not be a leak in the walk-in cooler.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to provide the approved serving size for pureed meals. The facility census was 52.Review of the facility's policy titled, Portion Variations, dated 2020, showed portion variations for the planned and approved menu which deviate from those listed on the spreadsheet or other communication tools are available based on estimated nutritional needs, physician order, or resident preference/request. 1. Review of the facility recipe for brown sugar meatloaf showed the following:-Combine ground beef, milk, eggs, cracker crumbs, chopped onion, salt, and black pepper in a mixer bowl on low speed just until well combined. Do not overmix;-Scale 1.5 pounds beef mixture in loaf pain, shaping the beef mixture into a loaf;-Bake one hour until the meat is browned, juices run clear and until desired internal temperature is reached;-While meatloaf is baking, combine brown sugar and ketchup. Spread over loaves the last 30 minutes of baking;-Let stand for 10 minutes, slice into three-ounce (oz) portions for serving. Review of the facility recipe for pureed brown sugar meatloaf showed the following:-Place the number of servings needed, from the regular prepared recipe, into a clean and sanitized food processor and blend until smooth;-If the consistency needed thinning gradually add an appropriate amount of hot liquid such as broth, gravy, hot milk, sauce or reserved cooking liquid;-If the consistency needed thickening alternate adding commercial thickener with processing;-Portion with a #6 scoop (2/3 cup). Observation on 05/21/26, at 11:02 A.M., showed the following:-Dietary [NAME] (DC) H used a four ounce ladle (1/2 cup) to serve out the pureed meatloaf (recipe showed to use a #6 (2/3 cup) scoop);-DC H did not refer to a recipe for portions during serve out. During an interview on 05/22/26, at 10:12 A.M., DC H said the following:-He/she did not really know where the menu spreadsheets were and did not refer to them for serve out, but thought he/she should be following a recipe;-The facility does not have enough serving utensils. During an interview on 05/22/26, at 10:25 A.M., the Dietary Manager (DM) said staff should follow the menu spreadsheet to serve out portions for all meals. During an interview on 05/27/26, at 9:06 A.M. the Registered Dietician (RD) said staff should follow the recipe for portions for all serve out meals. During an interview on 05/22/26, at 3:06 P.M., the Administrator said staff should follow recipes for serve out portions of all meals.

Based on observation, interview, and record review, the facility failed to have effective procedures in place to account for all medication when the emergency kit (E-Kit - a pre-stocked set of drugs designed for rapid access) medication lock tags were not monitoring routinely and failed to accurately match the logbook, for two of three E-Kit boxes. The facility census was 52. Review of the facility policy titled Medication Ordering and Receiving from Pharmacy, , dated 04/01/24, showed the following:-The facility may be equipped with emergency medication kits to be used outside of normal pharmacy business hours or if there is an emergent need to start a medication before the pharmacy will be able to deliver;-Only authorized and trained personnel as determined by the facility may administer medications from the E-Kit and are only for an interim time while waiting for the medication to arrive with the next pharmacy delivery;-Administration of medication from the E-Kit shall be based upon a physician order and shall be documented in accordance with the policy on ordering, documenting and receiving medication, the Emergency Kit Logbook, and the appropriate E-Kit Tag Log form;-Open the E-Kit by breaking the plastic seal;-The seal is red when the E-Kit's inventory is complete;-If a seal is green or black, the kit has been opened since it was received from the pharmacy;-Paperwork in the E-Kit will show what, if anything, has been removed;-Remove the items needed. Remove enough of the medication to last until the order is expected to be delivered from the pharmacy;-Complete the Emergency Kit Logbook slip and notify pharmacy by faxing the white copy from the from the Emergency Kit Logbook;-Re-lock the E-Kit with a green or black tag;-Document on the E-Kit Tag Log form the date, check the box indicating that the entry is not due to a shift change count, record the serial numbers of the tags removed, the serial numbers of tags that are used to relock the kit, medication name, resident name, and name of nurse removing the medications from the emergency kit;-For any Emergency Kit containing controlled substances, at each shift change, two nurses should document on the appropriate E-Kit Tag Log Form the date, check the box indicating that the entry is due to a shift change count, record the serial numbers of the tags on the kit, the name of the nurse beginning the shift and the name of the nurse ending the shift;-The pharmacy's delivery personnel will pick up and exchange the E-Kit. The nurse and the delivery person will both sign an Emergency Kit Exchange Log at the time of the exchange. 1. Review of the facility E-Kit Log, dated May 2026, showed the following:-On 05/01/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/02/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/03/26, no documentation of the tag numbers on either E-kit by the morning shift;-On 05/03/26, the evening shift documented the current tag number (00805962 and 00805961) and the new tag number (008805780 and 00805779). Staff did not note which kit (narcotic or non-narcotic). One nurse signed the log; -On 05/04/26, no documentation of the tag numbers on either E-kit by the morning shift;-On 05/04/26, the evening shift documented the current tag number (06524912 and 06524911) and the new tag number (00789506 and 00789505). Staff did not note which kit (narcotic or non-narcotic). One nurse signed the log; -On 05/06/26, the morning shift documented the current tag number (06524959 and 06524960) and the new tag number (00756284 and 00756283). Staff did not note which kit (narcotic or non-narcotic). One nurse signed the log; -On 05/06/26, the evening shift documented the current tag number (00756284 and 00756283) and the new tag number (06524930 and 06524929). Staff did not note which kit (narcotic or non-narcotic). One nurse signed the log; -On 05/07/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/08/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/09/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/10/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/11/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/12/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/13/26, the morning shift documented the current tag number (06524968 and 06524967) and the new tag number (113440 and 113439). Staff did not note which kit (narcotic or non-narcotic). One nurse signed the log; -On 05/13/26, the evening shift documented the current tag number (113440 and 113439) and the new tag number (06521090 and 06521089). Staff did not note which kit (narcotic or non-narcotic). One nurse signed the log with a note stating New E-Kit;-On 05/14/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/15/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/16/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/17/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/18/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/19/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/20/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/21/26, no documentation of the tag numbers on either E-kit by the morning or evening shift;-On 05/22/26, no documentation of the tag numbers on either E-kit by the morning shift. Observation on 05/22/26, at 12:00 P.M., of the medication room showed the following:-The non-narcotic E-kit sealed with four black numbered tags (00804991, 00804799, 00789268, and 00789264);-No E-Kit logbook located in the medication room. Observation on 05/22/26, at 12:35 P.M., of the medication room showed the following:-The narcotic E-Kit stored in a locked cupboard;-The E-Kit sealed with two black numbered tags (113211 and 113428);-No E-kit logbook located in the medication room. During an interview on 05/22/26, at 12:00 P.M., Certified Medication Tech (CMT) A said the following:-The emergency kits were provided by the pharmacy;-He/she did not have access to the narcotic E-Kit but had access to the non-narcotic medications;-If staff remove medications from the E-kit, staff must write the tag numbers into the log book;-He/she was unable to locate a logbook in the medication room. During an interview on 05/22/26, at 12:15 P.M., Licensed Practical Nurse (LPN) C said staff should write the old and new tag numbers on the logbook when opening any of the E-Kits. During an interview 05/22/26, at 12:35 P.M., LPN B said the following:-He/she could locate the logbook in the medication room;-Staff should write the old and new tag numbers on the logbook anytime the tags are removed to take out medications. During interview on 05/22/26, at 1:00 P.M., the Director of Nursing (DON) said the following:-Staff should write the old and new tags number on the logbook when opening any E-Kit;-Red tags indicate a new box from the pharmacy and black tags indicate the box has been opened and re-locked;-Staff should document in the logbook when they access the E-kit and change tags;-The pharmacy monitors the E-kit and would notify the facility if something was missing;-The logbook is currently at the nursing station with last tag numbers documented on 05/13/16 of 113440 and 113439;-The same logbook form is used for all three E-kits. During an interview on 05/22/26, at 3:00 P.M., the Administrator said she would expect the logbook to match the tag numbers on the E-Kits. The pharmacy also reviews the tags and monitors supplies in the kits.

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for three residents (Resident #43, #25, and #3). The facility census was 52. Review of the facility policy titled, Resident Bathing, undated, showed staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 1. Review of Resident #43's face sheet (a brief resident profile) showed the following: -admission date of 01/31/25; -Diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and colostomy status (presence of a surgically created opening (a stoma) that brings a part of the large intestine (colon) out through the abdominal wall). Review of the resident's care plan, updated 02/10/26, showed the following: -Resident required assistance with activities of daily living (ADL – bathing, grooming, etc.) related to bilateral below the knee amputee and diabetes mellitus; -Resident required extensive assistance and total assistance with transfers and bathing. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool administered by staff), dated 05/11/26, showed the following: -Cognitively intact; -Dependent on staff for toileting hygiene, showering, dressing, and transfers; -Substantial to maximal assistance for personal hygiene. Review of the resident's March 2026 Shower Sheet showed the resident received a shower on 03/05/26 and 03/26/26. Staff did not document refusals. Review of resident's March 2026 progress notes showed staff did not document any additional showers or refusals. Review of the resident's April 2026 Shower Sheet showed the resident received a shower on 04/03/26, 04/09/26, 04/16/26, and 04/24/26. Staff did not document any shower refusals. Review of resident's April 2026 progress notes showed staff did not document any additional showers or shower refusals. Review of the resident's May 2026 Shower Sheet showed the resident refused a shower on 05/15/26. Staff did not document any received showers. Review of resident's May 2026 progress notes showed staff did not document any additional showers or shower refusals. During an interview on 05/20/26, at 11:52 A.M., the resident said the following: -He/She received a shower about every two weeks; -The shower aide told him/her that he/she could get a shower when the aide could get someone to help with the Hoyer lift (mechanical lift); -He/She would prefer to take a shower twice per week; -He/she was a big person and felt dirty from sweating. During an interview on 05/22/26, at 11:00 A.M., the resident said the following: -He/She had not received a shower this week; -He/She did not know if there was a set schedule of when he/she could receive a shower. 2. Review of Resident #25's face sheet showed the following: -admission date of 09/18/23; -Diagnoses included Parkinson's disease anxiety disorder, presence of left artificial hip joint, acquired absence of left leg below the knee, traumatic brain injury, osteoarthritis (arthritis that occurs when the protective cartilage that cushions the ends of bones gradually wears away), and neuromuscular scoliosis of the thoracolumbar region (sideways curvature between the middle to lower back). Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool administered by staff), dated 02/27/26, showed the following: -Cognitively intact; -Resident dependent on staff for showers. Review of the resident's care plan, revised on 04/23/26, showed the following: -Resident required assistance to complete ADLs of care safely related to weakness in lower extremity and unsteady gait due to below the knee amputation and use of a prosthetic leg; -Resident able to dress upper half but required staff assist with dressing lower half; -Resident was able to self-transfer with help of position bars and bath bars; -Staff did not document related to shower preference/refusals. Review of the resident's March 2026 Shower Sheet showed the resident received a shower on 03/02/26 and 03/21/26. Staff did not document any refusals. Review of resident's March 2026 progress notes showed staff did not document any further showers or shower refusals. Review of the resident's April 2026 Shower Sheet showed the resident received a shower on 04/01/26, 04/09/26, 04/17/26, and 04/23/26. Staff did not document any refusals. Review of resident's April 2026 progress notes showed staff did not document any further showers or shower refusals. Review of the resident's May 2026 Shower Sheet showed the resident received a shower on 05/01/26 and 05/15/26. Staff did not document any refusals. Review of resident's progress notes, dated May 2026, showed staff did not document any additional showers or shower refusals. During an interview on 05/20/26, at 1:09 P.M., the resident said he/she only gets one shower every two weeks and would like at least one shower per week. He/she did not want to smell. Observation and interview on 05/22/26, at 9:11 A.M, showed the following: -The resident's hair looked oily, with visible flakey particles; -The resident said he/she had not had a shower recently and did not feel clean; -He/she would not leave the facility for an outing without a shower. During an interview on 05/21/26, at 3:12 P.M., Certified Nurse Assistant (CNA) D said he/she was not aware of the resident's preference for showers. During an interview on 05/22/26, at 12:50 P.M., CNA/Shower Aide F said the resident refused showers at times, but he/she did not document any refusals from 03/02/26 to 05/15/26. 3. Review of Resident #3's face sheet showed the following: -admission date of 01/15/26; -Diagnoses included cellulitis (common, potentially serious bacterial skin infection that affects the deep layers of the skin and underlying tissues) of right lower limb, weakness, and anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Supervision or touching assistance for oral hygiene; -Substantial to maximal assistance for toileting hygiene, showering; -Partial to moderate assistance for dressing; Review of the resident's care plan, updated 01/15/26, showed the following: -Resident was resistive to care at times; -Staff should encourage as much participation from the resident as possible during care activities; -Resident had limited physical mobility related to weakness; -Staff did not care plan related to shower preference or refusals. Review of the resident's March 2026 Shower Sheet showed the resident received a shower on 03/06/26, 03/11/26, and 03/24/26. Staff did not document any refusals. Review of resident's March 2026 progress notes showed staff did not document any additional showers or shower refusals. Review of the resident's April 2026 Shower Sheet showed the resident received a shower on 04/03/26, 04/09/26, 04/15/26, 04/22/26, and 04/30/26. Staff did not document any refusals. Review of resident's April 2026 progress notes showed staff did not document any additional showers or shower refusals. Review of the resident's May 2026 Shower Sheet showed the resident received a shower on 05/06/26, 05/11/26, and 05/19/26. Staff did not document any refusals. Review of resident's May 2026 progress notes showed staff did not document any additional showers or shower refusals. During an interview on 05/20/26, at 3:36 P.M., the resident said the following: -He/she had a shower four days ago, but prior to that it had been two weeks; -He/she preferred two showers per week in order to feel clean; -He/she did not like to feel dirty and worried about body odor. 4. During an interview on 05/21/26, at 3:12 P.M., Certified Nurse Aide (CNA) D said the following: -Residents should receive two showers per week; -Staff should document shower refusals in the electronic plan of care under bathing. During an interview on 05/22/26, and 11:59 A.M., CNA E said residents should receive two showers per week. During an interview on 05/22/26, at 12:30 P.M., Licensed Practical Nurse (LPN) C said the following: -The facility had a shower schedule, in which residents received two showers per week; - If a resident requested an additional shower, staff would try to accommodate their request; -Residents should not go two weeks without a shower. During an interview on 05/22/26, at 12:50 P.M., CNA/Shower Aide F said the following: -He/she was responsible for resident showers; -The facility had a shower schedule; - Residents should receive showers two times per week; -Staff should document refusals on shower spreadsheet with a R and showers received with a X; -Shower refusals should also be documented in the electronic plan of care; -If a resident refused a shower, he/she reapproached the resident the following day and continued to do so throughout the week; -He/she notified the Director of Nursing (DON) or Administrator if a resident continued to refuse a shower. During an interview on 05/22/26, at 1:15 P.M., LPN B said residents should receive two showers per week. During an interview on 05/22/26, at 1:00 P.M., the Director of Nursing (DON) said the following: -Residents should receive at least one to two showers per week; -The facility had a lot of non-compliant residents that refused showers; -Staff should document resident refusals; -The shower aide had not consistently been at work. During an interview on 05/22/26, at 3:00 P.M., the Administrator said the following: -Residents should be offered and provided with showers two times per week, or per their preference; -Staff should document refusals and showers received on shower sheets and in the electronic plan of care; -Residents who have refused a shower should be reapproached by different staff and at different times of day.

