Every finding on record at Hartville Care Center

Based on interview and record review, the facility failed to keep residents free accidents when staff failed to transfer one resident (Resident #1) per the resident's care plan and therapy assessment/direction resulting in a fall and bilateral tibia plateau fractures (break in the top of the shinbones). The facility census was 43.Review of the facility's policy titled Transfer Activities, undated, showed the following:-To transfer the resident from bed to chair, toilet, or tub safely with mechanical lift, or positioning devices, obtain assistance of another individual if necessary for safe transfer;-Obtain equipment from designated area and bring it to bedside. 1. Review of Resident #1''s face sheet (brief resident profile sheet) showed the following:-readmission date of 06/18/26;-Diagnoses included frontal lobe and executive function deficit following cerebral infarction (affects the blood flow to the brain and cuts off supply to brain cells which manages thinking, emotions, judgement, self-control and muscle movements), fracture of upper and end of left tibia (fracture or break in the shinbone just below the knee), chronic pain, morbid obesity (excess weight), paraplegia (inability to voluntarily move the lower parts of the body), muscle weakness, and depression (persistent sadness). Review of the resident's care plan, dated 01/30/26, showed the following:-Resident at risk of falls;- During transfers monitor for any new changes in balance;-Assist resident with daily living needs related to little to no functioning in legs;-Resident requires two staff to assist with transfers using the sit-to-stand (mechanical lift);-Resident is not actually appropriate for sit-to-stand due to not being able to support 25%-75% of his/her weight with legs, but resident does support a significant amount of weight with his/her arms;-Facility staff use sit-to-stand so staff can pull pants up and down when toileting;-Use sit-to-stand in room to toilet;-Resident required substantial assist with toileting, showering, dressing, personal hygiene, sit to stand, and transfers. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/15/26, showed the following information:-Cognitively intact;-Impairment to both sides of lower extremities;-Dependent on staff with toileting, personal hygiene, showers, and upper body dressing;-Dependent upon staff for lower body dressing. Review of the resident's physical therapy (PT) treatment note, dated 06/11/26, showed the following:-Resident educated on safely sequencing transfers as well as hand placement with resident continuing to require verbal cues to remind resident to reach back for armrests when sitting and push up from the armrests when standing to decrease change of fall with functional activities. Review of the resident's occupational therapy (OT) note, dated 06/12/26, showed the following:-Resident completed toilet transfer;-Staff training initiated/included transfer to/from wheelchair at grab bars with minimum assistance of two staff for safety with balance/activity tolerance/BLE (bilateral lower extremities) management. Review of the resident's progress note dated 06/14/26, at 5:06 P.M., showed the resident had a witnessed fall with no injury. Resident was being transferred from commode to wheelchair when his/her knee gave out and he/she went down on his/her knees. Certified nurse aide (CNA) had gait belt on the resident and held onto it but was unable to slow the resident down. The resident landed on both of his/her knees Review of resident's OT notes, dated 06/15/26, showed the following:-The resident experienced a recent fall when staff that was not trained by the therapy department attempted a single person transfer;-Resident presented with lower left extremity swelling and reported pain to the lower left extremity knee/hip. Resident was unable to tolerate wearing compression stockings;-OT notified the charge nurse who reported x-ray for BLE was scheduled and resident to remain off BLE for the time being. Review of the resident's progress notes dated 06/15/26, at 5:32 P.M., showed the following:-The resident had a fall yesterday;-Resident had complaints of pain to bilateral knees with left leg worse;-Physician ordered X-ray for left leg and right knee;-X-ray results showed bilateral tibia fractures;-Nurse contacted the Family Nurse Practitioner (FNP) who recommended sending the resident out if the doctor agreed;-Nurse contacted doctor who agreed to send resident to the hospital for further treatment. Review of the resident's physician's progress note, dated 06/15/26, showed the following:-The resident fell last night transferring from toilet;-X ray showed bilateral tibia plateau;-Resident had moderate pain and had paraplegia from spine osteomyelitis (infection in the bone). Review of the resident's hospital discharge, dated 06/18/26, showed the resident had bilateral tibial plateau fractures. During an interview on 06/23/26, at 2:20 P.M., the resident said the day of the accident Nurse Aide (NA) A assisted him/her with transferring from the toilet to the wheelchair. The resident said his/her left leg gave out and he/she went down on both knees. During an interview on 06/24/26, at 10:25 A.M., NA A said the following:-Normally he/she was told by the aides how a resident was supposed to be transferred from one place to another;-He/she had heard about care plans but didn't know where care plans were located;-The resident had been a sit-to-stand lift transfer that required two staff;-The day of the incident he/she heard another aide tell nursing staff that the resident told the aide that the resident was no longer required a sit-to-stand lift, but could stand to pivot;-The resident's call light went off and he/she went to assist the resident;-He/she asked the resident if he/she could stand with just him/her, and the resident said just you was fine;-He/she had the gait belt on the resident and the resident stood up fine and then his/her knees gave out, and the aide tried to lower the resident to the floor as slow as possible;-The resident said his/her knees hurt and were burning. The knees also had some scuff places that nursing treated;-He/she takes information from the aides on how to transfer the resident. During an interview on 06/24/26, at 5:55 A.M., the Restorative Aide said the following:-He/she knew how a resident transfers from the team sheets as they list their transfer method, and when there's changes, it's written down in the communication book. Therapy, office staff and nursing update the communication book to reflect changes;-The MDS Coordinator takes care of the care plans and the resident's transfer assistance in listed in there and also updated as needed by the MDS Coordinator;-The resident had been a sit-to-stand. He/she had been working in conjunction with therapy on the stand to pivot;-The day of the incident, he/she and a coworker had gotten the Director of Nursing (DON) to observe the resident with a stand to pivot, and the DON said he/she would speak to therapy about getting rid of the sit-to-stand;-He/she was not sure if information was miscommunicated, but the aide transferred without the sit-to-stand and the resident fell. During an interview on 06/24/26, at 11:48 A.M., Certified Occupational Therapy Assistant (COTA) said the following:-The resident had been a sit-to-stand with two person assist, and she was working with therapy staff to do stand, pivot transfers;-Therapy staff assess to determine when it's safe enough for the resident to do other transfers and then the facility nursing staff are trained by therapy on the transfers;-Therapy had initiated transfer training but never signed off for staff to do stand to pivot transfers with the resident. During an interview on 06/23/26, at 12:50 P.M., Certified Nurse Aide (CNA) B said the following:-Staff have an activities of daily living (ADL) sheet that showed what assistance a resident needed when transferring. It showed whether they required one or two staff assist and what devices should be used. The nurse updates the sheets when things change with the resident;-He/She was not sure how to access a resident's care plan;-Any resident changes are relayed during shift changes;-The resident used to be a sit-to-stand and required two person assist. He/She is now non-weight bearing. During an interview on 06/24/26, at 5:17 A.M., CNA F said the following:-He/she made a list of each resident and what transfer method they used. He/she updated the list when he/she came on shift;-The resident had been a sit-to-stand, and an aide tried to transfer the resident without the sit-to-stand and the resident's knees buckled and the resident fell. During an interview on 06/23/26, at 1:09 P.M., Certified Medication Technician (CMT) C said the following:-All nursing staff have access to care plans. He/She relayed any changes on residents to the next shift and the charge nurse;-The MDS Coordinator updated the care plans based upon the resident's needs;-He/she knew a resident's transfer assistance level by the care plan;-The nurses receive this information from hospital records, or therapy will assess the residents, and they tell staff how much assistance and what devices need to be used. They also provide training;-The resident did use a sit-to-stand and now he/she is transferred using a Hoyer lift (a mechanical lift for nonweight-bearing residents). During an interview on 06/23/26, at 2:40 P.M., CMT E, said the following:-Staff based transfer on hospital records when first admitted ;-If staff have no information on transfer, staff complete a two person assist until therapy has assessed the resident;-Saff have access the care plans and they list what assistance a resident required with transferring. He/she followed the care plan;-Before the resident fell, he/she was a sit-to-stand and had recently been approved to stop using the sit-to-stand and be a two person assist;-He/she now required a Hoyer transfer. During interviews on 06/23/26, at 1:21 P.M. and 2:55 P.M., Licensed Practical Nurse (LPN) D said the following;-When residents admitted they received information from the hospital and nursing assessed the residents. The team sheets showed what assistance the resident needed with transferring;-The resident had been a sit-to-stand transfer prior to falling. He/she had been working with OT and PT and was getting stronger;-The day of the incident the resident was on the toilet and NA A assisted the resident with a transfer to the wheelchair and the resident's knees gave out, and the resident fell to the floor;-The resident fractured his/her tibias;-The staff was supposed to be using a sit-to-stand and not transferring the resident by him/herself;-The care plan showed what assistance a resident needed with transfers, and it was updated by the MDS coordinator as the resident's needs change. During an interview on 06/24/26, at 6:55 A.M., LPN H, said the following:-Assistance with transfers information can be found in the resident's care plan. If the aides need to know, they can also ask nursing or therapy;-Therapy drives the method of transfers for residents;-Therapy had been working with the resident on transfers, and so had the restorative aide;-Prior to the resident's fall he/she had been a sit-to-stand transfer, now he/she required a Hoyer lift for transfers;-He/she sent the resident to the hospital. The resident said the aide was helping him/her transfer from the toilet and he/she fell on his/her knees. There should have been two aides assisting him/her with the sit-to-stand transfer. During an interview on 06/24/26, at 5:30 A.M., Registered Nurse (RN) G said the following:-Residents are assessed by nursing and therapy to see what they can do when transferring. This was done anytime there was a change;-The resident report sheet showed how much assistance a resident required with transferring. Any staff can update the sheet when the resident's needs change. This report was passed from shift to shift;-The resident had never been mobile and had been using a sit-to-stand lift prior to the fall. He/she was not sure if the resident had been working with OT or PT;-It was his/her understanding the resident had been telling aides that he/she could stand to pivot. NA A went into assist the resident from the toilet by him/herself, with using the stand to pivot and the resident's knees gave out, and the resident fell to the floor. During an interview on 06/23/26, at 1:39 P.M., the Assistant Director of Nursing (ADON) and MDS Coordinator said the following:-Staff communicate from shift to shift about the residents including how they are transferred. The team sheets also have this information about the residents;-The resident had paraplegia and used a sit-to-stand lift. The resident had a lot of upper body strength and had been working with therapy on stand to pivots;-The aide attempted to transfer the resident by using the stand to pivot and the resident fell to his/her knees and broke his/her tibia;-Therapy assessed residents and assisted with new interventions to put into the care plans;-All staff have access the care plans. During an interview on 06/24/26, at 7:02 A.M., the Director of Nursing (DON) said the following:-When residents were admitted the hospital notes typically state the means of transfer. If they don't the nurses will err on the side of caution and use a two-person assist or Hoyer lift. The nurses tell the aides what assistance a resident needs with transferring;-The team sheets have the transfer method, and the nurses update these sheets by direction from therapy or the change from a nurse's assessment;-The resident had been doing OT and PT and used a sit-to-stand lift. The restorative aides had also been working with the resident on the stand to pivot using two persons, in conjunction with therapy;-The day of the incident, NA A assisted the resident off of the toilet by him/herself. The aide should have used the sit-to-stand lift and another aide for assistance. The aide should not have attempted to transfer the resident alone. During an interview on 06/24/26, at 7:32 A.M., the Administrator said the following:-Care plans list the resident's daily care needs, and what assistance they need with transfers. The MDS Coordinator updated these as changes occur;-Information from the hospital tells how a resident transfers. Therapy also assesses and drives the transfer method. Therapy makes the determination on how the resident should be transferred and reassesses as needed;-The restorative aide work with therapy and the resident on transfers;-They have team sheets that lists the resident's level of care needs, and all staff have access to them;-The resident had been a sit-to-stand and had been working on pivot transfers with two staff assist. The day of the incident the resident told NA A that he/she was a pivot transfer, and the aide attempted this. The resident fell to his/her knees. The staff should have used a sit-to-stand lift;-Care plans list a residents transfer method, that's received from hospital records or from therapy;-The MDS Coordinator updated the care plan when residents have falls, along with interventions and any changes to a resident's transfers. Complaint #3051428

Based on observation, interview, and record review, the facility failed to ensure food was protected from potential contamination when staff failed to ensure the air gap for the ice machine had the required two inch gap between the drain in the floor and the tubing from the ice machine and when staff failed to ensure the stove top burners used to cook food for the residents were clean and free from grease. The facility census was 40. 1. Review of the 2013 Missouri Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Review showed the facility did not provide a policy related to the air gap. Observation on 06/16/25, at 10:05 A.M., and 06/19/25, at 11:00 A.M., showed an ice machine located in the kitchen. The plastic piece at the end of the drainage tubing from the ice machine rested directly on floor next to the drain area and did not have the required two inch air gap. (If the drain were to back-up the dirty water or waste could flow back into the tubing and cause the ice (a food substance) in the ice machine to become contaminated.) During an interview on 06/19/25, at 10:48 A.M., Dietary Staff A said he/she did not know about the required ice machine gap. During an interview on 06/19/25, at 10:52 A.M., Dietary Staff B said the ice machine tubing should be over the drain due to ice melts and it should drain out into the drain located on the floor. During an interview on 06/19/25 at 11:00 A.M., the Dietary Manager said there should be a two or three inch air gap between the drain on the ice machine and the drain in the floor to ensure no back flow goes back up into the ice machine. The cap at the end of the tubing is there to keep staff from kicking it when they mop the kitchen. Observations and interviews on 06/19/25, at 1:20 P.M. and 02:44 P.M., with the Maintenance Director showed the following: -He said there should be three inches of an air gap between the drain on the ice machine and the drain in the floor. He did not know how the tubing kept going down on the floor and it should be up from the drain to keep from back flow up into the ice machine; -He placed the end cap of the tubing in the middle of the tubing to hold it up two to three inches up from the drain and said it should not have been on the end of the tubing, that was not how it was intended. During an interview on 06/19/25, at 1:26 P.M., the Administrator said there should be a two inch air gap between the drain on the ice machine and the drain in the floor. 2. Observations on 06/16/25, at 10:05 A.M., and 06/19/25, at 11:00 A.M., showed the top of the stove had a build-up of grease. During an interview on 06/19/25, at 10:52 A.M., Dietary Staff B said the following: -The cooks should clean the top of the stove; -Staff remove the stove burners and run the through the dishwasher once a week; -There was a lot of accumulation of grease around the burners. During an interview on 06/19/25, at 11:00 A.M., the Dietary Manager said the following: -She usually took the burners off the stove and pressure washes them or run them through the dishwasher; -Staff should clean the stove burners once per month. During interviews on 06/19/25, at 1:26 P.M. and 2:44 P.M., the Administrator said the following: -Staff should clean the burners on the stove; -The facility did not have a policy for cleaning the stove burners and should refer to the cleaning schedule.

Based on observation, interview, and record review, the facility failed to provide a sanitary and functional environment when staff failed to keep the walk-in cooler floor maintained and cleanable. The facility census was 40. Review showed the facility did not provide a policy related to the floor of the walk-in cooler. Review of the 2013 Missouri Food Codes showed the following: -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 that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -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. 1. Observations on 06/16/25, at 10:05 A.M., and on 06/19/25, at 11:00 A.M., showed the floor in the walk-in cooler had a large area of peeling paint. The floor had a brown and rough surface area. During an interview on 06/19/25, at 10:52 A.M., Dietary Staff B said the following: -The evening aide or cook mops the walk-in cooler floor and freezer; -He/she did not know how long the floor was like this. During an interview on 06/19/25, at 11:00 A.M., the Dietary Manager said the following: -Staff tried painting the walk-in cooler floor in the past and it peels right up again; -The Administrator and maintenance staff talked about the floor one time of replacing it with tiles; -She tries to mop the floor but did not think it was a cleanable surface. During an interview on 06/19/25, at 1:20 P.M., the Maintenance Supervisor said the he was not aware of the walk-in cooler floor. He did not know what the dark area was. During an interview on 06/19/25, at 1:26 P.M., the Administrator said the following: -He talked with the Dietary Manager about two months ago about the floor; -He looked at an aluminum diamond plate material for over the floor that goes over the top so it would not rust; -The walk-in cooler floor should be cleanable.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control system to control the flies when flies were present in two residents' rooms (Resident #2 and Resident #24) and in the facility kitchen. The facility census was 40. Review of the facility's policy titled, Pest Control, undated, showed the following: -Purpose was to provide an environment free of pests; -The facility will have a pest control contract which provides frequency treatment of the environment for pests. It will allow for additional visits when a problem is detected; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Review of Resident #2's face sheet (admission data) showed an admission date of 11/05/21 and a readmisison date of 03/14/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/07/25, showed the resident had moderately impaired cognitive skills. Observation and interview on 06/16/25, at 10:47 A.M., showed the following: -The resident lay in his/her bed; -A fly landed on the resident's hat; -The resident had a fly swatter and said he/she cannot hit hard enough to kill the flies; -A fly landed on the resident's wheelchair; -The resident's family member said he/she killed two to three flies a day and it was normal to have flies around. 2. Review of Resident #24's face sheet showed an admission date of 05/31/22 and a readmission date of 12/21/23. Review of the resident's quarterly MDS, dated [DATE], showed the resident had cognitive skills intact. Observation and interview on 06/17/25, at 1:06 P.M., showed the following: -The resident sat in his/her chair in his/her room; -Two to three flies buzzed around the resident and landed on his/her hands, head, and meal tray; -The resident said he/she had a daily problem with flies, but he/she did not see well enough to kill them. 3. During an interview on 06/19/25, at 2:03 P.M., Certified Nurse Aide (CNA) C said the following: -Flies were everywhere and had been bad this year; -He/she reported to the Maintenance Supervisor of any flies; -A resident had complained to him/her about the flies and he/she gave the resident a fly swatter. During an interview on 06/19/25, at 2:07 P.M., Registered Nurse (RN) D said the following: -The facility had issues with flies. There was one day when the flies were bad; -Staff should report flies to the Administrator. During an interview on 06/19/25, at 2:14 P.M., CNA E said the following: -Flies had been in certain areas of the facility; -Some residents carry fly swatters with them. During an interview on 06/19/25, at 2:17 P.M., the Director of Nursing (DON) said the following: -She would report to the Administrator of any complaints of flies; -The pest control company comes to the facility which helps with pests. During an interview on 06/19/25, at 2:23 P.M., the Administrator said the following: -Staff use fly swatters to kill the flies; -The pest control company helps with pest control; -The facility had fly lights ballasts on order. 4. Observations on 06/16/25, at 10:05 A.M. and 11:38 A.M., in the kitchen showed the following: -At 10:05 A.M., Dietary Staff B stood at the preparation area and removed ham and beans out of a container. Four flies buzzed around the food cart located by the preparation area;. Three flies buzzed around and landed on the preparation area; -At 11:38 A.M., Dietary Staff B stood at the steam table and took temperatures of the food. Six flies sat on the hall cart located next to the preparation table. Three flies buzzed around and landed on the counter top located next to the steam table. Two flies buzzed around and landed on the ledge connected to the steam table. -At 12:25 P.M., Dietary Staff B stood at the steam table and prepared plates for the lunch meal. Three flies buzzed around the steam table and four flies landed on the hall tray cart which had five empty trays. Observations on 06/17/25, at 10:55 A.M., showed the following: -Three flies landed on a black cart; -Two flies buzzed around and landed on the ledge attached to the steam table; -A fly crawled around on a pot and a large metal spoon which hung above the preparation area; -Five flies crawled around on a black cart located next to the preparation area. Observations on 06/18/25, at 10:28 A.M. showed the following: -Four flies crawled around the floor under the dishwashing area; -Flies buzzed around the preparation area and counter top. During an interview on 06/19/25, at 10:48 A.M., Dietary Staff A said he/she worked at the facility about three weeks and did not know how to monitor the flies. He/she did not notice any flies in the kitchen. During an interview on 06/19/25, at 10:52 A.M., Dietary Staff B said the following: -He/she had noticed the flies in the kitchen; -The Dietary Manager and Administrator try to get rid of the flies; -The Administrator makes rounds in the facility and the resident rooms; -Staff are try their best to get rid of the flies; -Flies should not be on the serving spoons, pots, and/or preparation areas. During an interview on 06/19/25, at 11:00 A.M., the Dietary Manager said the following: -She noticed the flies in the kitchen; -The facility is suppose to receive bug lights, the current one above the ice machine did not work; -She tried to kill the flies with a fly swatter. She cannot use a spray to kill the flies in the kitchen. During an interview on 06/19/25, at 1:20 P.M., the Maintenance Supervisor said the following: -The fly traps had been out since last winter and the facility needed new fly traps; -The facility should had received a new one last month; -Staff should use a fly swatter to kill the flies. During an interview on 06/19/25, at 1:26 P.M., the Administrator said the following: -The pest company came to the facility and ordered three lights to replace the bug lights and they did not have a ballast; -The facility is in a rural area and flies had been bad lately due to summer; -The facility should get the new bug lights; -He made rounds in the facility when the flies are bad; -He noticed some flies in the kitchen; -Staff should kill the flies when they see them.

Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure staff changed and stored oxygen equipment per professional standards and when staff failed to care plan oxygen usage for two residents (Resident #22 and #10). The facility census was 40. Review of the facility's Oxygen Equipment Policy, undated, showed the following: -Disposable oxygen equipment will be discarded after each use; -Humidifier must be emptied and refilled every 24 hours with distilled water; -Humidifiers are to be dated, initialed, and replaced monthly; -Tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and as needed. 1. Review of Resident #22's face sheet (a document that gives resident's basic information) showed the following: -admission date of 11/11/23; -Diagnoses included acute respiratory failure with hypoxia (a severe medical condition where the lungs cannot adequately oxygenate the blood) and acute on chronic systolic congestive heart failure (a sudden worsening of chronic heart failure symptoms). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/14/25, showed the following: -Resident was cognitively intact; -Staff did not indicate oxygen therapy. Review of the resident's June 2025 Physician Order Sheet (POS) showed the following: -An order, dated 05/22/25, to administer 2 to 4 liters of oxygen as needed for shortness of breath or to keep blood oxygen levels above 90%; -An order, dated 05/22/25, to change oxygen tubing monthly; -An order, dated 05/22/25, to change oxygen tubing as needed; -An order, dated 11/11/23, to change nebulizer tubing monthly. Place name and date on tubing and plastic bag, once a month on the 25th of the month. Review of the resident's care plan, revised on 06/01/25, showed staff did not care plan the resident's oxygen use. Review of the resident's June 2025 Treatment Administration Record (TAR) showed staff documented oxygen tubing changed on 06/15/25. Observation on 06/16/25, at 10:20 A.M., of resident's room showed the resident lying in bed wearing an undated nasal cannula attached to an oxygen concentrator. The oxygen humidifier and tubing attached to the concentrator were not dated. A nebulizer machine was sitting on the floor next to the bed with attached tubing and mask, undated. Observation on 06/17/25, at 0:37 A.M., of resident's room showed resident lying in bed wearing an undated nasal cannula attached to an oxygen concentrator. The oxygen humidifier and tubing attached to the concentrator were not dated. A nebulizer machine was sitting on the floor next to the bed with attached tubing and mask, undated. Observation on 06/18/25, at 9:27 A.M., showed resident resting in bed wearing an undated nasal cannula attached to an oxygen concentrator set at 3 liters per minute (lpm) of oxygen. The oxygen humidifier and tubing attached to the concentrator were not dated. A nebulizer machine was sitting on the floor next to the bed with attached tubing and mask, undated. 2. Review of the Resident #10's face sheet showed the following: -admission date of 10/03/2024; -Diagnoses included frontal lobe and executive function deficit following cerebral infarction (a condition where blood flow to the brain is blocked), cough unspecified, shortness of breath, and chronic obstructive pulmonary disease (chronic disease affecting the lungs). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Staff did not indicate oxygen therapy. Review of the resident's June 2025 POS showed the following: -An order, dated 04/20/25, for ipratropium-albuterol solution (medication used to treat breathing difficulties) for nebulization, 0.5 milligram (mg) - 3 mg(2.5 mg base)/3 milliliter (ml), inhalation four times a day; -No orders to change nebulizer tubing or masks. Review of the resident's care plan, revised on 04/21/25, showed staff did not care plan the resident's oxygen use. Review of the resident's June 2025 TAR showed staff did not document cleaning or changing nebulizer tubing. Observation on 06/16/25, at 10:27 A.M., of the resident's room showed a nebulizer machine on the resident's bed side table with mask and tubing attached. Tubing attached to mask was dated 04/20. Observation on 06/18/25, at 9:29 P.M., of the resident's room showed a nebulizer machine on the resident's bed side table with mask and tubing attached. Tubing attached to mask was dated 04/20. Observation on 06/19/25, at 10:00 A.M., of the resident's room showed a nebulizer machine on the resident's bed side table with mask and tubing attached. Tubing attached to mask was dated 04/20. 3. During an interview on 06/18/25, at 9:49 A.M., Licensed Practical Nurse (LPN) G said the following: -Night shift nurses are responsible for changing oxygen, nebulizer tubing, and masks; -Tubing and masks should be changed every month; -Residents have orders in the computer for changing tubing and masks. During an interview on 06/18/25, at 11:42 A.M., Certified Medication Technician (CMT) F said the following: -All tubing for oxygen and nebulizer's are changed on night shift; -They are changed once a month by the night shift nurse; -Nebulizer treatments can be administered by the med tech. During an interview on 06/18/25, at 12:08 P.M., CMT H said the following: -Nurses change oxygen tubing and nebulizer masks on night shift; -Tubing should be kept off the floor. During an interview on 06/19/25, at 10:38 A.M., Registered Nurse (RN) D said the following: -Night shift nurses change oxygen tubing and masks once a month; -There is a schedule for those to be changed; -He/she was unaware of any tubing that has not been changed; -Tubing should be kept off the floor to prevent infection. During an interview on 06/19/25, at 10:53 A.M., Assistant Director of Nursing (ADON) said the following: -Oxygen is a standard of care and is not included in care plans; -Oxygen can be care planned if a resident has specific interventions they need; -Night shift nurses are responsible for changing oxygen tubing and masks monthly; -Oxygen tubing and masks should be dated; -Oxygen tubing and nebulizer machines should not be on the ground. During an interview on 06/19/25, at 11:17 A.M., the Director of Nursing (DON) said the following: -Oxygen tubing and nebulizer machines should not be on the ground; -Night shift nurses are responsible for changed oxygen tubing and masks monthly; -Oxygen tubing, masks, humidifiers should be labeled and dated. During an interview on 06/19/25, at 12:56 P.M., the Administrator said the following: -He/she expected nursing to follow all orders related to changing oxygen tubing and masks; -Management does rounds checking to insure those are being changed; -Oxygen masks, humidifiers should be dated; -Oxygen tubing should be dated and bagged.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for all residents, when staff failed to document in the medical record an injury and change of condition for one resident (Resident #36). The facility census was 40. Review of the facility's policy titled, Event Investigation, undated, showed the following: -Purpose was to investigate the cause of all marks, discoloration, skin breaks, and injuries which have not been witnessed and to identify any injuries after a resident sustains an event; -Complete a report of event form as soon as possible whenever there is an unusual, unexpected and/or unintended event; -Any staff member who discovers, witnesses, or is involved in an event should immediately report the event to the nurse in charge; -The charge nurse is responsible to complete the report of event and forward this to the Director of Nursing as soon as possible. Review of the facility's policy titled, Charting and Documentation, undated, showed the following: -Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations; -Accidents/incidents narrative documentation does not take the place of the event report form; -Documentation should include the circumstances surrounding the accident or incident, where it took place, date and time incident occurred, name of any witnesses, residents account of the incident, time the physician was notified, time and date family was notified, and the condition of the resident including vital signs. 1. Review of Resident #36 face sheet (admission data) showed the following: -admission date of 03/29/25; -Diagnoses include Down Syndrome (a genetic disorder), delusional disorders (a mental disorder the involves persistent false beliefs), bradycardia (slow heart rate), and cognitive communication deficit (communication problem). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/05/25, showed the following: -Resident was unable to complete mental status assessment; -Resident frequently rejected care; -Used a wheelchair. Review of the resident's care plan, revised 04/21/25, showed the following: -Required assistance with daily decision making and communication; -At risk for falls; -Resident liked to sit on the floor. Keep floor mats in place. Review of resident's progress notes showed the following: -On 06/14/25, at 3:37 P.M., Registered Nurse (RN) D documented family notification of the resident sustaining a bruise to his/her forehead earlier that week. Resident observed frequently resting head on table. Neuro checks completed and normal. Resident denied pain or discomfort; -On 6/15/25, at 3:27 P.M., RN D documented resident refusing care, bruise to resident's forehead faded and turning yellow. Resident denied pain or discomfort; -on 6/16/25, at 1:54 P.M., RN D documented resident denied pain or discomfort related to bruise to forehead. Resident continued to lay head on table during mealtimes; (Staff did not complete any other documentation related to the bruise to resident's forehead. Staff did not document when the event occurred to cause the bruise, an investigation into the cause, continued monitoring of bruise until healed, or physician and family notification of the bruise.) Observation on 06/16/25, at 12:05 P.M., of the resident in dining room showed resident sitting at table with head resting on table. Resident had a yellow colored bruise to his/her left forehead. During an interview on 06/18/25, at 9:49 A.M., Licensed Practical Nurse (LPN) G said the following: -The resident has a bruise to his/her forehead; -He/she was not here when it happened, but thinks resident bumped his/her head; -Resident is known to get on the floor and crawl on his/her floor mats in their room. During an interview on 06/18/25, at 11:59 A.M., Certified Nursing Assistant (CNA) I said the following: -The resident frequently bumps his/her head on the table in the dining room; -The resident frequently crawls around on the floor in his/her room; -Staff notify the nurse if any resident has a bruise. During an interview on 06/18/25, at 12:08 P.M., Certified Medication Tech (CMT H) said the following: -The resident liked to sit on the floor and has a low bed. This was care planned; -The resident liked to crawl on the floor in his/her room; -The resident had a bruise to his/her head from the table in the dining room; -Staff notify the nurse if any resident is found to have an injury. During an interview on 06/19/25, at 10:14 A.M., CNA C said the following: -He/she did not know how resident got the bruise to his/her forehead; -The resident crawls around on the floor a lot; -Staff report any injuries to the charge nurse. During an interview on 06/19/25, at 10:38 A.M., RN D said the following: -The resident had a bruise to his/her forehead; -He/she was not there when it happened; -The resident liked to rest his/her head on the table and crawl on the floor; -He/she completed a neuro check as part of his/her standard assessment; -He/she documented on the bruise when he/she was on duty; -He/she does not know if the physician was notified or if the physician had seen the resident. During an interview on 06/19/25, at 10:53 A.M., the Assistant Director of Nursing (ADON) said the following: -Resident was care planned with interventions for her behaviors such as crawling on the floor; -The resident's bruise came from the resident laying his/her head on the table in the dining room; -Nursing should assess and document any injury that a resident sustains. During an interview on 06/19/25, at 11:17 A.M., the DON said the following: -The resident got a bruise to his/her forehead from laying his/her head on the dining room table; -Staff discussed starting resident on neuro checks but decided not to since the bruise was not from an impact; -Staff should have documented the incident; -Staff should have measured and documented bruise; -Staff should have notified the physician and family when injury appeared. During an interview on 06/19/25, at 12:56 P.M., the Administrator said the following: -He/she did not recall the exact cause of the resident's bruise; -He/she would expect staff to document how an injury originates; -He/she expected staff to assess and document any resident who sustains and injury; -Documentation should include doctor and family notifications.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice when staff failed to keep the ice machine clean, failed to ensure the dishwasher chemicals tested at the recommended levels, and did not wear proper hair coverings. The facility census was 28. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/23, at 8:59 AM., showed the deflector shield on the inside of the ice machine had five black spots and a black substance along most of the bottom of the deflector shield. Review of the facility's weekly cleaning schedule, dated October 2023, showed the following: -Ice machine listed as being cleaned weekly; -Staff did not indicate cleaning of the ice machine in the month of October 2023. Review of the facilities' monthly cleaning schedule, dated October 2023, showed the following: -Ice machine-sanitize; -Staff did not indicate sanitizing of the ice machine in the month of October 2023. During an interview on 11/01/23, at 1:32 P.M., Dietary Aide (DA) A said the following: -The ice machine is everyone's responsibility to clean; -He/she was not sure if there is a schedule telling how often to clean it on the inside or outside; -It would not be appropriate to use the ice if there are black spots on the inside of the ice machine. During an interview on 11/01/23, at 1:41 P.M., DA B said the following: -Staff have a cleaning schedule that hangs on the door; -He/she does not know who is in charge of cleaning the ice machine; -He/she would tell the Dietary Manager if there were black spots inside of the ice machine; -He/she said the night kitchen staff do wipe down the outside of the ice machine. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -Staff have a cleaning schedule on the door and the ice machine is listed on it; -The Maintenance Manager cleaned the ice machine out a couple of months ago; -He/she said the ice machine has not been cleaned in a couple of months; -He/she would let the Dietary Manager know if there were black spots on the inside of the ice machine. During interviews on 11/01/23, at 1:56 P.M. and 2:20 P.M., the Dietary Manager said the following: -He/she and the maintenance person is responsible for cleaning the ice machine. It is completed one time per month; -The ice machine was not cleaned last month; -The maintenance person usually cleans the deflector shield; -He/she would not use the ice machine if there's black spots on the inside and would expect staff to not use it either; -He/she would clean the ice machine if he/she saw black spots. During an interview on 11/01/23, at 2:28 P.M., the Maintenance Manager said he/she does not clean the inside of the ice machine, that's is the responsibility of the kitchen staff. During an interview on 11/01/2023, at 2:33 P.M., with the Administrator said the following: -Maintenance is responsible for cleaning the inside and outside of the ice machine; -If dietary staff see an issue such as black spots on the inside, they should not use the ice, and the machine should be taken apart and cleaned. 2. Review of the 2013 Missouri Food Code showed the following: -Chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, should be completed as specified. Review of the facility's policy titled, Dietary Personnel Guidelines, dated May 2015, showed the following: -Chemically sanitized machines should be checked daily with test strip; -Dip end of test strip into waster in the reservoir, immediately after machine is completely finished with the cycle; -Compare strip to chart on test strip container; -Document on log; -Desired reading 50 to 100 ppm (parts per million). Review of the manufacture's recommendation, showed the following: -The black or gray wheel controls the sanitizer; -The sanitizer wheel is adjustable; -Set the sanitizer concentrations 50 ppm's, not to exceed 100 ppm's; -Monitor chlorine levels by using chlorine test strips. During an observation and interview on 10/31/23, at 8:59 A.M., with the Dietary Manager showed the following: -He/she had ran a set of dishes through the low temp dishwasher; -He/she dipped the test strip at the appropriate time and it showed a light purple color indicating under 10 ppm chemical solution; -He/she ran two more wash cycles, testing at the appropriate times each time and the test strip showed no chemical solution; -He/she said the test strip should show 200 ppm; -When they have issues, he/she messages the chemical provider; -The staff monitor the chemical solution by documenting the solution amounts on a clipboard that hung near the dishwasher. Review of the Dish Machine Temperature and Test Strip Log, dated October 2023, showed the following: -The dishwasher chemicals are tested at each meal; -The dishwasher chemicals tested at 200 ppm 13 days of October at each meal; -The dishwasher chemicals were not tested 14 days during October; -On 10/29/23, the dishwasher chemicals tested at 145 ppm for breakfast, 145 ppm for lunch, and was not tested at dinner; -On 10/30/23, the dishwasher was tested at breakfast and showed 145 ppm. During an interview on 11/01/23, at 1:32 P.M., DA A said the following: -All staff check the chemicals on the dishwasher two times per week; -The chemicals should register at 200 ppm each time they're tested ; -The chemical tests are documented on the clipboard that hangs by the dishwasher; -He/she would tell the dietary manager if the chemicals didn't test at the right level; -He/she wouldn't use the dishwasher if it doesn't test correctly, he/she would use the three compartment sink. During an interview on 11/01/23, at 1:41 P.M., DA B said the following: -The chemicals on the dishwasher are tested daily and all staff are responsible for testing; -He/she would not use the dishwasher if it did not read at the required level; -He/she is not sure what the chemical levels should be; -He/she would tell the Dietary Manager or the Maintenance Manager if the chemical levels in the dishwasher were not reading properly. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -The Dietary Manager and the Maintenance Manager keep an eye on the dishwasher chemicals; -The staff working nights test the chemicals and documents the results on the clipboard; -The chemical levels should be 200 ppm; -If staff test the chemicals and they're not at the proper level, they would clean the dishes by hand. During an interview on 11/01/23, at 1:56 P.M., with the Dietary Manager said the following: -All staff are responsible for checking the chemicals for the dishwasher; -The chemicals should be checked daily and written on the clipboard by the dishwasher; -The reading should be in the green color, 200 ppm, but no less than 150 ppm; -If the dishwasher chemicals don't read properly, staff shouldn't use the machine and would hand wash in the three sink compartments. During an interview on 11/01/23, at 2:33 P.M., the Administrator said the following: -Chemicals are tested daily; -He/she is not sure of what the ppm's should read, but would start with the manufacturer's recommendations; -He/she is not sure which staff have been trained to test the dishwasher chemicals; -After staff test the chemicals, the person should be documenting the chemical levels on the clipboard; -Maintenance and the Dietary Manager are responsible for making sure the chemicals are tested ; -The staff testing the chemicals should know the range and the dietician would adjust accordingly; -If the chemicals are not registering the proper numbers, staff should see what the issues are and let the Dietary Manager know, the staff shouldn't use the dishwasher if the chemicals don't test appropriately; -The three sink compartment should be used in place of the dishwasher when it's not working properly. 3. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review showed the facility did not provide a policy regarding facial hair in the kitchen. Observations of the kitchen on 11/01/23, at 12:30 P.M. and 1:41 P.M., showed the following: -DA B had facial hair around his/her mouth, chin, and upper lip; -DA B was not wearing a hair net to cover the facial hair; -DA B was mixing a powdery substance with milk, then poured this into the cup for a resident. During an interview on 11/01/23, at 1:32 P.M., DA A said the following: -Staff with facial hair are supposed to wear hair nets; -Staff should not be in the kitchen without a hair net covering all hair. During an interview on 11/01/23, at 1:41 P.M., DA B said he/she was told that a hair net did not have to be wore on a beard if the hair was shorter than his/her eyebrows. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -He/she isn't sure what the policy says on beard or facial hair; -He/she said in the past staff with a stubble of hair on their face were supposed to wear nets to cover; -Staff should wear hair nets to cover all hair when in the kitchen. During an interview on 11/01/23, at 1:56 P.M., with the Dietary Manager said the following: -He/she was told staff no longer needed to wear beard nets if the hair was no longer than the eye browns; -If the hair is longer, the staff would need to wear a hair net when in the kitchen. During an interview on 11/01/23, at 2:33 P.M., with the Administrator said the dietician recommendations are if facial hair is shorter than the eye brows no hair net is worn, if the hair is longer than the eye brows, a hair net is to be worn in the kitchen. During an interview on 11/01/2023, at 4:25 P.M., with the Registered Dietician said the he/she was told staff did not need to wear beard nets if the hair on the face was no longer than the eyebrows.