Based on observation, record review, and interview, the facility failed to provide all residents reasonable access to the use of a phone in a private environment when the resident use phone was located at the nurses' station providing a lack of privacy for two residents (Resident #1 and #2) when they used the phone. The facility census was 52. Review of the facility's policy titled Resident Rights, revised February 2021, showed the following: -Employees shall treat all residents with kindness, respect, and dignity; -Resident rights included the right to privacy and confidentiality; the right to access to a telephone, mail and email; and the right to communicate in person, by mail, email, and telephone with privacy. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included schizophrenia (a mental disorder characterized by disruptions in thought processes perceptions, emotional responsiveness and social interactions), anxiety disorder and cognitive communication deficit. Review of the resident's care plan, revised 12/05/24, showed the following: -The resident had a risk for impaired communication; -Allow adequate time for the resident's response; -Evaluate the resident's ability to comprehend. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/07/25, showed the resident's cognitive skills intact. During an interview on 04/24/25, at 7:50 A.M., the resident said the following:-He/she used the phone located behind the nurses' desk. The phone had a cord and he/she was not able to take the phone with him/her; -Facility staff talk around him/her when he/she used the phone and he/she did not have privacy; -He/she tried to talk to his/her family member every day and would like more privacy. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included depression and anxiety disorder. Review of the resident's admission MDS, dated [DATE], showed the resident's cognitive skills intact. Review of the resident's care plan, dated, 02/12/25 showed the following: -The resident was unable to care for himself/herself in his/her home; -The resident had decided to remain at the facility for long term care; -Encourage the resident's family or ones close to him/her remain involved and continue to provide support. During an interview on 04/25/25, at 8:08 A.M., the resident said the following: -The phone was located at the nurses' station; -He/she did not have privacy when he/she used the phone; -Facility staff were around the nurses' station when he/she had talked on the phone and he/she felt a lot of staff listen to his/her conversation. 3. Observation on 04/24/25, at 8:30 A.M., showed a phone with a cord on the nurses' desk located by a medication cart. One nurse sat at the desk on the computer and another nurse stood at the medication cart by the nurses' desk. 4. During an interview on 04/24/25, at 8:36 A.M., Licensed Practical Nurse (LPN) A said the following: -The phone used by residents was located at the nurses' desk; -He/she did not know for sure what happened to the cordless phone; -The privacy was not what the residents deserved. During an interview on 04/24/25, at 8:50 A.M., Certified Nurse Aide (CNA) B said the following: -Staff brought residents to the nurses' desk to use the phone; -He/she worked at the facility over a year and residents have used the phone at the nurses' desk; -There was a lot of traffic at the nurses' desk and there could be a better location for the phone. During an interview on 04/24/25, at 8:55 A.M., Certified Medication Technician (CMT) C said the following: -Staff take residents to the nurses' desk to use the phone; -There was not another place to take the residents when they wanted to use the phone; -There was always some staff at the nurses' desk; -The facility used to have a cordless phone. During an interview on 04/24/25, at 9:29 A.M., the Administrator said the following: -There was no privacy for residents at the nurses' desk; -She had worked on obtaining a phone for the residents the last couple of months. MO00252857

Based on record review and interviews, the facility failed to ensure the resident's environment remained free of accident hazards when the front door alarm was turned off resulting in one resident (Resident #1) exiting the building and obtaining injuries from a fall. The facility also failed to document a complete investigation into the elopement and fall including a root cause analysis. The census was 54. Review of a facility policy entitled Accidents and Incidents - Investigating and Reporting (revised July 2017) showed the following: -All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator; -Data, as applicable, shall be included on the Report of Incident/Accident form included -the date and time the accident or incident took place; the nature of the injury/illness (e.g., bruise, fall, nausea, etc.); the circumstances surrounding the accident or incident; the injured person's account of the accident or incident; the name(s) of witnesses and their accounts of the accident or incident; -the date/time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; the date/time the injured person's family was notified and by whom; the condition of the injured person, including his/her vital signs; any corrective action taken; follow-up information; other pertinent data as necessary or required; and the signature and title of the person completing the report; -Incident/Accident Reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review showed the facility did not provide a policy specific to the door alarms and locking mechanisms. 1. Review of Resident #1's face sheet (gives basic profile information at a glance) showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (central nervous system disorder that affects movement often including tremors), chronic obstructive pulmonary disorder (COPD - breathing disorder), anxiety, major depressive disorder, dementia, high blood pressure, muscle weakness, difficulty in walking, repeated falls, and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/24/25, showed the following information: -Severely impaired cognition; -Independent use of manual wheelchair; -Required partial to moderate assist with toileting, standing, and transfers; -Required substantial to maximum assist with bathing, dressing, and personal hygiene; -Did not walk. Review of the resident's care plan, dated 07/30/24, showed the following: -Resident had poor safety awareness and was at risk for falls. Despite interventions in place, the resident will continue to fall; -Resident chooses to remain as independent as possible; -Staff to ensure resident is wearing appropriate footwear such as non-slip socks or shoes when ambulating or mobilizing in wheelchair; -Staff to remind resident that he/she can't walk like they used to; -Resident needs a night light to help see at night; -Resident uses a wheelchair for mobility; -Staff to round frequently; -Staff to distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; -Staff to identify pattern of wandering (purposeful, aimless, or escapist; looking for something). Review of the resident's progress note dated 02/23/25, at 1:30 A.M., showed Registered Nurse (RN) A documented the following: -Resident observed to be lying on ground, hollering help. Staff assisted with resident to observe bruising to back of right shoulder and blood to back of head. Staff cleaned blood to find superficial abrasions to back of head. Resident was in wheelchair prior. Fall was un-witnessed fall. Staff informed physician, family member, Director of Nursing (DON), and Administrator. Resident responsive and verbalizing with staff. Staff observed no change from baseline. Nurse attempted to clean abrasion and resident kept moving head; -Staff notified physician notified, family informed of incident, and informed staff to monitor resident and that they will check in the morning. Neurological checks per fall protocol; -Resident oriented to person; -Predisposing environmental factors: poor lighting; -Predisposing physiological factors: impaired memory, weakness; -Predisposing situation factors: wanderer. Review of a Fall Documentation Checklist, dated 02/23 (no year specified) at 1:30 (no indication of A.M. or P.M.), for the resident showed the following information: -Concerns noted: open wound back of head, bruising on right shoulder; -Neighbor statement: (left blank); -Checklist indicated completion of: head to toe skin assessment including baseline comparison, legs are equal length and no rotation, grips equal or at baseline, family notified, physician notified, incident report completed, and neurological checks completed and documented; -Handwritten note stated to continue with 72-hour follow-up with required information. (The checklist did not address the resident's fall being outside of the facility or how the resident got outside of the facility.) Review showed the facility did not provide any additional investigation of the root cause for the fall or elopement and did not address interventions would prevent future falls and elopements. Review of the resident's care plan showed staff updated the care plan with the following: -On 02/23/25, staff to monitor resident whereabouts when up wandering; -On 02/24/25, elopement risk, wanders aimlessly. During an interview on 02/25/25, at 10:37 A.M., RN A said on 02/23/25, around 1:00 A.M., he/she noted the resident was in his/her wheelchair in the hallway. At approximately 1:30 A.M., he/she noticed the resident was not in the hallway or in his/her room. RN A asked Nurse Aide (NA) B and NA C if they knew the location of the resident. They said they had seen him/her in the hallway a short time prior, but did not know his/her current location. A search was made of all rooms in the building. RN A and NA B exited the front door of the building and heard the resident hollering for help. They found him/her on the ground on the parking lot pavement at the edge of the driveway with his/her the wheelchair was close by. Upon assessment, the staff noted bleeding from the back of the resident's head and an abrasion to his/her right shoulder. The resident said he/she didn't know what happened. RN A put his/her own sweatshirt on the resident while NA B went inside and quickly brought out blankets to wrap around the resident. RN A and NA B assisted the resident into the wheelchair and took him/her inside. RN A said he/she did not see the alarm system unplugged and did not know why the door would have been left unlocked and the alarm disconnected. RN A said another staff member's family members did go in/out the front door several times that evening. During an interview on 02/23/25, at 12:34 P.M., Certified Medication Technician (CMT) D said he/she worked on 02/22/25, from 2:00 P.M. until 10:00 P.M. CMT D said if the doors are not alarmed the staff should monitor the doors. He/she said they have several wanderers who would probably need frequent/15 minute checks. During an interview on 02/23/25, at 12:42 P.M., NA B said on 02/23/25, around 1:30 A.M., he/she and NA C were doing rounds to check residents. RN A came and asked them if they knew the whereabouts of the resident. They said they had seen him/her in the hallway awhile earlier, but did not know where he/she was currently. A search was made of the entire building. NA B said he/she and RN A noted the front door was not locked and the alarm did not sound when they exited the building. They heard the resident yelling for help and found him/her on the ground at the edge of the parking lot driveway. NA B ran back inside for blankets while RN A calmed and assessed the resident. NA B said the resident kept thanking them and apologizing, saying, You saved my life! NA B called the DON, and they could both hear the DON on the speaker phone. The nurse quickly assessed the resident, they assisted him/her back into the wheelchair, and took him/her back inside the building to warm him/her up. NA B said RN A tried to bandage the resident's head, but the resident kept taking of the dressing. NA B said the resident does wander around the facility in his/her wheelchair, but didn't appear to be exit seeking. During an interview on 02/23/25, at 12:00 P.M., the Maintenance Director said he/she had not received any reports of the door alarms not working, and he/she was not aware of the front door alarm being found unplugged. Staff should document any maintenance requests on the log in the employee break room or tell him/her directly if something needs immediate attention. He/she was always available by phone. During interviews on 02/23/25, at 1:40 P.M. and 3:03 P.M., the DON said the following: -The facility's front and back (employee) doors were alarmed and would emit a loud beep whenever the door was opened. He/she had not heard any reports that the front door or alarm were or had been inoperable prior to the incident. -RN A called her on 02/23/25, at approximately 1:30 A.M. and told him/her the resident was found outside on the ground in front of the building. The DON said he/she instructed the RN to complete a full assessment, clean the wounds, and to notify the family. -The resident's family was very concerned that the resident got outside in the cold temperature, but said to monitor the resident's condition and not to send the resident to the emergency department based on the current assessment. The family was going to come to the facility in the morning to see the resident. -The DON said he/she came to the facility and found the front door alarm system to be unplugged (located above the door). During interviews on 02/23/25, at 3:20 P.M. and 3:40 P.M., the Administrator the following: -He/she was not aware that the front door alarm was found unplugged; -The only reason the alarm would ever be unplugged was when the maintenance director was testing the system. No other staff should unplug the alarm system.; -Staff must enter a code on the keypad by the front and back doors before opening the door. A loud beep is heard briefly. When the front and back doors were opened without entering a code on the keypad, a loud beeping noise begins and remains sounding until the code is entered. The door alarms will also sound if the code is entered, but the door is held open too long. -If the doors are not alarmed, staff should monitor the front and back doors; -Staff should notify the Maintenance Director as soon as possible regarding immediate needs, like the door alarms not working. MO00250027