Based on observation, record review, and interview, the facility failed to provide a sanitary environment for all residents, staff, and visitors when staff failed to ensure fans and areas around fans located in the walk-in refrigerator and the vents on the ice machine were cleaned; failed to replace a missing vent cover on the side of the ice machine; and failed to repair the vent cover broken the other side of the ice machine. The facility census was 28. 1. Review showed the facility did not provide policies related to cleaning related to the fans in the refrigerator. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/2023, at 8:59 AM., showed two fans located at the back of the refrigerator had fuzzy gray lint and a build-up of lint above the fan on the left side. During an interview on 11/01/23, at 1:32 P.M., Dietary Aide (DA) A said maintenance staff cleans the fans in the refrigerator and around the fans. During an interview on 11/01/23, at 1:41 P.M., DA B said if the fans in the refrigerator have lint or dirt on them, he/she would clean them. He/she knows the fans are on the cleaning schedule, but was not sure how often. During an interview on 11/01/23, at 1:47 P.M., DA C said maintenance staff cleans the fans in the refrigerator and around the fans. If he/she sees lint, he/she would let the Dietary Manager (DM) or maintenance know. . During an interview on 11/01/23, at 1:56 P.M., the DM said maintenance staff cleans the vents in the refrigerator. -He/she tries to wipe down the fan covers and if unable to get them clean will tell the maintenance staff. During an interview on 11/01/23, at 2:28 P.M., the Maintenance Manager said kitchen staff should be cleaning the outside and around the fans in the refrigerator. He/she cleans the inside of the fans and makes sure they run. 2. Review showed the facility did not provide policies related to cleaning or maintenance of the ice machine. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/23, at 8:59 AM., showed the following: -The vent cover on the side of the ice machine had fuzzy lint on it and the bottom portion of the vent cover was broken/missing; -The vent on the other side of the ice machine had the vent cover missing. During an interview on 11/01/23, at 1:32 P.M., DA A said the following: -He/she does not know who cleans the vents on the outside of the ice machine; -Maintenance replaces the vent covers; -He/she does not know if the maintenance staff knows one of the vent covers is missing and one is broken. During an interview on 11/01/23, at 1:41 P.M., DA B said the following: -He/she wipes down the vents nightly on the outside of the ice machine; -If the vents have lint, he/she takes them off and rinses with water; -If no vent cover, would tell the dietary manager; -He/she doesn't know if the maintenance staff is aware one of the vent covers are missing and one is broken. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -He/she doesn't know about vents on the ice machine; -Maintenance takes care of anything broken so he/she would tell maintenance if there was something broken on the ice machine; -He/she doesn't know if the maintenance staff is aware that one of the vent covers are missing and the other one is broken. During an interview on 11/01/23, at 1:56 P.M., the DM said the following: -He/she would knock the lint off if he/she saw lint on the ice machine vent covers; -He/she would let the maintenance person know if the vent covers were missing or broken. During an interview on 11/01/23, at 2:28 P.M., the Maintenance Manager said the following: -Dietary staff are responsible for cleaning the grills/vent covers and the exterior of the machine; -He/she was aware the vent cover was missing on the side of the ice machine and the other vent cover is broken; -He/she has been unable to find replacement vent cover parts. During an interview on 11/01/23, at 2:33 P.M., the Administrator said maintenance staff are responsible for keeping the vents on the outside of the machine clean and repaired if they're missing parts. He/she did not know the vent cover on the side was missing, or the other one was broken.

Based on interview, and record review, the facility failed to report allegations of abuse to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of staff becoming aware of the allegation of abuse when one resident (Resident #5) made allegations of physical and sexual abuse. The facility census was 28. Record review of the facility's abuse policy titled, Reporting, from Section 1 of the Abuse Prohibition Manual, undated, showed the following: -It is the policy of this facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse; -The nursing home administrator or designee will report abuse to the state agency per state and federal requirements; -If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made and policy provides the Missouri state elder abuse hotline number. 1. Record review of Resident #5's significant change minimum data set (MDS - a federally-mandated, comprehensive assessment tool completed by facility staff), dated 5/7/21, showed the following: -Entered the facility on 11/3/20 from the hospital; -Severe cognitive impairment; -Exhibited delusions; -Physical and verbal behaviors directed toward others one to three days in the past week; -Required extensive assistance of one or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's nurse's note dated 2/10/21, at 8:51 P.M., showed Registered Nurse (RN) F documented the following: -Behaviors: The resident continues to get up and down unassisted. The resident became agitated with staff when attempting care. A male aide entered the resident's room with a female aide to assist and the resident became very aggressive toward the male aide. This nurse had the aides leave the room and visited with the resident who said the boy pulled the resident's hair and threw the resident across the room. The resident said he /she had enough and needed to go to his/her Grandma's house. The female aide said the male aide had only attempted to help the resident with his/her walker. Female staff assisted the resident for the rest of the evening in an attempt to decrease the resident's agitation. The resident also became angry when asked if staff could assist the resident with changing out of his/her dirty clothes and into pajamas before bed. Staff administered [MEDICATION(S)] (an antianxiety medication) and [MEDICATION(S)] (an antipsychotic medication) to the resident with very little improvement. (Staff did not document reporting the allegation of abuse to DHSS.) Record review of DHSS records showed the facility did not report the allegation of abuse to DHSS. During an interview on 5/12/21, at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 2/10/21, at 8:51 P.M., where in the nurse documented the resident alleged a male aide pulled the resident's hair and threw the resident across the room. The administrator said she would expect the nurse to notify the administrator immediately of the resident's allegation. The administrator said she would have further questioned the resident and staff to determine if this was an allegation of abuse. Record review of the resident's nurse's note dated 3/17/21, at 1:27 P.M., showed RN F documented the following: -Behaviors: The resident has been getting up in his/her room and out into the hallway without assistance and his/her alarm is sounding. Staff attempt to assist the resident and he/she becomes angry and agitated. The resident stated, he/she Ain't no baby and I can take care of myself. The resident yelled at an aide and said the aide threatened to hit him/her. Another staff member nearby, stated the aide did not threaten the resident. The staff attempted distractive activities. Staff gave the resident [MEDICATION(S)] with no relief and then gave the resident [MEDICATION(S)]. The resident later became tearful and said that his/her kids had been locked up. He/she then stated that they had not been locked up, but that they were trying to kill him/her. The resident said he/she would expect it from one family member, but not from the other. The resident's anxiety and behaviors continued throughout the shift. The resident is currently having a window visit with his/her family member. (Staff did not document reporting the allegation of abuse to DHSS.) Record review of DHSS records showed the facility did not report the allegation of abuse to DHSS. During an interview on 5/12/21, at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 3/17/21, at 1:27 P.M., where in the resident alleged that an aide had threatened to hit the resident. The administrator would expect staff to alert her immediately of this allegation. The administrator said she felt this was an allegation of abuse. Record review of the resident's nurse's note dated 5/04/2021, at 9:24 P.M., showed RN E documented the following: -Behavior: Resident became combative with staff during care and said, You're raping me. Staff (two aides present in the room) assured the resident that they were getting him/her ready for bed. The resident continued to fight staff and said, Get out of here. You are punching me. The resident also said, the roommate peed on his/her bed. Staff administered a [MEDICATION(S)] (an antianxiety medication) to the resident. (Staff did not document reporting the allegation of abuse to DHSS.) Record review of DHSS records showed the facility did not report the allegation of abuse to DHSS. During an interview on 5/11/21, at 2:11 P.M., Certified Medication Technician (CMT) A said the following: -The resident frequently exhibited anxiety; -The resident slaps at staff and tells staff to leave him/her alone during cares; -The resident generally responds better to one staff member, but with more staff, the resident becomes anxious and overwhelmed; -In the last few weeks, the resident kept saying someone grabbed and bruised his/her hand, the CMT has reported this in the past, but unsure to whom he/she reported; -When the resident is upset and believes someone is trying to hurt him/her, staff report this to the nurses; -He/she worked on 5/4/21, from 1:00 P.M. until 9:15 P.M., passing medications. On that evening, staff were having an issue with the resident. The CMT went into the resident's room to try and calm the resident down. The resident said he/she thought staff were trying to rape him/her. Staff reported this to the nurse, RN E. The nurse instructed the CMT to give the resident a [MEDICATION(S)] for anxiety, and the resident took the medication. During an interview on 5/11/21, at 2:34 P.M., Certified Nursing Assistant (CNA) B said the following: -On the evening of 5/4/21, the resident sat in a wheelchair in his/her room; -CNA B tried to convince the resident it was time to go to bed, but the resident did not want to go to bed. The resident had recently changed rooms and did not like his/her new roommate; -Two co-workers, CNA C and CNA D, walked in to the resident's room and assumed CNA B had convinced the resident to go to bed; -CNA C and CNA D attempted to lift the resident's arm, in order to put a gait belt around the resident. As staff raised the resident's arm, the resident said, You better not rape me. CNA B and CNA C left the room; -CNA A confirmed with the resident, again that he/she did not want to go to bed, and then left the resident's room; -CNA A immediately reported the incident to the nurse on duty, which the aide believes was RN E; -The resident had not made any prior allegations of rape, but was physically violent, at times, when staff need to change the resident's soiled clothing. In the past, the resident had punched, scratched, and kicked staff. During an interview 05/11/21, at 3:55 P.M., CNA C said the following: -He/she worked on the evening of 5/4/21, when the resident made the rape comment; -The resident said, Don't rape me, when the CNA attempted to put gait belt around the waist of the resident; -The resident then said someone was punching his/her back, when the CNA was attempting to lean the resident forward to attach the resident's personal alarm (an alarm that attaches to the back of the resident's wheelchair and to the resident's clothing to remind the resident not to stand without assistance); -Two other staff, CNA B and CNA D, were present in the room at the time; -The resident was not tearful, but was agitated and did not want to go to bed; -When the resident became agitated, staff stopped cares and left the resident's room; -CNA C immediately reported the incident to RN E. During an interview on 5/11/21 at 4:17 P.M., RN E said the following: -On the evening of 5/4/21, the nurse arrived to resident's room to find CNA B and CNA D in the room with the resident. The resident was screaming, 'You're raping me. The nurse assumed the resident was delusional. Staff were attempting to change the resident's pants because he/she was wet, but they had not started changing him/her at that time. The nurse said he/she believed staff taking the resident to his/her room caused the resident's behavior. The nurse directed the CNAs to leave the resident alone. The resident then accused his/her roommate of urinating on the resident's bed. The roommate was not in the room at the time; -The nurse asked the CMT to give the resident a medication for anxiety; -The nurse did not report the resident's rape comment to anyone; -The nurse said, if at any time, he/she thought the resident was making a serious abuse allegation, he/she would have reported it, but the nurse witnessed the staff not touching the resident while the resident said, You're raping me -The resident had no obvious physical injuries, but seemed very agitated with staff attempting to provide care; -The resident has days of delusions and the nurse has heard the resident yell out and become verbally aggressive with staff; -The nurse said he/she received abuse training every three months from the facility, and this training includes reporting of abuse; -The nurse said he/she is supposed to report any abuse to the Director of Nursing (DON) or the facility administrator, and they then report to DHSS within two hours, -The nurse said he/she never thought abuse was possible, in this case, because multiple staff were in the room at the time and no one was touching the resident. During an interview on 5/11/21, at 4:36 P.M., the DON said the following: -She reviewed the resident's notes a couple of days after 5/4/21, but did not report the allegation of abuse to anyone; -The DON spoke with CNA D, who reported all three aides (CNA B, CNA C, and CNA D) were in the resident's room at the time of the resident's allegations on 5/4/21; -CNA D said he/she touched the resident's arm the resident began yelling and accused the staff of raping him/her, and then the staff left the room and reported the incident to RN E; -The DON said the facility policy directs staff to report any abuse allegation, including rape and investigate; -The DON said all allegations of abuse are to be reported to DHSS within two hours. During an interview on 5/11/21, at 4:36 P.M., the administrator said the following: -She was unaware of the resident's statements on 5/4/21; -In this particular situation, the resident said, You are raping me, and since there were multiple staff in the room at the time observing the resident and the resident is demented, she expected staff to leave the resident's room and report to the charge nurse; -The administrator said she would need more information to make a determination as to whether this was an allegation of abuse or not; -The administrator said staff had notified her of the resident's statements, she would have come to the facility and interviewed the resident to determine if abuse; -If the resident made a valid allegation, such as, I have been raped or the staff have raped me then that would be an allegation of abuse and the facility would report to DHSS within two hours and the DON and/or administrator would come to the facility and do an investigation.