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection control program when staff failed to practice proper hand hygiene while providing care for three residents (Residents #2, #3, and #4) and when staff failed to gown as required for two residents (Resident #4 and #5) who had enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO -microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) in place due to wounds. The facility census was 51. Review of the facility policy, Hand washing/Hand Hygiene, revised October 2023, showed the following: -All personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc) were readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub dispensers were placed in areas of high visibility and consistent with workflow throughout the facility; -Hand hygiene is indicated immediately before touching a resident; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal; -The use of gloves does not replace hand washing/hand hygiene; -When applying and removing gloves, perform hand hygiene before applying non-sterile gloves and when removing gloves, perform hand hygiene. Review of the facility policy Enhanced Barrier Precautions, dated March 2024, showed the following: -It was the policy of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms; -EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities; -All staff receive training on EBP upon hire and at least annually and were expected to comply with all designated precautions; -All staff receive training in high-risk activities and common organisms that require EBP; -The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff were aware of which residents require the use of EBP prior to providing high-contact care activities; -EBP will be initiated for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling/implanted medical devices such as central lines, ports, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident was not known to be infected or colonized with a MDRO (multi-drug resistant organism) and infection or colonization with a CDC (Centers for Disease Control) targeted MDRO when contact precautions do not otherwise apply; -Make gowns and gloves available immediately near or outside of the resident's room (note: face protection may also be needed if performing activity with risk of splash or spray such as wound irrigation and tracheostomy care); -Personal Protective Equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room; -Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room); -Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room; -Place a yellow sticker or magnet on the name plate of the resident's door to identify the need of EBP; -High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central lines, urinary catheters, feeding tubes, and tracheostomy/ventilator tubes; -EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility; -EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the Centers of Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 04/02/24, showed the following; -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care; -Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, or tracheostomy/ventilator) and wound care (any skin opening requiring a dressing). 1. Review of Resident #2's face sheet (information at a glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - lung disease that blocks air flow and makes it difficult to breathe). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/02/24, showed the following: -Moderately impaired cognition; -Resident dependent on staff for personal hygiene, dressing, toileting, mobility, and transfers; -Incontinent of bowel and bladder. Review of the resident's care plan, undated, in the electronic medical record (EMR), showed the following: -Required two staff to help transfer the resident to the wheelchair; -Incontinent of both bowel and bladder related to impaired mobility. Staff were to clean perineal area with each incontinence episode. Observation on 01/30/25, at 5:00 A.M., showed the following: -Certified Nurse Aide (CNA) D asked the resident, who was in bed, if he/she wanted to get up. CNA E turned on the light, did not wash his/her hands, got a pair of gloves from the box on the wall, and put on the gloves. -CNA D could not find the cleansing wet wipes so he/she removed his/her gloves, left the room to get a box of wipes. CNA D returned and put on gloves without washing his/her hands. -CNA E shut off the oxygen concentrator and both aides dressed the resident who was in bed. -CNA D and CNA E, turned the resident to his/her side, put a clean incontinence brief underneath the resident's wet brief, removed the bed pad and brief wet with urine, and pulled up the clean incontinence brief. CNA D got the cleansing wipes and performed perineal care (without performing hand hygiene or changing gloves). CNA D took a tube of barrier cream and wiped the cream on the resident's buttocks (without performing hand hygiene or changing gloves). -CNA D removed his/her gloves, did not wash hands, and put on a clean pair of gloves. -CNA D attached the clean incontinence brief. -Both CNA D and CNA E kept the same pair of gloves on. CNA E took a mechanical lift sling and placed it underneath the resident. -CNA D removed his/her gloves and did not perform hand hygiene. CNA D put the resident's eye glasses on and his/her shoes lying on the bed. CNA E removed his/her gloves, did not perform hand hygiene, and took the trash bag of linens to the soiled utility room down the hall. CNA D touched his/her own personal watch, then got the foot pedals to the wheelchair and placed the foot pedals next to the bed. Without performing hand hygiene and donning gloves, CNA E brought the mechanical lift into the room and they attached the resident in the sling to the mechanical lift. -CNA D and CNA E transferred the resident. Without performing hand hygiene, CNA E put on gloves and tried to put the oxygen tubing per nasal cannula back on the resident who refused. CNA E put the tubing back on the machine. CNA D put a blanket over the resident's lap and sat the resident next to his/her bed and placed the call light on the resident. CNA D did not perform hand hygiene or put on gloves as he/she touched the resident personal items on the bedside table such as snacks. -CNA D removed the mechanical lift from the room and put in the hall. CNA E put on a pair of gloves without performing hand hygiene and took another bag of linens down the hall. -CNA D used the hand sanitizer on the wall as he/she left the room. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute respiratory failure, heart failure, COPD, type 2 diabetes mellitus (high blood glucose), unspecified head injury, convulsions (seizures), peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), acute kidney failure, dementia (progressive impairments in memory, thinking, and behavior which negatively impacts a person's ability to function and carry out every day activities). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Dependent for toileting, personal hygiene, upper/lower body dressing, and transfers; -Always incontinent of bowel and bladder. Review of the resident's care plan, undated, from the EMR, showed the following: -Required assistance with activities of daily living due to weakness in lower extremities related to a stroke; -Incontinent of both bowel and bladder related to impaired mobility. Staff to clean perineal area with each incontinence episode. Observation on 01/30/25, at 5:50 A.M., showed the following: -CNA D and CNA E entered the resident's room and did not wash or sanitize hands, and put on gloves. The resident sat up on the edge of the bed. The CNAs assisted the resident to dress. The resident wore an incontinence brief. -CNA D assisted the resident to stand up and removed the wet incontinence brief. While the resident stood, CNA E took cleansing wipes and cleansed between the resident's buttocks and outer buttocks, put a clean incontinence brief on the resident and assisted the resident to sit down in the wheelchair. -CNA D then removed his/her gloves and did not did not perform hand hygiene. CNA E removed his/her gloves, did not perform hand hygiene, and took the trash bag out of the room. -CNA D picked up a brush and brushed the resident's hair and then pushed the resident in his/her wheelchair out of the room. -CNA E came back to the room, put on gloves without performing hand hygiene, and raised the resident's bed, took the trash, removed gloves, and then used the hand sanitizer on the wall before leaving the room with the trash bag. 3. During an interview on 01/30/25, at 6:00 A.M., CNA E and CNA D both said they were to wash hands when they walk into a resident's room, before they put on gloves, and when they remove gloves. They could wash hands in the break room because there were no paper towels in the residents' rooms right now since they were changing out the towel dispensers. Most rooms had hand sanitizer. Observation on 01/30/25, at 6:03 A.M., showed there were paper towels in the towel dispenser in Resident #3's room. 4. Review of Resident #5's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus (high blood glucose), acute respiratory failure with hypoxia (low oxygen level), congestive heart failure (CHF), peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), kidney failure, and acquired absence of left leg above the knee. Review of the resident's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -Intact cognition and interviewable; -Lower extremity impairment on one side; -Supervision and touching assistance for toileting and personal hygiene; -Substantial/maximal assistance with transfers; -Surgical wound with surgical wound care and application of nonsurgical dressing with or without topical medications other than to feet. Review of the resident's care plan, dated 12/30/24, showed the following: -The resident required assist with activities of daily living with the above the left knee amputation; -Required staff assistance with lower dressing, transfers, and bathing; -Required two staff assistance for transfers and toileting; -Resident had an ischemic ulcer of the right ankle and a surgical wound to left groin. -On 01/28/25, staff initiated EBP to help protect him/her from infections related to his/her wound. Intervention included a sign placed on door alerting staff and visitors of precautions, staff and visitors to clean hands with alcohol-based hand sanitizer before and after entering and leaving room, staff to wear gown and gloves when caring for resident's wound; Observation on 01/30/25, at 6:30 A.M., showed no EBP sign on the resident's door. Observation on 01/30/25, at 9:30 A.M., showed CNA F and CNA G in the resident's room. Both aides had gloves on, but did not wear a protective gown. CNA F picked up the resident's hair brush and brushed the resident's hair as he/she sat on the edge of the bed. The resident had a left leg above the knee amputation. The aides transferred the resident from the bed to the wheelchair. CNA G made the resident's bed while CNA F walked out of the room with gloves pushing a mechanical lift that had been left in the resident's room. 5. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included cutaneous abscess of left lower limb (pus filled lump that develops in the skin or tissue of the leg), type 2 diabetes mellitus (high blood glucose), and left knee effusion (excess fluid builds up in or around the knee joint). Review of the resident's annual MDS, dated [DATE], showed the following: -Intact cognition and interviewable; -Lower extremity impairment on one side; -Dependent for toilet hygiene; -Substantial/maximal assistance for personal hygiene; -Frequently incontinent of bladder and occasionally incontinent of bowel; -Partial/moderate assistance for toilet transfer; -Open lesions other than ulcers, rashes, or cuts; -Applications of nonsurgical dressings with or without topical medications/other than to feet; -Applications of ointments/medications other than to feet. Review of the resident's care plan, dated 7/25/24, showed the following: -Required moderate staff assistance with upper dressing and maximum assistance for lower dressing, two assistance for toileting and transfers; -Resident has an open abscess on left knee related to hardware; -On 01/14/25, staff initiated EBP to help protect the resident from infections related to his/her wound. Interventions included a sign placed on door alerting staff and visitors of precautions, staff and visitors to clean hands with alcohol-based hand sanitizer before and after entering and leaving room, and staff to wear gown and gloves when caring for his/her wound. Observation on 01/30/25, at 6:38 A.M., showed an EBP sign next to the door. Observation on 01/30/25, at 6:38 A.M., showed CNA F entered the room, put on a pair of gloves, without washing and or sanitizing his/her hands, did not put on a protective gown, and went into the bathroom where the resident sat in the wheelchair waiting for staff to toilet him/her. CNA F placed a gait belt around the resident and transferred the resident to the toilet. The resident did not bend his/her left knee. CNA F removed his/her gloves, and used the hand sanitizer on the wall in the room before leaving the room. At 6:43 A.M., CNA F knocked on the resident's room door, put on gloves, without washing and or sanitizing his/her hands, and did not put on a protective gown. CNA F went into the bathroom, assisted the resident to stand, wiped the resident with toilet paper, pulled up the resident's pants, and transferred the resident to the wheelchair. CNA F removed his/her gloves and sanitized his/her hands before pushing the resident in the wheelchair to the dining room. During an interview on 01/30/25, at 7:37 A.M., CNA G said the resident was on EBP because the resident's left knee had a wound. During an interview on 01/30/25, at 7:50 A.M., CNA F said the resident had a wound on his/her leg which was bandaged and had tubi grips (elastic support bandage) on his/her legs. He/she would have put on a gown if they would get gowns down on the hall. 6. During an interview on 01/30/25, at 7:37 A.M., CNA G said EBP was for staff to wear a gown, mask, and gloves for wound care, isolation, catheters, colostomies, and for contact precautions. They keep the gowns and gloves in the supply room or the nurses have them. During an interview on 01/30/25, at 7:50 A.M., CNA F said EBP was when they were to change the residents, and put ointment on them. The wound care nurse has training on EBP for wound care. PPE (Personal Protective Equipment) is gloves and if a resident was in isolation, they would put on a mask and a protective gown. They will wear gowns if the charge nurse instructs them to do this. The charge nurse will tell what they were to use. During an interview on 01/30/25, at 7:47 A.M., Licensed Practical Nurse (LPN) A (wound nurse) said there was a cart on the hall for gowns and gloves for EBP. During an interview on 01/30/25, at 8:00 A.M., LPN C said he/she was new at the facility and had not heard of EBP before and did not know who was the Infection Control Nurse at the facility. If the nursing staff asked him/her what they needed to put on to take care of a certain resident, he/she would tell staff to put on gloves, mask, and gown. During an interview on 01/30/25, at 9:05 A.M., the Assistant Director of Nursing (ADON) said he/she had been the Infection Preventionist nurse since June 2024. There had been a lot of nursing turnover and he/she had been working as charge nurse. Staff were to wash and or sanitize their hands before gloving and after removing their gloves, during wound care, when they entered a resident's room, and after perineal care performed. There was hand sanitizer in all residents' rooms on the wall. For EBP, staff were to gown up and wear gloves when in contact with any resident with wound, catheter, or colostomy. The gowns were out in the drawers in hall and in the supply room and in their shed. He/she was responsible for putting up the EBP signs on residents' doors. They have a risk meeting every week with all infections and wounds. They are constantly trying to educate nursing staff that have direct contact about EBP. During an interview on 01/30/25, at 8:56 A.M., the Administrator said staff were to wash and or sanitize hands when they go into a room and before leaving a room, before gloving, after removing gloves, and any times in between like with personal cares. They have had a couple of in-services about EBP and new staff need training on it. He/she did expect the staff to wear gowns when going into resident rooms to do personal cares.

Based on interview and record review, the facility failed to provide care per standards of practice when for all residents when staff failed to administer one resident's (Resident #1) levothryroxine (medication for a low thyroid) as ordered. The facility census was 51. Review of the facility policy Administering Medications, revised April 2019, showed the following: -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform of process changes and or the need for additional staff training. Review of the facility Electronic Medical Record Admission Checklist, undated, showed the following: -Call and verify medications with provider and be sure to add to admission note; -Progress note must include the physician was notified of admission and the medication list was reviewed; -Every admission needs a TSH (thyroid stimulating hormone level - used to test the thyroid levels) lab test yearly; -Fax face sheet, discharge summary, and medication list to provider. 1. Review of Resident #1's face sheet (information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included systemic lupus erythematosus (a chronic illness that occurs when the immune system attacks healthy tissues and organs and can cause fatigue and joint pain and affects many parts of the body such as joints, skin, kidneys, blood cells, brain, heart, and lungs), epilepsy (seizures), hypothyroidism (low thyroid levels which may cause symptoms of fatigue, cold sensitivity, dry skin, unexplained weight gain, and hair loss), major depression, and anxiety. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/16/24, showed the resident's cognition was intact. Review of the resident's admission information provided from the transferring facility showed the following: -Diagnoses of hypothyroidism with onset date of 12/09/19; -A physician's order, dated 12/8/24, for levothyroxine sodium 88 micrograms (mcg), one tablet by mouth in the morning for hypothyroidism. Review of the resident's December 2024 Medication Administration Record (MAR) showed staff did not document an order for levothyroxine sodium oral tablet 88 mcg, to administer one tablet by mouth one time a day for hypothyroidism. Review of the resident's physician's orders showed an order, dated 01/24/25, with start date of 01/25/25, for levothyroxine sodium oral tablet 88 mcg. Staff to administer one tablet by mouth one time a day at 4:00 A.M. for hypothyroidism. Review of the resident's January 2025 MAR showed an order, with a start date of 01/25/25, for levothyroxine sodium oral tablet 88 mcg for staff to administer one tablet a day for hypothyroidism at 4:00 A.M. (Staff did not document administering levothyroxine prior to 01/25/25.) During an interview on 01/29/25, at 10:26 A.M., the resident said he/she was at another facility in December 2024 before coming to this facility. He/she was on levothyroxine 88 mcg every day, but had not been getting the levothyroxine until a week ago or so. He/she had lupus for [AGE] years and had a low thyroid since he/she was [AGE] years old. During an interview on 01/29/25, at 12:00 P.M., Licensed Practical Nurse (LPN) A said the resident came from another facility and did have a physician's order summary and profile sheet. The resident was on levothyroxine, but he/she was not sure if the order did not go in the electronic medical record or if there was a misunderstanding and miscommunication from the other facility about the levothyroxine. During an interview on 01/29/25, at 12:03 P.M., Certified Medication Technician (CMT) B said the resident came from another facility. The night nurse administers thyroid medication on night shift. The resident reported to him/her that he/she had not gotten his/her levothyroxine medication. When the resident was admitted to the facility, he/she had a medication card with three pills of levothyroxine 88 mcg. This medication card was in his/her medication cart with the regular medications, but he/she did not pay attention to this since he/she does not administer the thyroid medications. The night nurse administers the levothyroxine medications from 4:00 A.M. to 5:00 A.M. During interview on 01/30/25, at 4:00 A.M., the night nurse, LPN C, said another staff member pointed it out to him/her that the resident told them about the levothyroxine. When he/she went to administer a pain medication to the resident, he/she told him/her about not getting levothyroxine medication. He/she usually administered levothyroxine medication on his/her shift from 4-5:00 A.M. During interview on 01/29/25, at 4:00 P.M., the Associate Director of Nurse (ADON) said when they admit a resident to the facility, they do an assessment of the resident and will take the resident's medication list from the hospital and go over this with the physician. When the resident admitted , they had a nurse in training. The nurse put the resident's medications in the electronic medical record and must have overlooked the medication levothyroxine. When the resident came to him/her and said he/she didn't think he/she was getting the levothyroxine, the ADON looked at the resident's medication orders and did not see the order for the levothyroxine. Usually the Director of Nursing (DON) and ADON look at the resident's admission check list to double check the medications, but they did not do this for the resident. The charge nurse would give any medications to the medication technician upon admission. The night nurse would administer the levothyroxine. If the medication order was in the computer, the medication would have popped up for the night nurse to administer. They should have double checked the medications within 24 hours from admission. During interview on 01/29/25, at 3:52 P.M., the Administrator said the nursing staff have a checklist to use on a new admission to the facility. They found they missed a routine medication for the resident who has lupus and they made a medication error report. MO00246993

Based on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when light fixtures in the kitchen and dining area had dead bugs present, were not clean, were missing covers, and were not good working order; when the lower shelf of the prep table was not good repair with rust visible; when staff failed to keep the outside of the ice machine clean; and when the floor in the stock room had debris present and was dirty. The facility census was 46. Review of the facility's policy titled Sanitization, dated November 2022, showed the following: -All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; -All utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. 1. Observations on 06/24/24, beginning at 10:00 A.M., and on 06/26/24, beginning at 10:30 A.M., of the kitchen and dining areas showed the following: -Two lights located over the steam table had several dead bugs present; -The light at the back of the kitchen, located over the cabinet, had several bugs inside the light fixture and brown spots on the outside of the fixture; -The light over the refrigerator had the cover missing from the light; -Two lights located over the stove had dead bugs in the light fixture; -One light in the back of the dining room was not working. Review of the facility's weekly June 2024 Cleaning Schedule showed no task for cleaning the ceiling lights, replacing the covers, or ensuring the lights are functioning. During an interview on 06/26/24, at 12:43 P.M., Dietary Aide (DA) L said the following: -Ceiling lights are maintained by maintenance; -He/she doesn't pay close attention to the ceiling lights so he/she didn't notice there were bugs in them, or that one of the covers was missing in the kitchen; -He/she wasn't aware of any lights not working in the dining room; -He/she doesn't let maintenance know about issues with lights. During an interview on 06/26/24, at 12:51 P.M., DA K said the following: -Maintenance takes care of the ceiling lights. They clean them on the inside and outside, replace the bulbs, and put on new covers; -He/she is not aware if the maintenance person knows the lights have bugs in them, that one of the lights in the dining room isn't working, or that one of the lights in the kitchen doesn't have a cover; -He/she verbally tells the maintenance person if there is needed repairs in the kitchen. During an interview on 06/26/24, at 12:51 P.M., DA M said the following: -Maintenance is responsible for cleaning the ceiling lights, changing the bulbs, and replacing the covers; -He/she would dust the outside of the light,s but that's about all for the ceiling lights; -Staff verbally tell the maintenance person if there are repairs needed, bulbs needing replaced, or cleaning needed for the ceiling lights; -He/she hasn't told maintenance the lights need repaired and cleaned as he/she doesn't look at the ceiling so probably didn't notice. During an interview on 06/26/24, at 1:21 P.M., the Dietary Manager (DM) said the following: -The maintenance person is responsible for cleaning the ceiling lights inside and out and replacing the covers and bulbs. He/she didn't realize the light was out in the dining room or there were bugs in several of the lights in the kitchen; -He/she knew one of the light covers were missing. There have been new covers ordered and they have been broken when they arrive or shatter when maintenance tries to install them; -He/she tells maintenance when something needs to be done. During an interview on 06/27/24, at 9:50 A.M., the Maintenance Director said the following: -He/she is responsible for changing the bulbs on the ceiling and cleaning the lights inside and out. He/she tries to keep that done; -There were covers in the dining room that were broken when they arrived. He/she wasn't aware of one of the bulbs in the dining room being burned out or the lights in the kitchen had bugs in them; -He/she needed to order new bulbs and light covers; -He/she has weekly and monthly checks, but no paperwork that assists him/her of keeping track. He/she doesn't have cleaning the lights as one of his/her checks. He/she just tries to wash them off as needed; -The kitchen staff will let him/her know when they notice something wrong. During an interview on 06/26/24, at 2:34 P.M., the Administrator said the following: -Maintenance is responsible for cleaning the inside and outside of the ceiling lights, changing the covers, and replacing lights that are burned out; -The facility has ordered several covers for the lights and they always crack; -Staff should be telling maintenance when there are issues with the ceiling lights; -Currently the maintenance person if using paper to track things that need to be done in his/her maintenance binder, where there are work orders; -The DM should be following up and overseeing to ensure maintenance is told about the things that need to be done in the kitchen and dining room and making sure they're completed. 2. Review of the 2013 Missouri Food Code showed the following information: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -The physical facilities shall be cleaned as often as necessary to keep them clean. Observations on 06/24/24, beginning at 10:00 A.M., and on 06/26/24, beginning at 10:30 A.M., of the kitchen and dining areas showed the lower shelf of the prep table had grime around the edge of the shelf, was missing the initial coating over much of the top, and there was about a 16 inch X 16 inch area that had orange rust visible. Review of the facility's weekly cleaning schedule for June 2024 showed the following: -Wipe down prep table as needed on Saturday; -The week of 06/03/24, staff initialed as being completed; -The week of 06/10/24, staff initialed as being completed; -The week of 06/17/24, staff initialed as being completed. During an interview on 06/26/24, at 12:43 P.M., DA L said the following: -He/she is aware the table has grime and some of the top layer is missing and has rust. The staff put the plastic top sheet over it so the pans that sit on top won't get dirty; -They have a cleaning schedule, but there aren't many that mark things off. During an interview on 06/26/24, at 12:51 P.M., DA K said the following: -He/she is aware of the grime, and top layer of the table that's missing, as well as the rust; -The DM is aware of the issue and they put the plastic sheet over it to keep the pans from getting the rust on them; -They also put foil around the edge of the table to help keep it clean, but there's still grime and we routinely clean the table. During an interview on 06/26/24, at 12:51 P.M., DA M said the following: -He/she is aware and so is all staff of the table having the top coat missing, and the rust and grime. It's been like that for a long time; -Staff put the plastic sheet over the table between it and the pans, but the rust and grime could still get on the pans; -They clean the table and anything else that needs to be cleaned. During an interview on 06/26/24, at 1:21 P.M., the DM said the following: -They have gone through different cleaning schedules and everything they need to do isn't on them. They add and change as they go and he/she monitors the schedule to ensure the staff are completing the tasks; -The table has some of the top coat missing and rust, that's why they put the plastic on it. They try to make sure it's clean. During an interview on 06/26/24, at 2:34 P.M., the Administrator said the following: -He/she is aware the table has the top layer missing and the rust and grime. They probably need a new table. -The DM should be overseeing the cleaning schedule to ensure the dietary staff are following it. 3. Observations on 06/24/24, beginning at 10:00 A.M., and on 06/26/24, beginning at 10:30 A.M., of the kitchen and dining areas showed the outside of the ice machine in the back had several streaks of white substance and the vent on the front of the ice machine, just over the door, had fuzzy lint on it. Review of the facility's weekly cleaning schedule for June 2024 showed no task for cleaning the outside of the ice machine. Review of the facility's deep clean schedule showed no task for cleaning the ice machine. During an interview on 06/26/24, at 12:43 P.M., DA L said the following: -He/she doesn't know whose supposed to clean the outside of the ice machine; -He/she wasn't aware there was fuzzy lint on the vent over the door. During an interview on 06/26/24, at 12:51 P.M., DA K said the following: -He/she said there's been arguments with maintenance over whose responsibility it is to clean the outside of the ice machine. The facility used to have a person that serviced the machine but not anymore. During an interview on 06/26/24, at 12:51 P.M., DA M said the following: -Housekeeping is responsible for cleaning the outside of the ice machine, but he/she doesn't know how often; -He/she is not aware of the vent above the ice machine door having lint on it. During an interview on 06/27/24, at 7:50 A.M., Housekeeper N said the following: -He/she has not been told housekeeping is responsible for cleaning the outside of the ice machine; -He/she believes the kitchen staff are responsible for cleaning the ice machine. . During an interview on 06/26/24, at 1:21 P.M., the Dietary Manager (DM) said the following: -Since he/she started housekeeping has been responsible for cleaning the outside of the ice machine and the vents on the ice machine; -There has been discussion on whose job it is to clean them and he/she is going to taking over cleaning the outside and will ensure the white substance is gone and the vents are clean. During an interview on 06/27/24, at 7:53 A.M., Housekeeper O said the following: -He/she used to have a deep clean sheet that included wiping down the outside of the ice machine; -He/she wipes down the outside of the ice machine and didn't realize there was white streaks down the back of the ice machine; -Housekeeping used to clean the vent. He/she believes its on the deep clean sheet. During an interview on 06/27/24, at 9:50 A.M., the Maintenance Director said housekeeping is responsible for cleaning the outside of the ice machine and the vent. During an interview on 06/26/24, at 2:34 P.M., the Administrator said the following: -Housekeeping is responsible for wiping down the outside of the ice machine and should be cleaning the white substance on the outside; -Maintenance should be cleaning the vent that has fuzzy lint. It should be done monthly or as needed. 4. Observations on 06/24/24, beginning at 10:00 A.M., and on 06/26/24, beginning at 10:30 A.M., of the kitchen and dining areas showed the small stock room to the back of the kitchen, that holds large cans, had dirt/debris on the floor and a black substance present. Review of the facility's weekly cleaning schedule for June 2024 showed no task for sweeping or mopping the floors. Staff made a note on 06/15/24 that the kitchen floors were swept and mopped. During an interview on 06/26/24, at 12:43 P.M., DA L said the following: -They have a cleaning schedule for weekly cleaning, but there aren't many that mark things off; -Night shift is responsible for sweeping and mopping the floors; -He/she looked at the stock room and said the night shift should be sweeping it and cleaning it. During an interview on 06/26/24, at 12:51 P.M., DA K said staff have a cleaning schedule and the night shift usually clean the floor, including the storage room floors. During an interview on 06/26/24, at 12:51 P.M., DA M said the following: -Everyone helps with cleaning and there is a cleaning scheduled. Staff don't always remember to document when they clean something; -Night staff clean the storage rooms and they should be sweeping them; -He/she didn't know the storage room had a dirty floor. During an interview on 06/26/24, at 1:21 P.M., the DM said the following: -They have gone through different cleaning schedules and everything they need to do isn't on them. They add and change as they go and he/she monitors the schedule to ensure the staff are completing the tasks; -Evening shift should be cleaning the floors each night. Sometimes the stock rooms get forgotten since it is behind a closed door. During an interview on 06/26/24, at 2:34 P.M., the Administrator said the following: -All staff should be cleaning the kitchen and that would include the floors in the stock room. The floors should not be dirty; -The DM should be following up to make sure the kitchen is clean and the cleaning schedules are followed.

Based on observation, interview, and record review, the facility failed to maintain a complete infection prevention and control program when the facility failed to implement their policy regarding enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO -microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device), resulting in staff not being trained on EBP, personal protective equipment (PPE) and signage present not being present for residents that met the guidelines for EBP, and staff not wearing PPE in accordance with the Centers for Disease Control (CDC) guidelines for one resident (Residents #36), of two sampled resident, who met the guidelines for EBP. The facility also failed to administer the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test for six sampled staff members (Dietary Aide Q, Nurse Aide (NA) R, Certified Nurse Aide (CNA) S, Dietary Aide T, Registered nurse (RN) P and CNA U.) A total sample of 16 residents was reviewed in a facility with a census of 46. 1. Review of the CDC's Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 07/12/22, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care; -EPB use of PPE refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Examples of high-contact resident care activities requiring gown and glove use for EBP includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central line, urinary catheter (flexible tubing that is used to drain urine from the bladder), feeding tube, and tracheotomy/ventilator, and wound care on any skin opening requiring a dressing; -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE. For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility's policy titled 'Infection Control, revised October 2018, showed the following: -This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmissions of diseases and infections; -The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility; maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the general public; establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission-based precautions; maintain records of incidents and corrective actions related to infections; and provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment; -The quality assurance and performance improvement committee, through the infection control committee, shall establish, review, and revise infection control policies and practices and help department heads and managers ensure that they are implemented and followed; -All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, showed the following information: -EBPs are utilized to prevent the spread of MDROs to residents; -EBPs are used and as an infection prevention and control intervention to reduce the spread of MDROs to residents; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; -Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); -PPE is changed before caring for another resident; -Face protection may be used if there is also a risk of splash or spray; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting, device care or use (central line, urinary catheter, feeding tube, tracheotomy/ventilator), and wound care (any skin opening requiring a dressing); -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -The use of EBPs does not impose limitations on group activities or room restrictions for residents; -Staff are trained related to identifying the need for EBP and prior to caring for residents on EBPs; -Plain yellow sticker or magnet is to placed next to resident name outside room door to indicate that the resident requires EBP use; -PPE is available outside of the resident rooms; -Residents, families and visitors are notified of the implementation of EBPs throughout the facility. Review of Resident #36's face sheet (admission information at a glance) showed the following: -admitted [DATE]; -Diagnoses included cutaneous abscess (skin abscess) of left lower limb and left knee effusion (excess fluid builds up in and around the knee joint causing swelling and pain). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 4/15/24, showed the following: -Dependent upon staff supervision or touching for toileting, shower, and personal hygiene; -Open lesion other than ulcer, rash, or cut; -Application of non-surgical dressing other than to feet. Review of the resident's care plan, dated 05/30/24, showed the following: -Refer to wound specialist/wound clinic for evaluation; -Perform wound care as ordered; -Assess wound healing weekly; -Assess changes in skin status that indicate worsening of wound and notify the physician. (Staff did not care plan related to EBP.) Review of the resident's June 2024 Physician's Orders Sheet (POS) showed the following: -An order, dated 05/28/24, for a wound treatment to left knee. Clean with hypochlorous acid (a cleaning agent), pat dry, apply calcium alginate (a type of wound treatment), cover with ABD pad (a gauze dressing), and change daily; -An order, dated 06/12/24, for Zyvox 600 milligrams (mg) capsule (an antibiotic to treat serious highly resistant bacterial infections), administer one capsule by mouth twice a day for ten days; During an observation on 06/25/24, at 12:40 P.M., Certified Nurse Aide (CNA) F assisted the resident to the bathroom in his/her room. CNA F donned gloves, but did not put a gown on. CNA F assisted the resident to the bathroom. The CNA walked out of the resident's bathroom after he/she assisted the resident on the toilet without wearing a gown. The CNA assisted the resident off of the toilet and did not don a gown. The resident wore a bandage on his/her left knee. Observation on 06/26/24, at 9:06 A.M., showed the following: -No signage on the resident's door indicating resident was on EBP; -No PPE outside or inside of the resident's room; -Resident was up on the wheelchair with the left leg up on a footrest in the bathroom with CNA B assisting the resident. CNA B did not wear any personal protective equipment other than a pair of gloves; -Licensed Practical Nurse (LPN A) entered the room, sanitized hands, and put on a pair of gloves and completed the resident's wound treatment. The LPN did not put on any other personal protective equipment such as a gown. During an interview on 06/27/24, at 9:39 A.M., CNA F said staff did not provide education or inservices to wear a gown and gloves when he/she provides care to residents with wounds and/or indwelling devices. He/she did not know to wear gown with the resident the other day when he/she helped the resident in the bathroom. During an interview on 06/26/24, at 1:38 P.M., CNA F said the following: -One resident was on contact precautions where they had to wear gloves and gown in the room; -He/she had not heard of EBP and had not been instructed or trained regarding this. During interview on 06/26/24, at 1:45 P.M., CNA G said the following: -The staff put on gown for a resident in isolation in their room. If the door is shut or sign on the door about isolation, he/she will speak to the nurse first. -He/she did not know of EBP and had not been instructed or trained on EBP. During an interview on 06/26/24, at 2:09 P.M., Certified Medication Technician (CMT) H said the following: -Staff were to use gowns, gloves, mask, and goggles, if airborne infection is present. They will put up signs so the aides will know or everybody will know what to do; -He/she had not been instructed or trained on EBP. During an interview on 06/26/24, at 2:22 P.M., CNA E said the following: -He/she worked as needed; -He/she had not heard of EBP. During an interview on 06/26/24, at 2:29 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she had heard of EBP with putting on gloves and gown for doing care with wounds, catheters, and colostomy bags; -Staff discussed it one time, but staff were not doing this. During an interview on 06/26/24, at 3:27 P.M., the Medical Director said the facility discussed the EBP precautions, but they are not implemented yet. During an interview on 06/27/24, at 2:31 P.M., the interim Director of Nursing (DON) said he/she had not been trained or educated in EBP. During an interview on 06/27/24, at 2:34 P.M., the Corporate Nurse said they had updated their infection control policy with an EBP policy, but it was not in effect at this facility. During an interview on 06/27/24, at 2:35 P.M., the Administrator said the following: -They had not trained or educated staff about EBP process; -The staff were not doing the EBP process at the facility. 2. Review of the facility's policy titled Employee Screening for Tuberculosis, revised March 2021, showed the following: -All employees are screened for latent tuberculosis infections (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test or interferon gamma release assay (a blood test that measures the body's immune response to the bacteria that causes TB) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made, but prior to the employee's duty assignment; -Screening included a baseline test for LTBI using either a TST or IGRA, individual risk assessment, and symptom evaluation; -If the baseline test is negative and the individual risk assessment indicates no risk factors for acquiring TB, then no additional screening is indicated; -If the baseline test is positive, but the individual risk assessment is negative and the individual is asymptomatic, a second test is conducted. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers showed the following: -Long-term care facilities shall screen their staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit (5 TU) test; -Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all residents, employees, and volunteers; -All new longterm care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two-step tuberculin test within one month prior to starting employment in the facility; -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. 3. Review of Dietary Aide Q's personnel record showed the following information: -Hire/start date of 12/14/23; -Staff did not document administering the first or second step TB skin test. 4. Review of NA R's personnel record showed the following information: -Hire/start date of 03/14/24; -Staff did not document administering the first or second step TB skin test. 5. Review of CNA S's personnel record showed the following information: -Hire/start date of 04/26/23; -Staff did not document administering the first or second step TB skin test. 6. Review of Dietary Aide T's personnel record showed the following information: -Hire/start date of 09/07/23; -Staff administered the first test on 09/07/23; -Staff did not document the results of the first TB skin test; -Staff did not document administering the second step TB skin test. 7. Review of RN P's personnel record showed the following information: -Hire/start date of 11/30/23; -Staff did not document administering the first or second step TB skin test. 6. Review of CNA U's personnel record showed the following information: -Hire/start date of 07/28/23; -Staff did not document administering the first or second step TB skin test. 7. During an interview on 06/27/24, at 5:12 P.M., LPN J said he/she would sometimes administer a TB test on a new employee when they come in for orientation. He/she administered the first step and read it in three days or 72 hours later. He/she did not usually administer the second step TB skin test due to the DON or assistant DON did this. Any nurse can read the TB test. He/she documented on a paper and gave it to the DON or assistant DON. 8. During an interview on 06/27/24, at 2:03 P.M., the Corporate Nurse said the former DON was responsible for completing the employee TB skin tests. The facility has had several DONs and assistant DONs. 9. During an interview on 06/27/24, at 11:23 A.M., the Administrator said she did not find the TB skin tests for the employees. The former DON was responsible for completing the employee TB skin tests. The charge nurse can administer the TB skin test. Staff should administer the first TB skin test and read the results three days later. Staff should not work until the first TB skin test results are read. 33187 34871