Based on interview, and record review, the facility failed to complete full and timely investigations of allegations of abuse when one resident (Resident #5) made allegations of physical and sexual abuse. The facility census was 28. Record review of the facility's policy titled, Investigation, from Section 7 of the facility's, Abuse Prohibition Protocol Manual (undated) showed: -It is the policy of this facility that reports of abuse are promptly and thoroughly investigated; -When an incident or suspected incident of abuse is reported, the administrator will investigate the incident with the assistance of appropriate personnel. The investigation will include: Who was involved, resident statements, resident's roommate statements, interviews with three to four residents who received care from the alleged staff, interviews obtained from three to four different department staff, involved staff and witness statements of events, a description of the resident's behavior and the environment at the time of the incident, resident assessment, observation of resident and staff behaviors during the investigation, and environmental considerations; -The follow-up investigative notes will be submitted to Department of Health and Senior Services (DHSS) within five working days of the initial report. 1. Record review of Resident #5's significant change minimum data set (MDS - a federally-mandated, comprehensive assessment tool completed by facility staff), dated 5/7/21, showed the following: -admitted to the facility on [DATE] from the hospital; -Severe cognitive impairment; -Exhibited delusions; -Physical and verbal behaviors directed toward others, 1-3 days in the past week; -Required extensive assistance of one staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's nurse's note dated 2/10/21, at 8:51 P.M., showed Registered Nurse (RN) F documented the following: -Behaviors: The resident continues to get up and down unassisted. The resident became agitated with staff when attempting care. A male aide entered the resident's room with a female aide to assist and the resident became very aggressive toward the male aide. This nurse had the aides leave the room and he/she visited with the resident. The resident said the boy pulled the resident's hair and threw the resident across the room. The resident said he/she had enough and needed to go to his/her Grandma's house. The female aide said the male aide had merely attempted to help the resident with his/her walker. For the remainder of the evening, female staff assisted the resident to try to decrease the resident's agitation. The resident also became angry when staff asked the resident if they could remove the resident's dirty clothes and assist the resident in putting on his/her pajamas before bed. The resident has had [MEDICATION(S)] (an antianxiety medication) and [MEDICATION(S)] (an antipsychotic medication) with very little improvement. Record review of DHSS records showed facility staff did not provide an investigation summary or notes regarding the allegation of abuse. During an interview on 5/12/21, at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 2/10/21, at 8:51 P.M., where in the nurse documented the resident alleged a male aide pulled the resident's hair and threw the resident across the room. The administrator said she would expect the nurse to notify her immediately of the resident's allegation. The administrator said she would have further questioned the resident and staff to determine if this was an allegation of abuse; -The administrator would have investigated this allegation of resident abuse. Record review of the resident's nurse's note dated 3/17/21, at 1:27 P.M., showed RN F documented the following: -Behaviors: The resident has been getting up in his/her room and out into the hallway without assistance and his/her alarm is sounding. Staff attempt to assist the resident and he/she becomes angry and agitated. The resident stated, he/she Ain't no baby, and I can take care of myself. The resident yelled at an aide and said the aide threatened to hit him/her. Another staff member nearby, said the aide did not make the comment. Staff attempted distractive activities with the resident. Staff gave the resident [MEDICATION(S)] with no relief and then gave the resident [MEDICATION(S)]. The resident later became tearful and said that his/her kids had been locked up. The resident then stated that they had not been locked up, but that they were trying to kill the resident. The resident said that he/she would expect it from one family member, but not from the other. The resident's anxiety and behaviors continued throughout the shift. Resident is currently having a window visit with his/her family member. Record review of DHSS records showed facility staff did not provide an investigation summary or notes regarding the allegation of abuse. During an interview on 5/12/21 at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 3/17/21, at 1:27 P.M., where in the resident alleged that an aide had threatened to hit the resident. The administrator would expect staff to alert her immediately of this allegation. The administrator said she felt this was an allegation of abuse. -The administrator would have investigated this allegation of resident abuse. Record review of the resident's nurse's note dated 5/04/2021, at 9:24 P.M., showed RN E documented the following: -Behavior: Resident became combative with staff during care and said, You're raping me. Staff (two aides present in room) assured the resident that they were getting him/her ready for bed. The resident continued to fight staff and said, Get out of here. You are punching me. Resident #5 also said, the roommate peed on Resident #5's bed. Staff administered a [MEDICATION(S)] to the resident. Record review of DHSS records showed facility staff did not provide an investigation summary or notes regarding the allegation of abuse. During an interview on 5/11/21, at 2:11 P.M., Certified Medication Technician (CMT) A said the following: -The resident frequently exhibited anxiety; -The resident slaps at staff and tells staff to leave him/her alone during cares; -The resident generally responds better to one staff member, but with more staff, the resident becomes anxious and overwhelmed; -In the last few weeks, the resident kept saying someone grabbed and bruised his/her hand, the CMT has reported this in the past, but unsure to whom he/she reported; -When the resident is upset and believes someone is trying to hurt him/her, staff report this to the nurses; -He/she worked on 5/4/21 from 1:00 P.M. until 9:15 P.M. passing medications. On that evening, staff were having an issue with the resident and he/she went into the resident's room to try and calm the resident down. The resident said he/she thought staff were trying to rape him/her. Staff reported this allegation to the nurse, RN E. The nurse instructed the CMT to give the resident a [MEDICATION(S)] for anxiety, and the resident took the medication. During an interview on 5/11/21, at 2:34 P.M., Certified Nursing Assistant (CNA) B said the following: -CNA B worked on the evening of 5/4/21; -On the evening of 5/4/21, the resident sat in a wheelchair in his/her room; -CNA B tried to convince the resident it was time to go to bed, but the resident did not want to go to bed. Staff had recently placed the resident in a differed room and did not like his/her new roommate; -Two co-workers, CNA C and CNA D, walked in to the resident's room and assumed CNA B had convinced the resident to go to bed; -CNA C and CNA D attempted to lift the resident's arms, in order to put a gait belt around the resident. As staff raised the resident's arms, the resident said, You better not rape me. CNA B and CNA C then left the room; -CNA A confirmed with the resident, again that he/she did not want to go to bed, and then left the resident's room. -CNA A immediately reported the incident to the nurse on duty, which the aide believes was RN E; -The resident had not made any prior allegations of rape, but was physically violent with staff, at times, when staff need to change the resident's soiled clothing. In the past, the resident had punched, scratched, and kicked staff during cares. During an interview 05/11/21, at 3:55 P.M., CNA C said the following: -He/she worked on the evening of 5/4/21, when the resident made the rape comment; -The resident said, Don't rape me, when the CNA attempted to put a gait belt around the waist of the resident; -The resident then said someone was punching his/her back, while the CNA was attempting to lean the resident forward to attach the resident's personal alarm (an alarm that attaches to the back of the resident's wheelchair and to the resident's clothing to remind the resident not to stand without assistance); -Two other staff, CNA B and CNA D, were present in the room at the time; -The resident was not tearful, but was agitated and did not want to go to bed; -When the resident became agitated, staff stopped cares and left the resident's room; -CNA C immediately reported the incident to RN E. During an interview on 5/11/21, at 4:17 P.M., RN E said the following: -On the evening of 5/4/21, the nurse arrived to the resident's room to find CNA B and CNA D in the room with the resident. The resident was screaming, 'You're raping me. The nurse assumed the resident was delusional. Staff were attempting to change the resident's pants because he/she was wet, but they had not started changing the clothing at that time. The nurse said he/she believed the staff taking the resident to his/her room caused the resident's behavior. The nurse directed the CNAs to leave the resident alone. The resident then accused his/her roommate of urinating on the resident's bed. The roommate was not in the room at the time; -The nurse asked the CMT to give the resident a medication for anxiety; -The nurse did not report the resident's allegation of rape to anyone; -The nurse said, if at any time, he/she thought the resident was making a serious abuse allegation, he/she would have reported it, but the nurse witnessed the staff not touching the resident while the resident said, You're raping me; -The resident had no obvious physical injuries, but seemed very agitated with staff attempting to provide care; -The resident had periods of delusions and the resident yells out and becomes verbally aggressive with staff at times; -The nurse said he/she received abuse training every three months from the facility, and this training includes reporting of abuse; -The nurse said he/she is supposed to report any abuse to the Director of Nursing (DON) or the facility administrator; -The nurse said he/she never thought abuse was possible, in this case, because multiple staff were in the room at the time and no one was touching the resident. During an interview on 5/11/21, at 4:36 P.M., the DON said the following: -She reviewed the resident's notes a couple of days after 5/4/21, but did not report the allegation of abuse to anyone; -The DON spoke with CNA D, who reported all three aides (CNA B CNA C, and CNA D) were in the resident's room at the time of the resident's allegations on 5/4/21; -CNA D said he/she touched the resident's arm the resident began yelling and accused the staff of raping him/her, and then the staff left the room and reported the incident to RN E; -The DON did not interview any other staff involved; -The DON said, if there been just one staff in the room at the time, he/she would have interviewed staff and residents; -The DON said the facility policy directs staff to report and conduct an investigation on any abuse allegation, including rape. During an interview on 5/11/21, at 4:36 P.M., the administrator said the following: -She was unaware of the resident's statements on 5/4/21; -In this particular situation, the resident said, You are raping me, and since there were multiple staff in the room at the time observing the resident and the resident is demented, she expected staff to leave the resident's room and report to the charge nurse; -The administrator said she would need more information to make a determination as to whether this was an allegation of abuse or not; -The administrator said if staff had notified her of the resident's statements, she would have came to the facility and interviewed the resident to determine if abuse occurred; -If the resident made a valid allegation, such as, I have been raped, or, The staff have raped me, then that would be an allegation of abuse; -When a resident makes an allegation of abuse, the facility would report to DHSS within 2 hours and the DON and/or administrator would come to the facility to conduct an investigation.

Based on observation, interview, and record review, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to provide adequate indications for usage of an antipsychotic medication, failed to identify appropriate target behaviors for medication use, and failed to show the medication helped promote or maintain the resident's highest practicable mental, physical, and psychological well-being for one resident (Resident #6) in a selected sample of 14. The facility census was 29. Record review of the facility's policy titled, Psychoactive Drug Therapy, dated (MONTH) 2006, showed the following information: -This facility will use psychoactive drugs only in the best interest of the resident, never for the convenience of the staff or to punish residents, and in conjunction with non-drug interventions and approaches whenever possible; -An unnecessary drug is any drug when used in excessive dose or excessive duration, or without adequate monitoring, without adequate indication for use, or in the presence of adverse consequences, which indicate the dose should be reduced or discontinued. Psychoactive medications are those prescribed to control mood, mental status, or behavior. These include anti-anxiety agents, sedative-hypnotic, antidepressants, anti-psychotics, and anti-manic drugs; -Physician orders [REDACTED]. -Documentation of medication administration will be monitored along with targeted behaviors. Record review of the facility's policy titled, Behavior Management Program, dated (MONTH) 2006, showed the following information: -Each resident who is receiving a psychoactive medication will be placed on a behavior management plan; -Each resident will have a care plan identifying the reason for the medication and behavioral interventions to be implemented by each discipline; -Identification of a new problem behavior will be assessed to rule out other possible reasons for the resident's distress (i.e. environmental stressors, acute illness, medication change, etc.), prior to obtaining an order for [REDACTED].>1. Record review of Resident #6's face sheet (brief information sheet) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrumment completed by facility staff, dated 2/14/19, showed the following information: -Severely cognitively impaired; -Behavior of wandering daily; -Independent with walking, transfers, dressing, and eating. Record review of the resident's physician order [REDACTED]. -On 4/22/18, an order for [REDACTED]. Record review of the resident's monthly behavioral monitoring form, started 4/23/18, showed the targeted behavior each month as wandering; no other behaviors were listed. Record review of the resident's care plan, last updated 2/14/19, showed the following information: -Document behaviors and notify physician; -Resident wanders; -Nursing interventions to avoid over stimulation, assess for pain, toileting, or hunger, offer other activities, and redirect. Observation on 2/19/19, at 10:30 A.M., showed the resident asleep in his/her room in a recliner. Observation on 2/20/19, at 2:45 P.M., showed the resident asleep in a common area in a recliner. During observation and interview on 2/21/19, at 11 40 A.M., on a couch in a common area of the facility, the resident said he/she likes to walk and be outside. The resident was very pleasant, but confused. During observation on 2/22/19, at 8:50 A.M., showed the resident asleep in a recliner in the dining area. During an interview on 2/22/19, at 8:55 A.M., Certified Nurse Aide (CNA) A said the resident is pleasant, and not combative. The resident does not have hallucinations or delusions. The resident is easy to redirect. During an interview on 2/22/19, at 9:05 A.M., CNA B said the resident is not combative, and does not have negative behaviors. The resident will try to exit the facility, but is easy to redirect. During an interview on 2/22/19, at 9:10 A.M., Registered Nurse (RN) C said antipsychotic medications are used for residents with hallucinations or delusions. The resident is usually pleasant. The resident wanders, and is easy to redirect. The resident does not have hallucinations, delusions, or negative behaviors. During an interview on 2/22/19, at 11:10 A.M., the Director of Nurses (DON) said antipsychotic medications are used with residents with hallucinations, delusions or combative behaviors. All behaviors are tracked on the behavioral monitoring forms. The resident had behaviors when he/she was admitted . He/she was exit seeking and difficult to redirect. The resident wandered into other resident rooms and could be difficult to redirect. These behaviors should be on the monitoring form and detailed in the nurses notes. During an interview on 2/22/19, at 11:30 A.M., the administrator said antipsychotics are used with certain diagnoses, and must have appropriate target behaviors. Wandering is not a target behavior by itself. It should be shown the resident is in distress or has behaviors that effect care or other residents. The resident wandered frequently upon admission and became more difficult to redirect. Behavioral interventions were tried and should have been documented.