Based on interview and record review, the facility failed to have a system in placed to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when eighteen NA's failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test timely and continued to work providing direct care to residents. The facility's census was 64. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem or otherwise unless: -That individual is competent to provide nursing care and nursing related services, and -That the individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state, or; -That individual has been deemed competent as provided in 483.150 (a) and (b) of the requirements of participation; -Nurse assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. Review of the facility's Nurse Aide program syllabus form, Rules of Engagement for Class #11, undated, showed students may work as a nurse aide following the sixteen hours of orientation. If students fail the state test, students may continue to work as a nurse aide until they pass the test or satisfy a total of 120 calendar days from the beginning of the classroom training, whichever event occurs first. 1. Review of the facility's Staff Position Report, provided 06/24/24, showed the following employees' hired dates with no termination dates: -NA V was hired as a NA on 10/12/23; -NA C was hired as a NA on 10/19/23; -NA W was hired as a NA on 10/26/23; -NA X was hired as a NA on 11/08/23; -NA Y was hired as a NA on 12/04/23; -NA Z was hired as a NA on 12/14/23; -NA AA was hired as a NA on 12/21/23; -NA BB was hired as a NA on 12/21/23; -NA CC was hired as a NA on 01/04/24; -NA DD was hired as a NA on 01/22/24; -NA EE was hired as a NA on 01//11/24; -NA FF was hired as a NA on 02/05/24; -NA GG was hired as a NA on 02/23/24; -NA HH was hired as a NA on 02/22/24; -NA II was hired as a NA on 02/23/24; -NA JJ was hired as a NA on 02/29/24; -NA KK was hired as a NA on 02/29/24; -NA ZZ was hired as a NA on 03/14/24. Review of the facility's Certified Nurse Assistant Competency Score Sheet, dated December 2007, for NA C showed the following: -Started the program on 02/07/24. NA completed the required classroom, training hours, competency testing, and written exams at the facility on 05/08/24; -The NA had not completed the final written/oral exam and practicum exam. Review of the facility's Certified Nurse Assistant Competency Score Sheet, dated December 2007, for NA EE showed the following: -Started the program on 02/07/24. NA completed the required classroom, training hours, competency testing and written exams at the facility on 05/08/24; -The NA had not completed the final written/oral exam and practicum exam. Review of the facility's Certified Nurse Assistant Competency Score Sheet, dated December 2007, for NA FF showed the following: -Started the program on 02/07/24. NA completed the required classroom, training hours, competency testing and written exams at the facility on 05/08/24; -The NA had not completed the final written/oral exam and practicum exam. During an interview on 06/27/24, at 11:55 A.M., the Clinical Instructor (Nurse Aide Program) said the following: -Has worked at the facility completing the nurse aide training program for a year and a half; -The students have twelve weeks to complete the course and then complete the remainder of the final testing at a local college by appointment; -Currently there are three students waiting to take their test, but are unable to secure an appointment date. The students have one year to take the test and can work as a nurse aide during that time period. The students have three attempts to pass before they need to restart the program. Students will usually quit the program or work as a hospitality aide until they pass the course; -He/she was not aware of the 120 day regulatory timeframe to complete the course, but the staff should enforce the regulation. During an interview on 06/27/24, at 2:02 P.M., NA KK said the following: -Started at the end of February 2024 as a nurse aide in the facility training program; -Has completed his/her required prerequisite sixteen hours of training to start the program; -Scheduled to start 07/01/24 for the clinical portion of the program due to a lack of available classes; -Has not been informed of how long the course is suppose to take or how long he/she has to complete the course; -Has not been informed of any work restrictions if the course is not completed in the required training period or after the clinical portion is complete and work as a nurse aide; -Is currently working as an NA. During an interview on 06/27/24, at 2:06 P.M., NA JJ said the following: -Started at the end of February 2024 as a nurse aide in the facility training program; -Has completed his/her required prerequisite sixteen hours of training to start the program; -Scheduled to start 07/01/24 clinical portion of the program due to a lack of available classes; -Has not been informed of how long the course is suppose to take or how long he/she has to complete the course and work as a nurse aid; --Has not been informed of any work restrictions if the course is not completed in the required training period or need to work as a non-nursing hospitality aide if he/she does not pass their nurse aid testing; -Is currently working as an NA. During an interview on 06/27/24, at 2:09 P.M., NA ZZ said the following: -Started at the end of May 2024 as a nurse aide in the facility training program; -Has only completed initial orientation and is due to start the clinical portion of the program sometime next month; -Has not been informed of how long the course is supposed to take or how long he/she has to complete the course and work as a nurse aide; -Is currently working as a NA. During an interview on 06/27/24, at 4:30 P.M., with the Administrator, Cooperate Nurse, interim Director of Nursing (DON), and Clinical Instructor (Nurse Aide Program) said the following; -They were aware of the delay in getting the staff trained in the required four month completion of the course requirement; -The current staff have had to wait up to four months to start the program for a new class to begin; -The next class (starting next month) will be at a sister facility not at the current facility; -If the course is not completed within the required timeframe, the DON will make them as needed staff, hospitality and housekeeping, if available. All others will be terminated and made to restart the program. 34871

Based on interview and record review, the facility failed follow their abuse prevention policy when staff failed to ensure the Nurse Aide (NA) Registry was checked and staff did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility for two staff members (Maintenance Supervisor and Registered Nurse (RN) P) and did not check the NA registry in a timely manner for one staff (Interim Director of Nursing (DON)). The facility census was 46. Review of the facility's policy titled, Abuse Prevention Program, revised September 2021 , showed the following: -The nurse aide registry will be checked prior to employment for each state where a nurse aide has shown to have worked, or has listed certification. Nurse aides will not be hired whose name is on any state abuse registry; -Verification of background checks, nurse aide registry checks and reference checks will be maintained in the personnel file of each employee. A notation by facility staff member of telephone contacts for registry check and previous employer checks would constitute verification. 1. Review of the Maintenance Supervisor's personnel record showed a hire/start date of 11/21/23. Review of the facility's background checks for the Maintenance Supervisor showed facility staff did not check the NA registry for a Federal Indicator. During an interview on 06/27/24, at 2:03 P.M., the Medical Record Staff said he/she did not know for sure if he/she should run the Maintenance Supervisor's NA registry check. 2. Review of RN P's personnel records showed a hire/start date of 11/30/23 . Review of the facility's background checks for RN P showed the facility did not check the NA registry for a Federal Indicator. During an interview on 06/27/24, at 2:03 P.M., the Medical Record Staff said he/she ran RN P's NA registry check, but could not find the documentation. 3. Review of the interim DON's personal records showed a hire date of 12/28/23. Review of the facility's background checks for the interim DON showed the facility checked the NA registry for a Federal Indicator on 06/18/24 (six months after his/her hire/start date). During an interview on 06/27/24, at 2:03 P.M., the Medical Record Staff person said he/she ran the interim DON's NA registry several months after hire. He/she only looked at the nurse website and did not run the NA registry check prior to that 4. During an interview on 06/27/24, at 2:03 P.M., the Medical Record Staff said the following: -He/she checked the NA registry on new employees; -The department head gives him/her the new hire information; -He/she should check the NA registry on a new hire before they start working on the floor; -The former Business Office Manager (BOM) did not explain how to do the job. 5. During an interview on 06/27/24, at 4:30 P.M., the Administrator said the following: -The medical record staff person is responsible for conducting NA registry checks; -She expects staff to check the NA registry for new employees.

Based on observation, interview, and record review, the facility failed to provide services all dependent residents to maintain good grooming and personal hygiene when three dependent residents (Resident #7, #29 and #246), of four sampled residents, did not receive timely showers and had hair that appeared matted or unkept. The facility's census was 46. Review of the facility's policy titled, Resident Bathing, undated showed staff shall provide person-centered care that emphasizes the residents' comfort, independence. personal needs, and preferences. 1. Review of Resident #7's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included left artificial hip joint, osteomyelitis (infection in a bone), fibromyalgia (widespread musculoskeletal pain accompanied by fatigue, sleep and mood issues), morbid obesity (overweight), neuromuscular dysfunction of bladder (lack bladder control due to brain, spinal cord, or nerve problems), and rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility). Review of the resident's care plan, dated 12/23/23, showed the following information: -The resident will maintain self care as evidenced by assisting with bathing face and upper/lower body; -Resident requires staff assistance with mobility and transfers; -Resident requires two person extensive assist with bed mobility Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/07/24, showed the following: -Cognitively intact; -Partial/moderate assist for transferring from bed to chair, shower transfers, and showers/baths. Review of the resident's May 2024 Shower Sheets showed staff documented providing a shower on 05/03/24. Review of the resident's June 2024 Shower Sheets showed the following: -Staff provided a shower on 06/04/24 (31 days since the resident's last documented shower); -Staff provided a shower on 06/07/24; -Staff did not document a shower provided or offered between 06/08/24 and 06/26/24. Observations and interviews on 06/25/24, at 1:42 P.M., and on 06/26/24, at 3:30 P.M. and 5:09 P.M., showed the following: -The resident had matted hair on the back of his/her head and his/her hair was unkept; -The resident said his/her last shower was on 06/06/24; -He/she felt nasty because it had been so long since he/she had received a bath; -The facility used to have a different shower aide and he/she got showers at least one time per week which is what he/she prefers; -The new shower aide doesn't asked if the resident wants a shower. The resident will ask and sometimes the aide will do it and sometimes the aide won't give him/her a shower. During an interview on 06/26/24, at 1:04 P.M., CNA F said the following: -The resident did good with him/her with showers. The resident informed him/her when being weighed recently that staff did not come in and ask him/her for a shower. During an interview on 06/26/24, at 1:26 P.M., Licensed Practical Nurse (LPN) A said the resident was alert and oriented and can get up for a shower with the use of a slide board. 2. Review of Resident #29's face sheet showed the following information: -admitted [DATE]; -Diagnoses included heart disease, aphasia (affects how you communicate), physical debility (slower process of slowing and weakening), anxiety disorder (persistent feelings of worry or fear), legal blindness, deformity of right hand, personal history of transient ischemic attack and cerebral infarction (short period of symptoms similar to those of a stroke). Review of the resident's care plan, dated 04/29/24, showed the following information: -Resident required assistance to complete daily activities of care safely related to weakness in his/her lower extremities and unsteady gain; -Resident uses a wheelchair for ambulation with staff assist with transfers and mobility. He/she required assistance with dressing, toileting, and bathing; -Resident is occasionally incontinent of the bladder and bowel. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Substantial assistance required for transfers, personal hygiene, showers, dressing, and toileting hygiene. Review of the resident's May 2024 Shower Sheets showed staff document a shower provided to the resident on 05/13/24. Staff did not document any other showers/baths offered or provided in May 2024. Review of the resident's June 2024 Shower Sheets showed the following: -Staff provided a shower on 06/07/24 (25 days since the resident's last documented shower); -Staff provided a shower on 06/12/24; -Staff did not document offering or providing additional showers between 06/13/24 and 06/26/24 Observations and interviews on 06/25/24, at 11:36 A.M., and on 06/27/24, at 8:47 A.M., showed the following: -The resident's hair appeared unkept and stood straight; -The resident said he/she felt dirty. During an interview on 06/26/24, at 1:04 P.M., CNA F said the resident did not refuse showers and liked to have them as scheduled During an interview on 06/26/24, at 1:26 P.M., LPN A said the resident did not refuse showers usually. During an interview on 06/27/24, at 10:13 A.M., the interim DON said the resident has dementia and staff should provide the resident showers. 3. Review of Resident #246's face sheet showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease, stage 3 (kidneys have mild to moderate damage and they are less able to filter waste and fluid out of the body), muscle weakness, unsteadiness on feet, type 2 diabetes (body doesn't regulate insulin properly), osteoarthritis, and metabolic acidosis (cells throws off the chemical balance in the blood). Review of the resident's entry tracking MDS, dated [DATE], showed the following: -Moderately impaired cognition. -Required partial/moderate assistance with showers, lower body dressing, and supervision with transferring. Review of the resident's care plan, dated 06/06/24, showed staff did not address the resident's need for assistance with bathing. Review of the resident's June 2024 Shower Sheets showed the resident did not receive showers during his/her stay from 06/06/24 through discharge on 06/26/24. Observations and interviews on 06/24/24, at 2:30 P.M., and on 06/27/24, at 8:47 A.M., showed the following: -The resident's hair appeared unkept and stood straight up; -The resident said he/she hadn't received a shower since he/she was admitted ; -The resident said he/she felt dirty. During an interview on 06/26/24, at 1:04 P.M., CNA F said the resident had been in isolation since his/her admission to the facility. The resident had not had a shower since his/her admission During an interview on 06/26/24, at 01:26 P.M., LPN A said staff should offer the resident a bed bath. The resident did not come out of his/her room. During an interview on 06/27/24, at 10:13 A.M., the interim DON said the previous shower aide asked about the resident last week since he/she is on isolation, the interim DON instructed the shower aide to give the resident a bed bath. She did not find documentation on the completed bed bath. 4. During an interview on 06/26/24, at 12:33 P.M., CNA B said the following: -He/she worked Wednesday and Thursdays and staff try to get the showers completed; -He/she did not know of the shower schedule. 5. During an interview on 06/26/24, at 1:04 P.M., CNA F said the following: -The facility did not really have a shower schedule; -He/she was the shower aide and now is the restorative nurse aide; -The former DON gave him/her a calendar for the shower schedule; -Staff should complete the shower sheet and turn in to the DON; -He/she did not report to anyone if a resident refused a shower, he/she would just pick the resident up for a shower the next time around. 6. During an interview on 06/27/24, at 8:50 A.M., CNA G said the following: -The facility did have a shower aide, but he/she will be taking over the showers; -The residents are given showers Monday through Friday; -There is a sheet completed each time a resident receives a shower and it shows any skin issues; -Residents are offered showers at least one timer per week, and if they refuse that's documented on the sheet; -He/she doesn't know which residents have been given showers and when; -He/she doesn't know if residents on isolation gets showers, but believe they should be offered. 7. During an interview on 06/26/24, at 1:26 P.M., LPN A said the following: -A new shower aide just moved into the position; -Residents should get two showers a week; -He/she did not know for sure of the shower schedule; -Staff should document the shower on a shower sheet; -Nurses review the completed shower sheets and turn them into the DON; -He/she did not know of the computer system the CNAs document in; -Residents have complained about showers not getting done. The shower aide is pulled to work the floor at times; -He/she expects staff to complete showers and inform him/her if they are not completed. 8. During an interview on 06/27/24, at 9:00 A.M., LPN J said the following: -He/she doesn't know if the aides have a certain process or specific days they give showers to specific residents; -Aides are to complete the shower sheets and if a resident refuses a shower, they should be marking that on the shower sheets; -Residents on isolation should still be offered showers. 9 During an interview on 06/27/24, at 10:13 A.M., the interim DON said the following: -Residents should get a showers twice per week; -The shower aide completes the shower sheet and documents it in the computer system; -She expects staff to complete showers and report to the nursing management if not completed. 10. During an interview on 06/27/24, at 10:13 A.M., the Corporate Nurse said the following: -Staff document yes or no in the computer system after a shower is completed; -Staff should report to the DON if a resident refuses a shower; -Staff give the shower sheet to the DON who reviews the sheet for any skin issues; -He/She expected staff to complete showers and report to the nursing management if not completed; -The facility replaced the former shower aide. The former aide did not report or document to staff about showers; -The DON and/or nursing management are responsible for ensuring showers are completed. 11. During an interview on 06/27/24, at 4:30 P.M. the Administrator said she expects staff to report to the assistant Director of Nursing (ADON), or DON if showers were not completed. Staff should give two showers per week and as needed to residents. 34871

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population when multiple flies were present in and around three residents (Residents #5, #12, and #29) and in resident common areas. The facility census was 46. Review of the facility policy titled Pest Control, revised May 2008, showed the following: -The facility shall maintain an effective pest control program; -This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 1. Review of Resident #5's face sheet (admission data) showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly minimum data sheet (MDS - a federally-mandated assessment form completed by facility staff), dated 04/25/24, showed the following: -Memory problems; -Required supervision or touching assistance of staff while eating; -Partial/moderate assistance of staff with toileting hygiene and showers. Observation on 06/24/24, at 2:44 P.M., showed the following: -The resident sat in his/her wheelchair in the hallway with his/her eyes closed; -Three flies buzzed around the resident and one fly landed on his/her left arm. Observations on 06/26/24, at 9:27 A.M. and 11:14 A.M., showed the following: -The resident sat in his/her wheelchair in the hallway; -A fly crawled on his/her back; -Two flies buzzed around the resident. Observation and interview on 06/27/24, at 9:36 A.M., showed the following: -The resident sat in his/her wheelchair in the hallway; -Two flies buzzed around the resident and crawled on him/her; -The resident said, they bother him and land on his/her food. 2. Review of Resident #12's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitive skills intact; -Set up assistance of staff with eating; -Substantial/maximal assistance of staff with toileting hygiene and showers. Observation and interview on 06/27/24, at 12:15 P.M., showed the following: -The resident sat in his/her room in his/her chair and swatted at flies; -He/she said the flies land on his/her face and had been in the facility for a while; -Beside of the resident's chair and there were two dead flies. 3. Review of Resident #29's face sheet showed the resident admitted on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Substantial assistance of staff with transfers, personal hygiene, showers, dressing, and toileting hygiene. Observation and interview on 06/24/24, at 10:45 A.M., showed the following: -The resident sat in his/her room in his/her wheelchair; -A fly landed on the resident's face and he/she waved his/her hand during the interview in an attempt to keep the fly from his/her face; -He/she said the facility had problems with flies for some time. 4. Observation on 06/24/24, at 11:54 A.M., showed several flies in the hallway leading into the dining room and several flies buzzed around in the dining room while residents ate their meal. 5. During an interview on 06/27/24, at 7:50 A.M., Housekeeper N said the following: -All residents complained about the flies trying to land on them; -The flies are in the rooms and all over the facility. 6. During an interview on 06/27/24, at 8:50 A.M., Certified Nurse Aide (CNA) G said the following: -Several residents complained about the flies; -Many of the staff go around the facility with fly swatters and try to kill them; -He/she hasn't noticed any flies on the residents or their food. 7. During an interview on 06/27/24, at 09:39 A.M., CNA F said the following: -Flies are terrible every summer; -He/she used a fly swatter to kill the flies; -The facility had a fan on the inside of the door that goes to the smoking area; -The residents hold the door open day and night when they come inside from smoking; -Staff spray coffee on the concrete to help with the flies. 8. During an interview on 06/27/24, at 9:50 A.M., the Maintenance Director said the following: -The flies have been bad the past few weeks; -The pest company came to the facility on [DATE] and said a new product is coming out and the company will inform him/her how it works; -There is a bug light by the back door, one in the dining room, and the kitchen. 9. During an interview on 06/27/24, at 10:37 A.M. the Corporate Nurse said the following: -There is a blower by the black door and black light; -She knows it is an issue; -She expects staff to use a fly swatter to kill flies. 10. During an interview on 06/27/24, at 11:23 A.M., the Administrator said the following: -The pest control company visited the facility on 06/26/24 and is working on getting a new product out to kill the flies; -She expects the staff to kill the flies as needed. 45176

Based on observation, interview, and record review, the facility failed to promote each resident's right to self-determination when staff failed to provide routine baths or showers to one resident (Resident #196) out of a sample of four residents. The facility had a census of 46. Review of the facility's policy titled, Resident Bathing, undated showed staff shall provide person-centered care that emphasizes the resident's comfort, independence, personal needs, and preferences. 1. Review of Resident #196's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included major depressive disorder, muscle weakness, and pain. Review of the resident's care plan, revised 06/19/24, showed the following: -Staff to provide the resident with assistance to gather items for bathing and assistance to the bathing area as needed; -Make the resident's bathing process pleasant by ensuring a non-hurried atmosphere; -Encourage the resident to wash, rinse, and dry the areas that are within his/her physical ability. (Staff did not care plan the resident's preferred frequency of showers/baths.) Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/27/24, showed the following: -Moderately impaired cognitive skills; -No rejection of care; -Required partial/moderate assistance of staff with showers and bathing; -Required partial/moderate assistance of staff with the ability to get in and out of a tub/shower. Review of the resident's shower sheets, dated 06/19/24 through 06/24/24, showed staff did not document providing or offering a shower/bath to the resident. Observations and interviews on 06/25/24, at 11:11 A.M., and on 06/26/24, at 3:06 P.M., showed the following: -The resident sat in his/her wheelchair outside in the designated smoking area. The resident had facial hair. His/her hair appeared not combed; -The resident said he/she wanted shaved; -The resident said he/she had not had a shower since his/her admission to the facility; -He/she feels grungy. During an interview on 06/26/24, at 1:04 P.M., Certified Nurse Aide (CNA) F said the following: -The resident had not had a shower since his/her admission; -The facility did not really have a shower schedule; -He/she was the shower aide and now is the restorative nurse aide; -The former Director of Nursing (DON) gave him/her a calendar for the shower schedule; -Staff should complete the shower sheet and turn in to the DON; -He/she did not report to anyone if a resident refused a shower, he/she would just pick the resident up for a shower the next time around. During an interview on 06/26/24, at 12:33 P.M., CNA B said the following: -He/she worked Wednesday and Thursdays and staff try to get the showers completed; -He/she did not know about a shower schedule. During an interview on 06/26/24, at 1:26 P.M., Licensed Practical Nurse (LPN) A said the following: -A new shower aide just moved into the position; -Residents should get two showers a week; -He/she did not know for sure about the shower schedule; -Staff should document the shower on a shower sheet; -Nurses review the completed shower sheets and turn them into the DON; -He/she did not know of the computer system the CNAs document in; -Residents have complained about showers not getting done. The shower aide is pulled to work the floor at times; -He/she expects staff to complete showers and inform him/her if they are not completed. During an interview on 06/27/24, at 10:13 A.M., the interim DON said the following: -Residents should get a showers twice per week; -The shower aide completes the shower sheet and documents it in the computer system; -She expects staff to complete showers and report to the nursing management if not completed. During an interview on 06/27/24, at 10:13 A.M., the Corporate Nurse said the following: -Staff document yes or no in the computer system after a shower is completed; -Staff should report to the DON if a resident refuses a shower; -Staff give the shower sheet to the DON who reviews the sheet for any skin issues; -She expects staff to complete showers and report to the nursing management if not completed. During an interview on 06/27/24, at 4:30 P.M., the Administrator said she expects staff to report to the charge nurse, Assistant Director of Nursing (ADON), or DON if showers are not completed. Staff should give two showers per week and as needed to residents.

Based on interview and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for a mental disorder or intellectual disability prior to admission) prior to or at admission for one resident (Resident #21), out of five sampled residents, to ensure the resident received appropriate care and services. The facility census was 46. Review of the facility's policy titled Fiscal Management and Control, dated December 2021, showed the following: -DA-124C (form completed prior to admitting the resident to a skilled nursing facility to ensure the resident doesn't trigger a level II screening, part of the PASARR process) must be dated on or before the date of admission; -No resident will be admitted without a level II screening if the diagnosis indicates that one is required. 1. Review of Resident #21's face sheet (brief information sheet about the resident) showed the following information: -admitted [DATE]; -Diagnoses included recurrent major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff), dated 04/11/24, showed the following information: -admitted [DATE]; -Moderately impaired cognition; -Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), depression, bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Parkinson's Disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); -Resident received antidepressant medications. Review of resident's DA-124 A/B PASARR form (used to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 10/13/21, showed the following information: -Diagnoses included major depressive disorder; -Potential problem areas included aggression with intermittent combativeness; -Level one screening criteria for serious mental illness showed resident diagnosed with depressive disorder and dementia with Lewy Bodies (progressive dementia that leads to a decline in thinking, reasoning, and dependent function); -Dementia with Lewy Bodies is the primary reason for nursing facility placement. (The screening was completed almost six months after the resident's admission.) During an interview on 06/27/24, at 9:31 A.M., the Social Services Director said the following: -He/she did not complete the PASARR for the resident as he/she had only been in the position 10 months; -When a resident is at the hospital the hospital will began the PASARR or level one screening. If there was a level II needed, the resident is supposed to stay in the hospital until that's completed; -If the level one is not started from the hospital, he/she completed the PASARR as soon as the resident admitted ; -If the PASARR isn't completed at the hospital, the case manager at the hospital provides SSD with a code and he/she submits the level one screening; -He/she has been checking weekly to see what resident applications have been processed. During an interview on 06/27/24, at 11:25 A.M., the Administrator said the following: -The hospital usually completes the level I screening; -SSD is responsible for making sure the level one is completed upon admission; -If a Level II is triggered, there is a code from the hospital where the SSD can view on the progress of the application; -The resident admitted in April and his/her level one screening should've been completed in April.

Based on interview and record review, the facility failed to ensure all residents received care per professional standards of practice when staff failed to obtain ordered blood tests in a timely fashion for one resident (Resident #19), out of five sampled residents. The facility census was 46. Review of the facility's policy titled, Laboratory, Radiology and other Diagnostic Services, undated, showed the following: -Provide or obtain laboratory, and other diagnostic services only when ordered by a physician, in accordance with state law, including scope of practice laws; -The facility is responsible for assuring the quality and timeliness of laboratory services; -The facility must provide or obtain laboratory, and other diagnostic services to meet the needs of its residents. Review showed the facility did not provide a policy regarding physician's orders. 1. Review of Resident #19's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included hearing loss, osteoarthritis (protective tissue at the ends of the bones, wears down), cerebral atherosclerosis (arteries in the brain become hard, thick and narrow due to plaque buildup), anemia (problem of having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue), and personal history of transient cerebral ischemic attack (interruption of blood supply to the brain). Review of the resident's care plan, dated 02/12/24, showed the following: -Report any changes in condition to physician; -Administer cardiac and diuretic medications as ordered; -Report any abnormal labs to physician. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/15/24, showed the following: -Cognitively intact; -Resident received an anticoagulant medication. Review of the resident's June 2024 Physician Order Sheet (POS) showed an order, dated 02/09/24, for a comprehensive metabolic panel (CMP), complete blood count (CBC), and lipids (blood test that measures the amount of certain fat molecules in the blood), be drawn every three months and yearly. Review of the resident's medical records showed the facility obtained the labs including a CMP, CBC, and lipids on 02/13/24. Review of the resident's medical record, on 06/27/24, showed staff had not obtained the CMP, CBC, and lipids labs due in May 2024. During an interview on 06/27/24, at 1:30 P.M., Certified Medication Technician (CMT) H said he/she looked in the resident's paper medical record and said the last labs were completed on 02/13/24. The labs have not been completed since then; During an interview on 06/27/24, at 1:45 P.M., Licensed Practical Nurse (LPN) I said the following: -He/she knows what labs a resident is supposed to have based upon the orders in the medical record; -The facility now has a lab tracking book where all of the lab orders are kept; -When a resident has an order for labs, staff print off the lab sheet and when the lab company comes in to draw the labs, they're given the sheet; -He/she looked on the lab company's website and did not see an order for the resident to have labs drawn; -He/she looked at the resident's orders and verified the resident did have an order to have labs drawn every three months; -The resident should have had labs drawn in May, if they were last drawn in February; -He/she doesn't know if anyone monitors to ensure the labs are being done as ordered. During an interview on 06/27/24, at 1:53 P.M., LPN J said the following: -Nurses put in orders for labs; -When a nurse received an order from physician, he/she put that order into the electronic record and made a nurse's note; -The facility now has a lab log book, where staff keeps track of what labs are being drawn and what they're being drawn for; -He/she isn't sure if lab book includes on-going orders, or only new orders; -The facility just began using this book recently; -The computer system pops up when the resident needs labs to be drawn. The night shift is usually the ones that print those out when the lab people arrive and the lab people receive a copy of the sheet. The facility keeps a copy and puts it into the book; -He/she isn't sure how it populates those labs if the labs are drawn on 02/13/24 and needed again in three months. During an interview on 06/27/24, at 2:45 P.M., the Director of Nursing (DON) and Corporate Nurse said the following: -Nurses put lab orders into the computer; -The facility now has a lab tracking book binder at the nurses' station and they are to check daily to see who needs labs drawn and when; -The nurses are supposed to pull lab orders monthly, review, and see if any are needed that month; -Nurses put the requisition in to the lab system the day the labs need to be drawn. This was not being done; -If the resident had blood drawn in February, and there was an order for every three months, he/she should've had blood drawn in May; -The orders say when the residents should have blood drawn and they should be followed; -The medical records system does not pop up a notification for when labs are to be completed, that's why the facility implemented the lab draw binder this month; -Staff are told to bring any new orders to morning meetings. They're supposed to write new orders in the books, including who they've reported the results too; -The DON is to check daily during clinical meetings to ensure labs have been completed; -The DON is to pull the labs from the system daily and input into the lab system; -CMT H is assisting with this process monthly; -The lab long binder is to record the results and responses; -The nursing staff are to notify the doctor of the results and this is documented in the lab book. During an interview on 06/27/24, at 4:30 P.M., the Administrator, DON, and Corporate Nurse said the following: -The facility now has the lab tracking binder. The nurses are pulling the orders monthly so they ensure they are being done and they are being tracked in the log; -If a resident had an order for labs to be drawn every three months, they should be drawn every three months.

Based on interview and record review, the facility failed to ensure all dialysis residents received services consistent with professional standards of practice when staff failed to routinely communicate and collaborate with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center after appointments for one resident (Resident #15) out of a sample of one resident. The facility census was 46. Review of the facility's policy titled 'Hemodialysis Catheters (a flexible tube inserted through a narrow opening into a body cavity), revised February 2023, showed the nurse should document in the resident's medical record every shift as follows: -Any part of report from dialysis nurse post-dialysis being given; -Observations post-dialysis. (The policy did not refer to use of a communication form.) 1. Review of Resident #15's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included end stage renal disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) and muscle weakness. Review of the resident's care plan, revised 06/09/24, showed the following: -Dialysis on Monday, Wednesday and Friday; -The facility provides and coordinates transportation to the dialysis center. (The care plan did not refer to the use of a communication form.) Review of the resident's current Physician Order Sheet (POS) showed an order, dated 06/13/24 , for dialysis every Monday, Wednesday, and Friday. Review of the resident's medical record showed it did not include dialysis communication forms between the facility and the dialysis center. The nurses did not document follow-up contact with the dialysis center after each dialysis visit. During an interview on 06/25/24, at 10:50 A.M., the resident said he/she did not take a form to his/her dialysis appointments. During an interview on 06/26/24, at 11:28 A.M., the Transportation Staff said he/she did not take a communication form to or from the appointment. During an interview on 06/26/24, at 4:09 P.M., Licensed Practical Nurse (LPN) A said he/she did not send a communication form with the resident to dialysis appointments. The dialysis company will provide routine labs and will call the facility with any abnormal lab results. During an interview on 06/26/24, at 4:11 P.M. LPN J said staff used to send the communication forms to the dialysis appointments, but the company did not send them back to the facility. During an interview on 06/27/24, at 10:13 A.M., the Corporate Nurse said the following: -Nurses should complete the communication form and give to the transportation staff person and the dialysis company should send back to the facility upon the resident's return; -She did not see any communication forms completed for the resident's dialysis appointments. During an interview on 06/27/24, at 4:30 P.M., the Administrator said she expects staff to send the communication form with the resident and it should be returned with the resident.