Based on observation, interview and record review, the facility failed to perform appropriate catheter (flexible sterile tube inserted into the bladder for urinary elimination) care and proper catheter management for two residents (Resident #14 and #15) with indwelling urinary catheters. A sample of 12 residents was selected in facility with a census was 39. According to Fundamentals of Nursing by Taylor, Lillis, LeMone and Lynn, seventh edition, urinary tract infections are the leading cause of systemic infections in older adults. About half of all individuals with an indwelling catheter become infected within one week after the catheter's insertion. Most of the pathogens (microorganisms capable of causing infection) are introduced by the handling of the catheter and drainage device after placement of the catheter. Caring for individuals with an indwelling catheter require staff to always wash hands before and after caring for an individual with an indwelling catheter and always clean the perineal area (area from the urinary tract to the rectum) thoroughly, especially around the meatus (the opening to the urinary tract) after each bowel movement. The staff should cleanse the catheter by cleaning gently from the meatus outward. The staff should be aware of the importance of thorough cleaning after having a bowel movement and thorough, frequent hand hygiene. Record review of the facility's policy titled Catheter Care (Indwelling), dated March 2015, directed the staff on the following: -The purpose of this policy is to prevent infection and reduce irritation; -The staff member should wash his/her hands; -Place gloves on his/her hands; -Use one area of the washcloth for each downward, cleansing stroke; -Change the position of the washcloth with each downward stroke; -Change the position of the washcloth and cleanse around the urethral meatus (opening into the urinary tract); -Do not allow the washcloth to drag on the resident's skin or bed linen; -With a clean washcloth, rinse with warm water using the above technique; -Use a clean washcloth with soap and water to cleanse and rinse the catheter from the insertion site to approximately four inches outward; -Check drainage tubing and bag to insure that the catheter is draining properly; -Remove his/her gloves and wash and dry hands thoroughly. Record review of the facility's policy titled, Catheter, Emptying a Urinary Drainage Bag dated March 2015, directed the staff on the following: -One of the purposes of this policy is to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder; -Wash and dry hands thoroughly; -Put on disposable gloves; -Place a paper towel on the floor beneath the drainage bag and position the measuring container under the drainage bag; -Remove the drain tube/spigot from it's sleeve/holder; -Open the drainage bag/spigot and let the urine flow into the measuring container; -After the drainage bag has emptied, close the spigot; -Wipe the spigot with an alcohol swab; -Replace the drain tube back into it's holder; -Staff should not allow the drain spout/spigot to come into contact with the measuring container, hands or any other object; -If accidental contamination occurs, wipe the drain spout with an alcohol swab; -Staff should observe the character of the urine such as color, clarity and odor; -Staff should keep the drainage bag below the level of the resident's bladder; -Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. 1. Record review of Resident #15's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 04/07/17, showed the following information: -The resident had a catheter in place at the time of the assessment; -[DIAGNOSES REDACTED]. -The resident was receiving antibiotics at the time of the assessment. Record review of the resident's laboratory results showed the following information: -The resident's urine culture and sensitivity (C & S) report (laboratory test performed to identify the bacteria and the appropriate antibiotic for treatment of [REDACTED]. Coli (bacteria found in the environment and in an individual's intestinal tract); -The resident's physician prescribed an antibiotic for treatment of [REDACTED]. -The resident's urine C & S report, with a collected date of 07/24/17, was positive for a urinary tract infection. The lab identified the bacteria was Proteus Mirabilis (a bacteria normally found in the intestinal tract). Record review of the resident's nurses' notes showed the following information: -On 07/24/17, the staff notified the physician the resident had increased complaints of abdominal pain, very foul-smelling, black colored urine; -On 08/04/17, the resident had a low grade temperature and had thick and nasty urine; -On 08/05/17, the resident had a large amount of mucous present in the urine; -On 08/09/17, the resident complained of burning and discomfort around the site of the catheter and the resident's urine was cloudy and had an odor; -On 08/10/17, the physician prescribed an antibiotic for the resident's urinary tract infection. The antibiotic was started on 08/10/17; -On 08/12/17, the resident had a low-grade temperature of 99.2 degrees and complained of feeling dizzy. The resident's urine was dark with sediment visible in the urine; -On 08/15/17, the resident continued to receive the antibiotic for the Proteus Mirabilis in the resident's urine. Record review of the resident's laboratory reports showed the following information: -On 09/07/17, a urine sample for C & S was obtained from the resident's catheter; -On 09/10/17, the C & S final report was positive for a urinary tract infection based on the presence of E. Coli and Proteus Mirabilis. Record review of the resident's nurse's, dated 09/10/17, showed the resident was started on an antibiotic for a urinary tract infection. Observations on 12/07/17 at 11:30 A.M., showed the following: -Certified Nurse Aide (CNA) C and CNA E prepared to transfer the resident out of the bed and into his/her wheelchair; -The staff hung the catheter drainage bag on the cross bar of the mechanical lift in preparation of his/her transfer; -The drainage bag was approximately 12 inches above the level of the resident's bladder. Observations on 12/11/17 at 1:30 P.M., showed the following: -CNA C and CNA E prepared to transfer the resident from his/her wheelchair to the bed; -The resident's catheter drainage bag had been hung on the crossbar of the mechanical lift; -The catheter bag hung approximately 12 inches above the resident's bladder; -The catheter tubing had straw colored urine with thick sediment visible in the tubing; -The resident was transferred to the bed using the lift; -The resident had been incontinent of stool; -CNA E used a wet washcloth to cleanse the resident's perineal area, then used the same cloth to wipe the catheter tubing; -CNA C removed the resident's catheter drainage bag from the mechanical lift's cross bar and held it approximately 12 inches above the above the resident's bladder while CNA E prepared to empty the drainage bag; -CNA E removed the spigot from the sleeve on the drainage bag and unclamped the drain tube; -CNA E emptied the drainage bag into a urinal then tapped the spigot three times on the opening of the urinal (CNA E did not use an alcohol wipe on the spigot before reinserting into the sleeve of the drainage bag); -The resident's urine had a strong, foul-smelling odor with sediment visible. During an interview on 12/13/17 at 1:00 P.M., CNA C said the following information: -The resident complained of itching around the catheter about every time the staff performed catheter care; -He/she had not reported anything to the charge nurse about the resident's urine output or the resident's complaints of itching. 2. Record review of Resident # 14's annual MDS, dated [DATE], showed the following information: -The resident had an indwelling catheter at the time of the assessment; -[DIAGNOSES REDACTED]. -The resident had received antibiotics at the time of the assessment. Record review of the resident's physician's progress notes showed the following information: -On 06/14/17, the nurse practitioner noted the resident had cloudy, tea-colored drainage in the urinary drainage bag. The practitioner ordered lab studies and encourage the resident to drink more fluids; -On 06/21/17, the physician's nurse practitioner noted the resident's catheter had dark drainage. The resident's assessment included a current urinary tract infection requiring antibiotics. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -The resident had an indwelling catheter at the time of the assessment; -The resident had a urinary tract infection and had been on antibiotics. Record review of the resident's laboratory results showed the urine sample collected on 09/28/17, had the presence of E. Coli and Proteus Mirabilis; positive for a urinary tract infection. Record review of the resident's physician's progress note, dated 10/04/17, showed the resident had an acute urinary tract infection. The resident's urine culture was positive for E. Coli and Proteus Mirabilis bacteria. Observation on 12/11/17 at 11:45 A.M., showed the following: -CNA C and CNA F prepared to transfer the resident from the bed into the wheelchair using a mechanical lift; -The resident was able to stand and partially support his/her body weight; -CNA C placed the urinary collection bag on the floor under the resident; -CNA F lifted the drainage bag off the floor and clipped it to the resident's wheelchair seat; -CNA F removed the spigot from the sleeve of the drainage bag and wiped the spigot with an alcohol wipe, emptied the urine into a urinal then tapped the spigot against the urinal opening repeatedly; -The resident's urine was dark straw colored with a strong, foul-smelling odor. 3. During an interview on 12/13/17 at 1:00 P.M., CNA C said the following information: -When the staff are transferring a resident using a mechanical lift, the staff should hang the resident's catheter bag on the loop of the sling (a fabric sling with loops that attach to the mechanical lift for transferring a resident in or out of bed) or on the cross bar of the mechanical lift. (These two identified areas are above the level of the bladder, which would allow urine to flow back into the bladder creating a potential for infection); -He/she recalled an inservice in the recent past when the staff were taught how to clean a urinary catheter, but he/she did not recall any information about proper placement of the urine drainage bag; -He/she recalled the drainage bag should be kept low so it can drain; -He/she had reported to the charge nurse in the past when a resident had cloudy, bloody or strong smelling urine or if the resident had complained of pain. 4. During an interview on 12/13/17 at 1:22 P.M., CNA D said the following information: -He/she would hook the urine drainage bag onto the loop of the sling when transferring the resident with a mechanical lift; -He/she recalled an inservice on catheter care a few months ago; -He/she empties the urine drainage bag into a urinal and then closes the spigot before putting it back in to the sleeve; -He/she makes sure the spigot stays in the urinal when emptying the drainage bag; -He/she had never been instructed to wipe the spigot with an alcohol wipe before reinserting into the sleeve of the drainage bag; -He/she had never been instructed to not tap the spigot against the urinal when emptying the drainage bag; -He/she said the staff should clean the resident's urethra (opening in to the urinary tract) and the catheter tubing daily to prevent urinary tract infections; -The staff should use a wet washcloth to wipe the catheter tubing starting at the insertion site and wiping away from the resident's body; -He/she would report to the charge nurse if a resident could not urinate or if the resident had any redness or irritation at the catheter insertion site. He/she could not recall any additional concerns related to a resident with a catheter that she would report to the charge nurse; -He/she had not reported any concerns to the charge nurse in the last three days. 5. During an interview on 12/13/17 at 3:55 P.M., the Director of Nursing (DON) said the following information: -She had been doing quarterly random checks on the CNA's performance of proper perineal care, but had not done on random checks on the staff's ability to perform catheter care appropriately; -She expected the CNA's to perform catheter care every shift for the residents with a catheter, in addition to anytime the residents with a catheter had an incontinent episode; -The CNA staff should perform hand hygiene (washing hands with soap and water or using the alcohol based hand sanitizer), don gloves, and either use disposable wipes or wet washcloths with soap and water for cleaning the resident's urethra (opening of the urinary tract) and the catheter tubing; -The CNA should clean each side of the perineum (folds of skin on either side of the urinary outflow tract), using a new wipe or a fresh area of the washcloth with each swipe followed by using a new wipe or washcloth to wipe the catheter tubing starting at the insertion site and wiping away from the body; -The facility staff had identified a high incidence of urinary tract infections and had advised the staff to encourage residents to drink more fluids, to remove residents' briefs when the residents were placed in bed, and to provide perineal care (cleansing of the resident's urinary outflow tract) for all resident's that could not perform their own perineal care; -The facility educated the staff on perineal care and catheter care at the staff inservice (training) in May 2017; -The facility updated and educated the staff on the facility's updated perineal care policy in July 2017; -She had not tracked the incidence of catheter-related urinary tract infections; -She expected the CNA to empty a catheter drainage bag into a urinal then wipe off the inside and outside of the drainage bag spigot with an alcohol swab before reinserting the spigot into the spigot's sleeve; -The staff should never allow the end of the spigot to touch another surface; -She expects the staff to hang the drainage bag below the level of the bladder at all times; -The staff should never allow the catheter bag to touch the floor, even when the drainage bag is stored in a dignity bag (a cover used to protect the resident's dignity by disguising the catheter); -She expects the CNAs to report any unusual urine odor, any blood in the urine, cloudy urine, fever, or any resident's complaints of pain or burning to the charge nurse. 6. During an interview on 12/13/17 at 5:13 P.M., the facility's administrator said the following information: -She would expect the staff to position and maintain the resident's catheter bag below the level of the resident's bladder at all times, including when the staff used a mechanical lift to transfer the resident ; -She would expect the staff to use an alcohol wipe on the spigot after emptying the drainage bag and before reinserting the spigot back into the sleeve.