Based on observation, record review, and interview, the facility staff failed to follow approved menus for all residents when staff failed to provide cornbread, or comparable substitute, at a meal for two resident (Resident #3 and #40), out of two sampled residents, who received pureed diets. The facility census was 46. Review of the facility's policy titled, Menu and Diet Guidelines, dated 2022, showed the following: -The pureed diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency; -Serve with appropriate scoop number or divide equally to provide number of portions; -All of the pureed food must be used in order to deliver the correct nutrient density to each resident. 1. Review of the facility menu, dated 06/26/24, showed turkey crunch, peas, cornbread, and pudding for the noon meal. Observations on 06/26/24, at 10:30 A.M., showed the following: -Dietary Aide (DA) K had the menu items cooked and he/she had pureed the peas; -DA K pureed the Turkey Crunch; -DA K did not puree the cornbread listed on the menu. Observation on 06/26/24, at 11:21 A.M., showed DA K placed the correct amount of pureed peas and pureed turkey crunch on the residents' plates. He/she did not give the residents cornbread, or something to replaced the cornbread. 2. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included cardiac pacemaker (used to control or increase the heartbeat) and gastro-esophageal reflux disease (GERD - stomach acid repeatedly flows back up into the tube connecting the mouth). Review of the resident's June 2024 Physician Order Sheet (POS) showed the resident received a purred diet. Review of the resident's care plan, dated 06/14/24, showed the following: -Resident on a pureed diet with nectar thickened liquids and shake with all meals; -Provide diet as ordered. Observations and interviews on 06/26/24, at 11:48 A.M. and 3:00 P.M., showed the following: -The resident had pureed peas, turkey crunch and pudding, but no cornbread; -He/she isn't sure if he/she gets the same things as other residents; -He/she likes cornbread. 3. Review of Resident #40's face sheet showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes (problem with the way the body regulates and uses sugar), GERD, and dysphagia (difficulty swallowing). Review of the resident's June 2024 POS showed the resident to receive a puree diet and nectar thick liquids. Review of the resident's care plan, dated 04/22/24, showed staff did not care plan regarding a pureed diet. Observations and interviews on 06/26/24, at 11:52 A.M. and 2:57 P.M., showed the following: -The resident had pureed peas, turkey crunch, pudding, and yogurt. The resident did not have cornbread; -He/she said he/she gets pureed foods and loves cornbread. 4. During an interview on 06/26/24, at 12:43 P.M., DA L said the following: -Residents receiving puree foods should receive the same food options as those on a regular diet; -He/she doesn't know if the residents on pureed foods were given the same foods normally, as those on regular foods. 5. During an interview on 06/26/24, at 12:51 P.M., DA K said the following: -Residents receiving pureed foods get the same foods as those on regular foods; -He/she can puree all foods, including rolls and cornbread; -He/she forgot to puree the cornbread today so the two residents did not receive cornbread. 6. During an interview on 06/26/24, at 12:51 P.M., DA M said the following: -There is a book in the back of the kitchen that shows how to puree all foods; -Residents on pureed foods get the same foods and amounts as those on regular diets; -If the menu has cornbread, the residents should all get cornbread unless they have a different preference. 7. During an interview on 06/26/24, at 1:21 P.M., the Dietary Manager said the following: -Residents on pureed foods are served the same foods most days; -One of the cooks likes to give chicken instead of pork that's stringy; -Residents on pureed foods should receive the same foods as those on different diets, taking into consideration their preferences and orders; -He/she did not know the residents did not receive cornbread during lunch. They should be offered cornbread. 8. During an interview on 06/27/24, at 3:05 P.M., the Registered Dietician (RD) said the following: -All residents receive the same foods, whether on pureed diet or regular. If the meal includes cornbread, the residents on pureed foods should also be given pureed cornbread; -He/she had not been told of any issues regarding staff not providing all residents the same food choices; -The staff should be following the menu and spreadsheets and this should be carried over to the pureed foods in every aspect. 9. During an interview on 06/26/24, at 2:34 P.M., the Administrator said the following: -All residents should be offered the same foods, considering their diets and preferences; -He/she was not aware that the residents did not receive cornbread during the lunch meal today.

Based on observation, record review, and interview, the facility failed to protect all residents from misappropriation of property, including medications, when one resident's (Resident #1) fentanyl patch (a schedule IV controlled substance used for adults who have chronic pain) went missing from the resident while in the facility. The facility census was 42. On 05/26/24, the Administrator was notified of the Past Non-Compliance that occurred on 05/26/24. The Administrator and the charge nurse conducted an audit to ensure all other fentanyl patches were intact as placed on residents per documentation and accounted for in storage behind two locks. The Administrator notified the physician, hospice agency, police department, and the resident's family. The Administrator interviewed staff and residents and reviewed the camera surveillance. The maintenance department changed the access code on the back door utilized by the staff. Administration completed in-service education with all staff regarding controlled substances and monitoring for placement of pain patches. The facility ordered a replacement patch at their expense. The noncompliance was corrected on 05/28/24. Review of a facility policy entitled Controlled Substances, revised November 2022, showed the following: -The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976); -Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises. 1. Review of Resident #1's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included atrial fibrillation (a-fib - irregular heart function) with implanted pacemaker (helps maintain regular heart beat), congestive heart failure (CHF - heart's capacity to pump blood cannot keep up with the body's need), shoulder disorder, depression, and convulsions. Review of the resident's care plan, last updated 04/23/24, showed the following: -Coordinate with physician to manage pain medication for optimum control of pain; -Observe for non-verbal signs of pain; -Observe for factors that increase/decrease pain; -Provide resident with comfort measures as needed, such as back rubs, lotion to body, sponge baths, and repositioning; -Observe for intolerable pain and notify physician if not relieved; -Give scheduled pain medicine as ordered. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/02/24, showed the following information: -Severely cognitively impaired; -Resident on scheduled pain medication regimen within the last five days; -Resident received as needed pain medication within the last five days; -Resident had frequent pain that affected sleep and day to day activities frequently; -Pain intensity at level five (rating of worst pain over the last five days on a zero to ten scale, with zero being no pain and ten as the worst pain you imagine). Review of the resident's May 2024 Physician Order Sheet (POS) showed the following: -An order, dated 11/16/23, to check and record placement of fentanyl patch every shift (every 6 A.M. and 6 P.M. shift); -An order, dated 12/07/23, to record pain level every shift, every day (every 12 hours); -An order, dated 04/23/24, for fentanyl 75 microgram (mcg) transdermal (through the skin) patch. Apply to the skin every 72 hours and remove old patch. Review and record administration site. Review of the resident's May 2024 electronic Treatment Administration Record (eTAR) showed on 05/26/24, at 7:00 A.M., Licensed Practical Nurse (LPN) A documented placement of a fentanyl 75 mcg patch to the resident's left upper arm. Observation and interview on 06/06/24, at 10:20 A.M., showed camera footage of the 100 hall dated 05/26/24, at 4:30 P.M. The camera footage showed an individual identified by the Administrator as former employee CNA E entered the back door of the facility wearing a hoodie over his/her hair and turned the corner toward the resident's hall. The Administrator said the footage showed the same person in the same hoodie in the building on the previous day when they came in to pick up their last paycheck. Review of Licensed Practical Nurse (LPN) A's written statement, dated 05/26/24, showed the following: -While passing medication, he/she saw someone run out of the resident's room and out the back door; -LPN A ran to a room on the 200 hall for a direct view of the employee parking lot and called out to Certified Nurse Aide (CNA) B, who came into the room and agreed that the person getting into a vehicle was former CNA E; -LPN A and CNA B quickly went to the resident's room to assess him/her. The resident lay in bed. They noted the left gown sleeve was pulled down at the shoulder; and the fentanyl patch the LPN placed that morning was not in place. There was a slight red outline where the patch had been. During an interview on 06/06/24, at 11:00 A.M., LPN A verified his/her written statement. The nursing staff checks placement of fentanyl patches every shift and documents the body location of the patch. Review of a CNA B 's written statement, dated 05/26/24, showed the following: -He/she was passing dinner trays on the long hall (200 hall). LPN A called out to him/her and asked him/her to identify the person getting into the a vehicle. CNA B said it was former CNA E. The driver of the vehicle drove through the grass and away; -The CNA went with LPN A to the resident's room. The resident's gown was pulled off the shoulder and no patch was there. They noted redness where LPN A said he/she had place a patch that morning. During an interview on 06/07/24, at 9:02 A.M., CNA B said on 05/26/24, around 4:30 P.M., he/she was passing dinner trays on the 200 hall. LPN A called out to him/her to come into a room and look out the window. LPN A asked him/her who was getting into a vehicle in the lot. CNA B told the LPN the individual was former CNA E. CNA B said he/she could not see if CNA E was holding anything. The CNA went with LPN A to the resident's room. The resident's gown was pulled off the shoulder and no patch was there. They noted redness where LPN A said he/she had place a patch that morning. During an interview on 06/06/24, at 3:04 P.M., LPN D said staff is supposed to check the placement of all pain patches every shift (day shift and night shift). Fentanyl patches are placed every three days and staff documents where the patch is applied. All narcotics and controlled medications are counted each shift change. LPN D said the resident usually refuses to change positions in bed and stays on his/her back most of the time. The resident's pain patches do not come off easily. During an interview on 06/06/24, at 10:20 A.M., the Administrator said the following: -LPN A called the Administrator to report seeing a former employee coming out of the resident's room and going out the back door of the facility. The identity of the individual was also confirmed at the time by CNA B; -LPN A and CNA B went to the resident's room to assess him/her and noted the resident's left gown sleeve was pulled down from the shoulder, and the fentanyl patch placed that morning by LPN A was not in place. There was a slight red outline on the resident's skin where the patch had been previously; -The Administrator came into the facility to start an investigation and make notifications; -NA B stated he/she was in the dining room at that time and did see a vehicle matching the description to that of former CNA E's drive past the dining room window toward the employee parking lot, but did not see the driver; -The Administrator notified the physician, the hospice agency, the resident's family, the police department, and the State Agency of the incident and missing pain patch; -The facility had the pharmacy replace the missing fentanyl patch at facility expense. MO00236731