Based on observation, interview and record review, the facility failed to follow appropriate infection control practice when staff failed to glove prior to administering eye drops to two residents (Resident #27 and #34). A sample of 12 residents was selected in a facility with a census of 39. Record review of the Certified Medication Technician (CMT) Student Manual. produced by the Missouri Center for Career Education, revised April 2008, showed CMTs were instructed to out on gloves prior to administering eye drops. Record review of the facility's policy titled Instillation of Eye Medication, dated March 2015, showed direction for staff to glove when performing this task. 1. Record review of Resident # 34's December 2017 Physician order [REDACTED]. -A [DIAGNOSES REDACTED]. -An order, dated 10/25/17, for [MEDICATION NAME] (eye drops), one drop in each eye three times a day for dry eye syndrome. Observations on 12/8/17 at 10:56 A.M., showed CMT A prepared the resident's medications at the medication cart outside the resident's room. The CMT took oral medications and bottle of eye drops into resident's room. The CMT administered the resident's oral medication and then administered the [MEDICATION NAME] eye drops in each eye. (The CMT did not wear gloves to administer the eye drops.) 2. Record review of Resident #27's December 2017 POR showed the following: -A [DIAGNOSES REDACTED]. -An order, dated 11/22/16, for [MEDICATION NAME] acetate (a steroidal eye drop), one drop in left eye three times a day for [MEDICAL CONDITION]. Observations on 12/8/17 at 11:05 A.M., showed CMT A prepared the resident's medications at the medication cart outside the resident's room. The CMT carried the oral medications in a med cup and the [MEDICATION NAME] acetate eye drops into the resident's room. The CMT set the medication cup on the nightstand. The CMT administered one drop of the [MEDICATION NAME] acetate into the resident's left eye. (The CMT did not wear gloves to administer the eye drops.) 3. During an interview on 12/13/17 at 1:00 P.M., CMT A said gloves should be worn to administer eye medication and hands should be washed. 4. During an interview on 12/13/17 at 1:38 P.M. CMT B said staff should wear gloves to administer eye drops and wash their hands before and after administration. 5. During an interview on 12/13/17 at 3:55 P.M., the Director of Nursing (DON) said she would expect a CMT to wear gloves while administering eye drops and to wash his/her hands before and after administering eye drops. 6. During an interview on 12/13/17 at 4:15 P.M., the facility administrator said she would expect CMTs to wear gloves and wash their hands when administering the residents' eye drops.

Based on observation and interview, the facility failed to ensure all the pertinent State client advocacy groups were prominently posted with all the required information when the facility failed to post the state abuse and neglect telephone number and failed to post the contact information for Medicare. The facility census was 34. 1. Observations from 2/17/15 through 2/20/15, showed the facility did not display the state abuse and neglect telephone number and the contact information for Medicare in a prominent location for resident and visitors. During an interview on 2/20/15, at 11:22 A.M., Housekeeper C said the state abuse and neglect telephone number is on the back of the employee name badges and in the employee's break room. He/she was not aware of the abuse and neglect being posted anywhere for residents and visitors to see. During an interview and observation on 2/20/15, at 11:23 A.M., Certified Nursing Assistant (CNA) D said he/she thought the facility posted the state abuse and neglect telephone number by the dining room. The surveyor checked this location and the facility had not displayed the abuse and neglect telephone number there. The facility had not displayed the Medicare contact information in that location either. During observation and interview on 2/20/15, at 11:25 A.M., the administrator said the facility gives residents and the responsible parties the abuse and neglect telephone and Medicare information at admission with the admission packet. She said the facility posted abuse and neglect telephone number in the employee break room and put it on the back of the employees' name badges. She said the social worker has several numbers posted in her office as well. The administrator unlocked the social worker's office to show where the posted telephone numbers. The facility did not post the state abuse and neglect telephone number and Medicare numbers in the social worker's office. This was not a prominent location for all residents and visitors to see. During observation and interview on 2/20/15, at 11:50 A.M., the administrator said she had the state abuse and neglect and Medicare information posted in the resident dining room. The information was not in a prominent; was too high for residents in a wheelchair to see. The administrator said she would have the information posted in a more prominent location.

Based on observation, interview and record review, the facility failed to ensure staff maintained acceptable infection control measures when staff did not appropriately and thoroughly disinfect shared glucometers (a device used to measure blood glucose levels) while checking blood glucose levels for two residents on two separate occasions. (Residents #2 and #11). This deficient practice affected one (Resident #2) of 10 residents selected for review and one additional randomly selected resident (Resident #11). The facility's census was 34. Record review of the CC Guideline Infection Prevention during Blood Glucose Monitoring and Insulin Administration, last updated 3/23/2011, showed if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. Record review of the American Society of Consultant Pharmacists Summary of Glucometer Cleaning Guidelines dated February 2010, showed the following information: -If the manufacturer does not provide specific cleaning recommendations or as a conservative approach to infection control for glucometer with minimal cleaning requirements, facilities may want to consider cleaning glucometer with high-level disinfectants; -Be familiar with the amount of time the disinfectant solution is supposed to contact the equipment or how long active cleaning should be performed to ensure complete disinfection. For example, simply wiping equipment with a disinfectant-soaked swab (like an alcohol prep pad) may not be adequate. Record review of the Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2008, showed the following information: -High-level disinfectant: agent capable of killing bacterial spores when used in sufficient concentration under suitable conditions. It, therefore, is expected to kill all other microorganisms; -[MEDICATION NAME] alcohol and ethyl alcohol (the ingredient in alcohol prep pads) have been excluded as high-level disinfectants because of their inability to inactivate bacterial spores. During an interview on 02/20/15, at 11:00 A.M., the Director of Nursing said staff members must clean and disinfect the glucometer's with a Cavi-distinctive solution after each use. Record review of the manufacturer's instructions for the use of Cavi-distinctive solution wipes showed, contact surfaces (blood glucose meters) must remain wet with the solution for two minutes in order to disinfect equipment. 1. Observations on 02/18/15, showed the following: -At 11:32 A.M., Registered Nurse (RN) A did not disinfect the glucometer prior to obtaining Resident #11's blood glucose level. After obtaining the resident's blood glucose level, RN A disinfected the glucometer with Cavi-distinctive solution for approximately 10 seconds. LPN A did not keep the glucometer wet with the disinfecting solution for two minutes as instructed on the container of the Cavi-distinctive solution wipes. -At 11:40 A.M., RN A obtained Resident #2's blood glucose level. After obtaining the resident's blood glucose level, RN A disinfected the glucometer for 20 seconds with Cavi-distinctive solution. RN A did not keep the glucometer wet with the disinfecting solution for two minutes as instructed on the container of the Cavi-distinctive solution wipes. During an interview on 02/18/15, at 11:45 A.M., RN A was unaware the glucometer needed to remain wet for two minutes. Observations on 02/19/15 showed the following: -At 11:37 A.M., LPN B did not disinfect the glucometer prior to obtaining Resident #11's blood glucose level. After obtaining the resident's blood glucose level, LPN B disinfected the glucometer for approximately 10 seconds. LPN B did not keep the glucometer wet with the disinfecting solution for two minutes as instructed on the container of the Cavi-distinctive solution wipes. -At 11:44 A.M., LPN B obtained Resident #2's blood glucose level. After obtaining the resident's blood glucose level LPN B did not disinfected the glucometer with Cavi-distinctive solution. LPN B did not keep the glucometer wet with the disinfecting solution for two minutes as instructed on the container of the Cavi-distinctive solution wipes. During an interview on 02/20/15, at approximately 9:00 A.M., LPN B said he/she would wipe the glucometer with Cavi-distinctive solution after each use and let the machine sit for at least two minutes.

Based on observation, interview and record review, the facility failed to ensure direct care staff reported deterioration in skin condition for one resident (Resident #8). This deficient practice affected one of 10 residents selected for resident review in a facility with a census of 34. 1. Record review of Resident #8's medical chart showed the following information: -[DIAGNOSES REDACTED]. -Frequently incontinent of bowel and bladder; -Required staff assistance for activities of daily living (ADLs) including personal hygiene, bathing, transfers, repositioning, and mobility using a wheelchair; -At risk for pressure ulcers, but none present on admission. Observation on 2/19/15 at 10:52 A.M. showed CNA E and CNA F prepared to provide incontinent care to the resident. The CNAs removed the resident's covers, a pillow that was underneath the resident's legs, a soft blanket from between the knees, and a pillow propped behind his/her back to position the resident somewhat to the right. The CNAs unfastened the resident's incontinent brief and rolled it inward and tucked it between the resident's legs. As CNA E began to use wet wipes to clean the resident's groin areas, the resident said it was very "itchy" there. The CNAs held the skin of the abdomen and thighs apart, revealing a dark red line, approximately 10-12 centimeters long, to each groin area. The CNAs turned the resident to his/her right side to clean the coccyx and buttocks. An area to the right and several inches above the coccyx appeared as dark pink, with the skin peeled back. The area was approximately the size of a quarter. Both CNAs said the area had been red recently and they were supposed to apply a protective cream ([MEDICATION NAME]) to the skin after cleaning. The CNAs were not sure if the skin had been peeled before. CNA F proceeded with cleaning the resident's coccyx and buttocks, changed gloves and applied the [MEDICATION NAME] cream. The CNAs turned the resident onto his/her back and CNA E changed gloves to apply [MEDICATION NAME] cream to the groin areas at the resident's request. CNA E told the resident they would tell the charge nurse about the resident's skin. Record review of the resident's physician order [REDACTED]. Record review conducted on 2/20/15 at 10:42 A.M. of the resident's medical chart, for the four consecutive shifts from 2/19/15 at 10:52 A.M. to 2/20/15 at 10:42 A.M., showed no staff from any of the four shifts documented information in the nurse's notes regarding the resident's skin condition and did not document any new physician orders [REDACTED]. During an interview on 2/20/15 at 10:45 A.M., Registered Nurse (RN) B said no CNA or nurse from the current day shift or previous three shifts had reported to him/her any information on the resident regarding red lines to the groin areas or peeled skin to the coccyx or buttocks. Observation on 2/20/15 at 10:55 A.M. showed RN B and the Director of Nursing (DON) assessed the resident's coccyx, buttocks, and groin areas. After cleansing the coccyx and buttocks of [MEDICATION NAME], the DON measured a reddened area to the right buttock and said it was 1.5 centimeters (cm) wide by 1 cm long and was blanchable (blood flow returned quickly to the area when pressed with a finger and released). Assessment of the right and left groin areas showed red lines located where the edge of the brief came in contact with the skin, with the right line wider than on the previous day. The left groin showed peeled, raw skin and resultant open areas (uneven shapes) above and below the red line. The open area above the line was approximately 6-7 cm long and 3 cm wide. The open area below the line was approximately 4 cm long and 2.5 cm wide. The DON said the groin skin areas appeared to be cracked and thought the condition was moisture-related skin breakdown. During an interview on 2/20/15 at 10:55 A.M., the DON said the CNAs who noted a change in the resident's skin condition on 2/21/15 should have reported that information to the charge nurse. All CNAs should use the "STOP and WATCH" forms used by the facility to relay any relevant information to the charge nurse regarding a resident's condition. During an interview on 2/20/15 at 1:23 P.M., CNA F said the CNAs should report anything out of the ordinary regarding a resident to the charge nurse, using the facility form called "STOP and WATCH." The charge nurse can then treat the resident accordingly and make changes to the "Team Sheets" used by the CNAs as a guideline to the type of care needed by each resident. He/she said he/she forgot to report the resident's change in skin condition to the charge nurse and did not know if any other CNA had reported the condition.