Based on record review, observations and interviews the facility failed to follow the implemented interventions for one sampled resident (Resident #4) who experienced an 11.4 % severe weight loss in 90 days and one randomly sampled resident (Resident #14) who experienced an 11.3% severe weight loss in 90 days. The facility failed to implement interventions and monitoring to prevent further weight loss, and follow recommendations from the registered dietitician. Staff failed to appropriately document the intake percentage for one resident's (Resident #5) physician ordered supplement for weight management. A sample of 10 residents were selected for review and the facility census was 44. Federal Guidelines define suggested parameters for evaluating significance of unplanned & undesired weight loss as: -One (1) month loss of 5% indicates significant weight loss and greater than 5% indicates severe loss; -Three (3) months loss of 7.5% indicates significant weight loss and greater than 7.5% indicates severe loss; -Six (6) months loss of 10% indicates significant weight loss and greater than 10% indicates severe loss. 1. Record review of Resident #4's minimum data set (MDS) a federally mandated assessment tool to be completed by facility staff dated 3/11/12, showed the following information: -Long and short-term memory problems;-Severely impaired cognitive decision-making skills;-Totally dependent on staff for mobility, transfers, personal hygiene, and toileting;-Extensive assistance for eating;-Four Stage II pressure ulcers (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater);-One unable to stage pressure ulcer; -Swallowing problems: -Mechanically altered diet;-Weight loss: Yes, on physician prescribed weight loss program. Record review of the care plan, last reviewed on 3/22/12, showed the following information: -Resident receives a pureed diet;-Diet as ordered;-Allow adequate time to eat;-Weigh monthly and record. Report significant weight loss to the physician;-Offer snacks between meals;-Assess and record intake at each meal;-Staff did not document problems, goals and approaches to address the resident's weight loss, and the administration of supplements. Record review of the form titled 2012 monthly weights showed the resident's March weight as 123 pounds; Record review of the nutritional progress record showed the registered dietitician (RD) noted in part on 3/26/12, the following information: -Wounds monitored and resolving;-Medications noted and one package of [MEDICATION NAME] (specialized nutrients to provide support during wound healing. Provides calories and protein, as well as other essential nutrients required to help protect and maintain lean muscle mass) twice a day until healed;-Diet: puree, receives chocolate whole milk at all meals and supercereal at breakfast;-Oral intake ranges from fair overall;-Weight: 12/2011-125 pounds, 1/2012-129 pounds, 3/2012-120 pounds=nine pounds loss in one month (severe);-Resident may benefit from: 120 milliliters (ml) 2 Cal (nutritionally complete, high-calorie liquid food designed to meet the increased protein and calorie needs of residents) four times and day. Will continue to monitor weight. Record review of the March 2012, physician's orders [REDACTED]. -Diagnoses/history of fractured femur, dementia, wound infection and high blood pressure; -Diet puree;-One package of Alginaid twice a day until pressure ulcers were healed;-Staff did not note if the physician ordered any further supplements or the 2 cal recommended by the RD. Record review of medical record showed staff placed a form titled A Bookmark for Nutrition and Hydration Care in the front of the nurse's notes and showed in part the following information: -Carry this bookmark to double-check a warning sign or action step: -Unintended Weight Loss-Watch for warning signs: -The following are some signs that a resident may be at risk for or suffer from unintended weight loss: -Needs help to eat or drink;-Eats less than half of meals/snacks served;-Has a hard time chewing or swallowing;-Is confused, wanders or paces;-Report and take action: -Below are some action steps to increase food intake, create a positive dining environment and help residents get enough calories;-Report observations and warning signs to nurse and RD;-Offer many kinds of food and beverages;-Record meal and snack intake. Record review of the nurse's notes showed staff did not document between 3/19/12 to 4/8/12. Staff did not note if the physician ordered further supplements or the 2 cal recommended by the RD. Record review of the form titled 2012 monthly weights showed the following information: -March: 123 pounds;-April: 115 pounds (8 pound loss, 6.5% in 30 days) Record review of the nurse's notes on 4/8/12, showed staff noted the resident had low output. The resident had lost 6 pounds in a week. He/she was not eating or drinking well. Record review of the POS showed staff noted an order dated 4/9/12, for 2 Cal three times a day. Staff did not document the amount of 2 Cal to be administered to the resident. Record review of the medication administration record (MAR) for April 2012, showed the following information: -On 4/9/12, order for 2 Cal three times a day. Staff did not document the amount of 2 Cal to be administered to the resident. -Between 4/9/12 to 4/30/12, staff initialed they administered 2 Cal to the resident three times a day. Staff did not document the amount of 2 Cal they administered to the resident. -The front and back of the MAR showed staff did not document the amount staff were to administer and if the resident refused the 2 Cal at any time. Record review of the nutritional progress notes showed the RD noted in part on 4/26/12, the following information:-Wounds monitored, improving slowly per nursing;-New order for 2 cal three times a day on 4/9/12, (no amount indicated); -The certified medication technician (CMT) stated he/she offered the resident 60 ml (2 Cal), but the resident will barely take half as he/she refused to open his/her mouth;-As per nursing, resident oral intake very poor as resident was refusing most meals and 2 Cal equals slowing wound progress and contributing to weight loss;-Diet-puree with one package [MEDICATION NAME] twice a day;-Weights: 3/2012-123 pounds, 4/15/12-116 pounds, 4/22/12-115 pounds. 8 pounds in one month (severe);-Again resident appears to be refusing most meals and supplements;-Please consider: Chocolate milkshake with health shake three times a day between meals and an medication appetite stimulant by mouth daily. Record review of the April 2012, PO, showed staff did not note if the physician ordered further supplements and/or appetite stimulant recommended by the RD. Record review of the nurse's notes showed staff did not document between 4/24/1/12 to 5/31/12. Staff did not note if the physician ordered any further supplements and/or appetite stimulant recommended by the RD. Record review of the form titled 2012 monthly weights showed the following information: -March: 123 pounds;-April: 115 pounds;-May: 112 pounds; -June: 109 pounds: (14 pound loss, 11.3% in 90 days). Record review of the MAR for May 2012, showed the following information: -Order for 2 Cal three times a day. Staff did not document the amount of 2 Cal to be administered to the resident. -Between 5/1/12 to 5/30/12, staff initialed they administered 2 Cal to the resident three times a day. Staff did not document the amount of 2 Cal they administered to the resident. -The front and back of the MAR showed staff did not document the amount staff were to administer and if the resident refused the 2 Cal at any time. -Staff did not note if the physician ordered further supplements and/or appetite stimulant recommended by the RD. Record review of the food intake record for May 2012, showed the following information:-Instructions: Enter percent eaten or ml of fluid consumed at each snack or meal. For supplements use the following code: 0=offered and % consumed, R=refused, N=not offered and A=alternate offered; -Breakfast: 26 of 30 times staff noted the resident ate 50 to 100%;-Lunch: 20 of 30 times staff noted the resident ate 50 to 100%;-Supper: 21 of 30 times staff noted the resident ate 50 to 100%;-Staff did not document percentage for supplements consumed at any meals. Record review of the MAR for June 2012, showed the following information: -Order for 2 Cal three times a day. Staff did not document the amount of 2 Cal to administer to the resident. -Between 6/1/12 to 6/7/12, staff initialed they administered 2 Cal to the resident three times a day. Staff did not document the amount of 2 Cal they administered to the resident. -The front and back of the MAR showed staff did not document the amount staff were to administer and if the resident refused the 2 Cal at any time. -Staff did not document if the physician ordered any further supplements and/or appetite stimulant recommended by the RD. Record review of the food intake record from 6/1/12 to 6/7/12, showed the following information: -Breakfast: 5 of 7 times staff noted the resident ate 100%;-Lunch: 4 of 7 times staff noted the resident ate 50%;-Supper: 5 of 7 times staff noted the resident ate 50 to 100%;-Staff did not document percentage for supplements consumed at any meals. Observation on 6/5/12, showed the following information: -At 7:10 A.M., the resident sat in the geri-chair (reclining chair on wheels). The resident appeared thin with a small to medium frame. The resident was non-verbal with confusion and smiled when spoken to. Staff assisted the resident with a puree consistency breakfast on a divided plate with a bowl at the side of the plate. The resident had an orange juice type drink ([MEDICATION NAME]). The resident ate more than 50% of the meal;-At 12:20 P.M., CMT A assisted the resident with lunch;-At 12:50 P.M., the resident had eaten at least 50% of his/her meal. Observation on 6/7/12 at 12:36 P.M., showed the resident sat in the geri-chair in the dining room. The staff assisted the resident with lunch. The resident had a divided plate with puree consistency diet, two bowls of puree food, glass of [MEDICATION NAME], tea and water. At 1:21 P.M., staff continued to assist the resident. The resident ate at least 30% of the meal and drank at least 90% of the [MEDICATION NAME]. During an interview on 6/7/12 at 9:40 A.M., the charge nurse, licensed practical nurse (LPN) B said the following: -Staff record intake for residents receiving skilled services, new admissions and residents with weight loss;-Staff document supplement intake for residents with weight loss on the MAR and on the food intake record;-The CMTs administer the 2 Cal. When staff receive an order for [REDACTED].#4 has orders for 2 Cal. The nurse reviewed the order in the resident's record and said the order said 2 Cal three times a day but did not say how much to administer. He/she was not sure how much to give the resident. During an interview on 6/7/12 at 9:45 A.M., CMT A said the following: -He/she had been giving the resident 60 ml of 2 Cal. CMT A reviewed the physician's orders [REDACTED]. -When administering the 2 Cal, staff initial they administer it to the resident on the front of the MAR;-Staff should document on the back of the MAR if a resident did not take all of the supplement;-Staff do not document the percentage of the 2 Cal the resident drank, just an initial, that is why it was so important to document on the back of the MAR;-The 2 Cal should be treated just like any other medication. During an interview on 6/7/12 at 9:50 A.M., and 11:15 A.M., the Director of nursing (DON) said the following: -The RD comes to the facility monthly; -Staff do not need a physician'sorder for a health shake. Dietary staff note they give the health shakes to residents at meals. Nursing staff do not document the percentage of the health shakes that the resident drank;-The [MEDICATION NAME] was given to the resident with meals by dietary staff. Nursing staff do not document the percentage of the [MEDICATION NAME] that the resident drank;-Nursing staff document the percentage of the 2 Cal on the MAR. The DON looked at the MAR and said, staff have just been initialing that they administered the 2 Cal;-The DON said staff should be writing the percentage of 2 Cal they administered to the resident on the MAR. During an interview on 6/7/12 at 11:15 A.M., the DON said the following: -She was responsible for communicating to the staff about the RD recommendations. -She was getting clarification orders from physician on the 2 Cal for Resident #4; -The DON reviewed the RD's 4/26/12, note. She was not sure what the RD meant by "chocolate milkshake with health shake three times a day between meals". The DON had not clarified the suggestion with the RD;-When asked about the appetite stimulant, the DON said she was not aware the RD suggested an appetite stimulant for the resident. During an interview on 6/7/12 at 11:17 A.M., the dietary manager (DM) said the following: -The RD writes a paper with her recommendations and gives them to the DON. Nursing staff should then give a dietary communication form to the kitchen if any changes;-Resident #4 received [MEDICATION NAME] twice a day for breakfast and lunch. The dietary staff put the [MEDICATION NAME] on the tray and nursing staff administer the 2 Cal. -Nursing staff were responsible for administering and documenting the percentages of the Arginarid and supplements. During an interview on 6/8/12 at 8:58 A.M., the RD said the following: -She visited the facility monthly;-Staff had a book prepared for her when she arrived at the facility;-She looked at new admissions, readmissions, residents with weight loss, pressure ulcers and tube feeding and any other issues brought to her attention by staff;-When completing assessments, she reviewed the resident's weight records, notes, labs, meal intake, weight history, and supplements. She checks with staff to see if a resident was taking his/her supplements;-She made suggestions in the resident's dietary notes and gives a consultation report to the DON; -She was not aware that the suggestions for Resident #4 had not been reviewed and implemented; -On 4/26/12, regarding Resident #4, the chocolate milkshake with health shake meant the RD wanted the staff to add chocolate ice cream to a chocolate health shake to make a milkshake. Also suggested an appetite stimulant;-She did recall talking to nursing staff back in April about Resident's#4's order for 2 Cal needing to be clarified with the physician with an amount to be administered;-She had discussed with the previous DM about staff recording supplement percentages administered to residents at meals. She thought it was on the meal intake record. During an interview on 6/8/12 at 9:25 A.M., LPN B said he/she received physician's orders [REDACTED]. During an interview on 6/8/12 at 10:00 A.M., certified nurse assistant (CNA) E said nursing staff documented the percentages of the meals and supplements on the resident's meal intake record at each meal. CNA E said the [MEDICATION NAME] was given to residents to help with their bowel movements. ([MEDICATION NAME] is a high calorie supplement for wound healing). He/she was not sure where staff documented the percentages of the [MEDICATION NAME]. During an interview on 6/8/12 at 11:20 A.M., the DON and assistant director of nursing (DON) said the following: -The ADON had a weekly weight meeting, they discussed residents at risk for weight loss and those with weight loss and go over what interventions were on place like shakes and supplements. If needed they contact the physician for medications;-The DON said she reviewed the RD recommendations but never brought them to the weekly weight meeting;-The ADON said weekly weights were completed for new admissions for four weeks and for residents with weight loss until stabilized. The other residents were weighed at least monthly. She keep a log to track resident weights. 2. Record review of Resident #14's annual MDS assessment dated [DATE], showed the following information: -Long and short-term memory problems;-Moderately impaired cognitive decision-making skills;-Limited staff assistance with dressing, hygiene and toileting;-Supervision and cueing with eating;-Weight 123 pounds;-Weight loss: yes-not on physician prescribed weight loss regimen. Record review of the April 2012, POS showed the following information: -Diagnose of Alzheimer's and high blood pressure;-Regular diet;-[MEDICATION NAME] (appetite stimulant) 15 milligrams (mgs) one tablet every night (started 7/5/11);-2 Cal 60 mls three times a day with meals;-Ice cream with meals;-Health shake three times a day. Record review of the form titled, 2012 monthly weights, showed the following information: -January: 132 pounds;-Februrary: 123 pounds (9 pound loss, 6.8 % in 30 days)-March: 128 pounds; -April: 117 pounds, (11 pound loss 8.5% in 30 days. 15 pound loss 11.3% in 90 days). Record review of the annual nutritional evaluation showed the RD noted in part on 4/26/12, the following information:-Current diet order: regular with ice cream with meals;-Supplement order: health shake three times a day, 60 ml of 2 Cal with medication pass;-Current weight: 124 pounds (Staff noted on the MDS 123 pounds, and on the monthly weights 117 pounds);-RD calculated a 3% loss in 30 days (March 128-April 124) and 6% loss in 90 days (Janurary 132-April 124);-Oral fluids encouraged taken well. The DON said the resident does not eat well. He/she drinks liquids a lot in the day and will sometimes snack at night;-Medications: [MEDICATION NAME];-Problem: unintended weight loss-Nutritional interventions: Increase 2 Cal to 90 ml three times a day before meals and chocolate whole milk with all meals. Record review of the care plan dated 4/26/12, showed the following information: -Resident receives a regular diet and has a poor appetite;-Diet as ordered;-If less than 75% of the meal is consumed, offer an alternate;-Weigh monthly and record. Report significant weight loss to physician;-Offer snacks between meals;-Assess and record intake at each meal;-Supplements as ordered;-Appetite stimulant as ordered. Record review of the May 2012, weekly weight meeting form showed staff did not note they increased the resident's 2 Cal and added the chocolate whole milk with all meals Record review of the food intake record for May 2012, showed the following information: -Breakfast: -21 of 30 times staff noted the resident refused;-4 of 30 times staff left a blank;-Lunch: -17 of 30 times staff noted the resident refused; -7 of 30 times staff left a blank;-Supper: -17 of 30 times staff noted the resident refused; -4 of 30 times staff left a blank;-Staff did not document percentage for supplements consumed at any meals. Record review of the 2012 monthly weights showed the following information: -May: 118 pounds; -June: 119 pounds. Record review of the food intake record between 6/1 to 6/7/12, showed the following information: -Breakfast: 5 of 7 times staff noted the resident refused;-Lunch: 5 of 7 times staff noted the resident refused; -Supper: 5 of 7 times staff noted the resident refused; -From 6/1 to 6/6/12, staff did not document percentage for supplements consumed at any meals. Record review of the MAR for April, May and June 2012, showed the following information: -Order for 2 Cal 60 ml three times a day for weight loss. (the RD recommended any increase to 90 ml on 4/26/12). -Staff initialed they administered the 2 Cal to the resident three times a day. -The front and back of the MAR showed staff did not document the percentage of 2 Cal the resident consumed; Observation on 6/5/12, showed the following information: -At 7:00 A.M., the resident lay in bed;-At 8:05 A.M., the resident lay in bed. The resident's breakfast tray was on the bedside table. The resident had eaten less than 10%-At 8:20 A.M., the resident pushed the bedside table with the breakfast tray out into the hall. Staff assisted the resident with the tray and the table. The resident ate less than 10% of the meal. The resident drank the white milk. During an interview on 6/7/12 at 11:17 A.M., the dietary manager (DM) said the following: -She tries giving the resident chocolate milk but he/she liked whole white milk better;-She sent chocolate milk out to the resident yesterday and it came back unopened;-She was not aware of the RD suggestion for the chocolate milk. The resident does drink real well;-If she had known about the RD suggestions she would have informed the RD and the DON that the resident would not always drink chocolate milk. Observation on 6/7/12, showed the following information: -At 12:00 P.M., and 12:35 P.M., the resident lay in bed;-At 12:40 P.M., staff in the room said the resident was in the bathroom, then he/she was going to the dining room;-At 1:20 P.M., dietary staff said the resident had come to the dining room then left. The resident's table showed the resident had not eaten any food. One of the bowls contained ice cream. The resident had a carton of strawberry health shake that had been opened. The resident drank 50% of the shake. The resident had a pint of 2% white milk and a glass of an orange colored drink. The resident drank 100% of the milk and orange drink. 3. Record review of the facility's weight loss protocol (undated) showed in part the following information: -It is the policy of this facility to assist all residents to reach or maintain their optimal nutritional level as evidenced by no preventable weight loss and nutritional lab work to be as normal as possible; -Notify physician/responsible party of weight loss;-Obtain RD consult;-Obtain orders for supplements three times a day until weight stabilizes unless RD or physician order [REDACTED]. -If weight loss continues additional supplements may be given with medication passes or additional calories. 4. Record review of Resident #5's admission information sheet showed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's most current MDS assessment showed staff assessed the resident as: -Moderately impaired cognitive skills. -Extensively dependent on staff for eating and totally dependent on staff for transfer, ambulation, dressing, hygiene and bathing. Record review of the resident's current care plan updated 03/15/12, showed: -Resident receives a pureed, no added salt diet;-If less than 75% of meal is consumed, offer alternative;-Offer snacks between meals;-2 Cal between meals for weight management;-Assess and record intake at each meal. Record review of the resident's current physician orders [REDACTED]. -Snack of choice between meals -Offer 4 ounce health shakes if he refuses snacks or eats less than 75% of meal;-[MEDICATION NAME] one packet at breakfast and lunch until wound heals. Record review of the resident's current care plan updated 03/15/12, showed: -Resident receives a pureed no added salt diet;-If less than 75% of meal is consumed, offer alternative;-Offer snacks between meals;-2 Cal between meals for weight management;-Assess and record intake at each meal;-Monitor and record meal/po fluid intake every meal. During interview on 06/07/12, at 11:00 A.M., the Dietary Manager said dietary staff serve the supplements. Dietary staff mix the [MEDICATION NAME] packet with 8 ounces of water. She was not aware where nursing staff documented fluid and supplement intakes. Staff document in a meal intake book. A list is posted in the dining room where CNAs were to document supplements and additional items the residents consume. She was not sure where the list went and was not aware of staff currently documenting on a list of supplement intake. She was unaware of the location of the meal intake book. During interview on 06/08/12 at 9:10 A.M., LPN B said the facility only monitored supplement intake for weights for skilled admissions, 30 days of admission and residents with identified weight loss. He/she said Resident #5 was not listed in the supplement book and there was no documentation of the resident's supplement intake. 5. During an interview on 6/7/12 at 9:50 A.M., and 11:15 A.M., the DON said staff should be writing the percentage of 2 Cal they administered to the resident on the MAR.