Based on observations and interviews the facility failed to discard an expired insulin vial, for Resident #12; staff members were using the expired vial. The facility failed to ensure glucose control solution vials for residents' testing of blood glucose levels were not expired. The facility failed to ensure the additional back-up solutions were not expired. This deficient practice could affect the safety and potency of the insulin as well as the effectiveness of the glucose control solutions, potentially affecting the resident who received those insulin injections and the accuracy of glucose levels for all residents who required monitoring. The facility's census was 43. 1. According to the United States Pharmacopoeia Dispensing Information (USPDI) as well as the United States Food and Drug Administration (FDA), once opened, multiple dose vials must not be used after 28 days due to loss of potency and the risk of contamination. 2. Record review of the Resident #12's annual Minimum Data Set (MDS) a federally mandated assessment completed by facility staff dated, [DATE] showed the following information: -[DIAGNOSES REDACTED]. -Received an insulin injection seven out of the seven previous days. Record review of the resident's [DATE] physician's orders [REDACTED]. -Recent admission date of [DATE]; -[DIAGNOSES REDACTED]. -An order dated [DATE] for Novolin R, a regular insulin (regular insulin is a short-acting form of insulin) per sliding scale (parameters set for amount of administration based on blood glucose testing levels). -An order dated [DATE] for Novolin ,[DATE], a mixture of 70% intermediate-acting insulin and 30% short-acting insulin (regular), injection of 36 units subcutaneously every morning. -An order dated [DATE] for blood sugar checks twice daily. During observation and interview on [DATE] at 10:00 A.M., in the medication room located behind the nurse's station, showed the following: -A Novolin R 10 milliliter (ml) vial, regular insulin, for Resident #12, which staff dated with an opened date of [DATE]; -The Director of Nursing (DON) said the insulin vials are "good" for 28 days after they were opened. During an interview on [DATE] at 11:37 A.M. Licensed Practical Nurse (LPN) A, working as a charge nurse, said the following: -Staff dated the resident's insulin vials when they opened it; -Staff checked expirations dates as well as the opened dates for insulin to ensure they were not expired. 2. During observation and interview on [DATE] at 10:00 A.M., in the medication room located behind the nurses' station showed the following: -Victory glucose control solutions, both low and high values, in the portable carrying container staff used to transport from resident to resident. -The DON said the staff members were currently using the glucose control vials; - Both the low and the high control solutions showed staff labeled an open date of "[DATE]". -Both the low and the high control solutions showed an expiration date of November/2013. -Two unopened boxes in the cabinet drawer of both a low and a high control solution labeled with the manufacturer's expiration dates of August/2013. -The DON said the staff had the unopened glucose control boxes for "back up". During an interview on [DATE] at 11:37 A.M. LPN A, working as a charge nurse, said the following: -Staff dated glucose control vials when opened -Staff checked expirations dates as well as the opened dates for glucose controls to ensure they were not expired. -Staff kept the back-up glucose controls in the drawer in the medication room. During an interview on [DATE] at 12:45 P.M., the DON said the following: -She expected staff to check expiration dates for medication and glucose supplies "at minimum daily". -Staff should have dated the glucose control solutions when they opened the bottles. -She was not sure how long an opened glucose control solution was viable. -The facility pharmacy staff checked the medication room, which included the glucose control strips, on a monthly basis for expiration dates. Record review of a facility form titled "Expiration Dates" hung on a board in the medication room showed the following: -Insulin expired "one month" after opened. -See the manufacturer's container for the expiration date.

Based on observations, record review and interviews the facility failed to implement interventions to promote optimal food intake for one resident (Resident #4). The facility identified the resident at risk for continued weight loss and altered nutritional status. The facility administered mood-altering medications prior to meals after they had identified the resident's intake and nutritional status could possibly be improved by administering the mood altering medications after meals. The facility failed to properly engage and provide the needed assistance and encouragement to the resident during meals and when providing physician-ordered nutritional supplements in between meals. The resident was dependent on staff for extensive assistance with eating and experienced a significant weight loss of 10.4 pounds or 8.36% body weight in 30 days. 1. Record review of face sheet showed Resident #4 admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Record review of the September 2011 physician's order sheet (POS) showed the physician ordered [MEDICATION NAME] sprinkles (a mood altering medication) 250 milligrams (mg) by mouth three times daily. The order did not state to administer the medication after meals. Record review of the 2013 Mosby's 26th edition Drug reference book showed [MEDICATION NAME] showed the following: -Sprinkle cap contents on food; -Give with food or milk to decrease GI symptoms such as nausea and vomiting; Side effects listed include sedation, drowsiness, incoordination, depression, aggression, weakness and taste perversion. Record review of the August 2011 weekly weight sheet showed the resident had lost some weight and on 9/1/11 in the comments sections staff documented to administer the [MEDICATION NAME] after meals to reduce sedation at meal time. Record review of the October 2011 POS showed the resident received [MEDICATION NAME] sprinkles 250 mg by mouth twice daily. The order directed staff to give after eating so the resident would eat better Record review of July 2012 POS showed on 7/5/12 the physician decreased the [MEDICATION NAME] sprinkles to 125 milligrams by mouth three times a day. Then on 7/18/12, the physician decreased the order to 125 mg twice daily. The order directed staff to give after eating so the resident would eat better. During an interview on 1/10/13 at 3:45 P.M., the physician said the resident is sometimes delusional and has psychotic behaviors. The physician has tried variations in doses of the medications for mood stabilization. The reason for the medication to be given after meals is to prevent drowsiness. The physician said he/she did not originally order it that way, but maybe the nurses or dietitian recommended it. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/18/12, showed the following: -The resident scored a "3" on the BIMS, which is indicative of severe impairment of cognitive skills; -The resident had continuous inattention, was easily distracted or out of touch; -The resident had continuous disorganized thinking; -The resident had fluctuating altered level of consciousness; -The resident required extensive assistance of one for eating. Record review of the care plan, dated 11/26/12, showed the following: -The resident had [DIAGNOSES REDACTED]. -The resident had difficulty with daily decision-making secondary to impaired cognitive function related to dementia; -Set up the resident's food and allow him/her to attempt to eat without assistance, then feed him/her; -Monitor for changes in cognitive status related to [MEDICAL CONDITION] medications; -Potential for altered nutrition due to leaving 25% of food uneaten at meals and weight loss; -Provide snacks between meals; -Report weight losses of 5% or greater to physician. Record review of the care plan for weight loss, dated 2/01/11, showed the following: -On 9/14/, no year indicated, the facility wrote to give the [MEDICATION NAME] after meals; -On 12/15, no year indicated, the staff placed the resident at the feeding assist table area, and initiated super cereal three times a day. Record review of the December 2012 POS showed the following: -An order dated 7/18/12 for [MEDICATION NAME] Sprinkles 125 mg by mouth twice daily. The order directed staff to give after eating so the resident would eat better; -On 12/12/12, the physician increased the [MEDICATION NAME] order to three times daily; -The resident is to recieve hosue supplment (Magic cup)(a high calorie ice cream to assist with weight gain) twice daily between meals. Record review of the December 2012 weight flow sheet showed the following: -The resident had a beginning weight for the month of December of 124.4 pounds; -The second week the resident's weight dropped to 119 pounds; -The third and forth weeks the resident's weight was 115.5. Record review of the December 2012 treatment administration record (TAR) showed the resident was to receive house supplement twice daily between meals. The staff documented the resident had 0-5% intake of the house supplement during December. Record review of the January 2013 POS showed an order for [REDACTED]., 12:00 P.M. and 4:00 P.M. Give the medication after eating so the resident will eat better. The resident is to recieve house supplment (Magic cup)twice daily between meals. Record review of the January 2013 weight flow sheet showed the resident's weight the first week was 114. The staff documented this was a decreased in 8.36% in the last 30 days. Record review of the January 2013 treatment administration record (TAR) showed the resident was to receive house supplement twice daily between meals. The staff documented the resident had 0-5% intake of the house supplement in the month of January. Observation on 1/8/13 at 12:20 P.M. to 12:54 P.M. showed the resident in his/her wheelchair in the dining room with a bedside table in front him/her. The resident sat next to the table for residents who required assistance with eating. The square table had four residents sitting at it. The Restorative Aide A sat at the corner of the table with the resident at his/her back. Throughout the course of the meal, the resident slept with his/her head in his/her hand. When the restorative aide turned to give a bite, she would come from the resident's left side, out of the resident's sight, with the utensil of food at the resident's mouth. The resident was sleeping and the restorative aide startled the resident each time. The restorative aide would say something to the resident as the utensil moved towards the resident's mouth. The resident would react by pulling head back and putting his/her hand up and pushing the utensil away. The restorative aide would then turn back to the table with his/her back to the resident and the resident would fall back to sleep. The restorative aide failed to engage the resident in conversation or keep the resident's attention. During an interview on 1/9/13 at 10:30 A.M. LPN D said that the resident receives the house supplement from the restorative aide between meals. Observation on 1/9/13 at 11:28 A.M. showed CMT B gave the resident the 12:00 P.M. dose of [MEDICATION NAME] sprinkles in applesauce. Observation on 1/9/13 at 12:20 P.M. to 12:47 P.M. showed the resident in his/her wheelchair in the dining room with a bedside table in front him/her. Again, the resident sat next to the table for residents who required assistance with eating. Throughout the course of the meal the resident slept with his/her head in his/her hand. When the restorative aide turned to give a bite, she would come from the resident's left side, out of the resident's site, with the utensil of food at the resident's mouth. The resident was sleeping and the restorative aide startled the resident each time. The restorative aide would say something to the resident as the utensil moved towards the resident's mouth. The resident would react by pulling his/her head back and putting his/her hand up and pushing the utensil away. At times the resident would open his/her mouth for the bite, when the utensil of food would touch lips or tongue he/she would pull head back and swat at the restorative aide. The restorative aide would then turn back to the table with his/her back to the resident and the resident would fall back to sleep. The restorative aide failed to engage the resident in conversation or keep the residents attention. Observation on 1/9/13 at 2:20 P.M. showed CMT C passing afternoon snacks. CMT entered the resident's room with a magic cup in his/her hand. CMT C said the magic cup is the house supplement the resident receives between meals. The resident was sleeping. CMT opened the magic cup and woke the resident. CMT C said "let's take a bite of this". The resident said "no". The CMT said "Ok,That's Ok". The CMT said "you can refuse if you want to" and left the room. Observation on 1/9/13 at 4:55 P.M. to 5:50 P.M. showed the resident awake and alert in the dining room with the bedside table in front of him/her. NA E approached the assist table. NA E spoke to each resident and engaged them in a conversation. NA E turned and put his/her arm around the resident's back and spoke to him/her. The NA and the resident had a conversation about the day. The resident was alert and able to answer questions. The NA assisted the resident to eat and was able to get the resident to eat several bites without assistance. The NA made several trips back and forth around the table assisting all the residents. The NA engaged the resident in conversation during the meal and kept him/her alert and on task. At 5:36 P.M. CMT C gave the resident medication. During an interview on 1/9/13 at 5:57 P.M. CMT C said he/she gave the resident the [MEDICATION NAME] sprinkles during the meal service. The CMT said he/she always gives the medication during the meal service otherwise; the resident will refuse to take it. Observation and interview with the restorative aide on 1/10/13 showed the following: -At 9:05 A.M., the restorative aide said he/she only passes magic cup to the resident. The restorative aide said he/she did pass the house supplement on 1/9/13 in the afternoon but could not get the resident to take any of the magic-cup. The restorative aide said the CMT must have tried to pass the magic cup again after she failed to get the resident to take a bite; -At 9:35 A.M. the restorative aide obtained the magic cup from the snack cart in the hall. The restorative aide entered the resident's room with the magic cup. The restorative aide raised the resident's head and said "Can you take a few bites of this for me". The resident said "yes". The restorative aide gave a spoon full of the magic cup to the resident. As the spoon entered the resident's mouth, the resident pulled her head back and said "no". The restorative aide asked the resident to take a drink of water, the resident took the drink. The restorative aide offered another bite of the magic cup and the resident said "no". The restorative aide said "Ok, I guess no means no". The restorative aide lowered the resident's head and left the room; -At 9:40 A.M. the restorative aide said the resident has never been a good eater but you heard her say "No". I can usually get her to take a few bites then she starts refusing. Observation and interview on 1/10/12 at 11:34 A.M. showed the following: -CMT B in the hall outside the resident's room. CMT B said he/she was going to give the resident the [MEDICATION NAME] sprinkles. CMT B prepared and administered the [MEDICATION NAME] sprinkles; -CMT B said the resident's eyes were open so he/she was going ahead and giving the noon medications. CMT B said he/she usually gave the [MEDICATION NAME] sprinkles prior to lunch because he/she had better luck at that time. CMT B said he/she never gave the [MEDICATION NAME] sprinkles after lunch. During an interview on 1/10/13 at 2:30 P.M., LPN D said the following: -He/she expected the CMT to pass the [MEDICATION NAME] sprinkles during or after the meal service; -It is not acceptable to give the medication prior to meals; -When entered into the computer as three times a day the system automatically set the times as 8:00 A.M., 12:00 P.M. and 4:00 P.M. Staff can over ride the system to set the times desired. During an interview on 1/10/13 at 3:45 P.M., the physician said there were many contributing factors to the weight loss but with the increased drowsiness and lack of engagement during the meal, he/she could see the weight loss as being a problem. During an interview on 1/11/13 at 10:00 A.M. the Director of Nursing (DON) said the following: -All staff should monitor the residents for level of consciousness continuously. No staff members have brought to her attention about the resident being more drowsy than usual; -It is difficult to balance sleeping through the day and increased anxiety in the evening with the resident; -The facility moved the resident so the restorative aide could help him/her and give more interaction during the meal. The DON said he/she was hoping the restorative aide could be a perfect balance of cueing and assisting without being in the resident's face. The resident had been by the ice machine for meals and was not getting the level of attention he/she required; -The DON said he/she expected the CMT to give the [MEDICATION NAME] sprinkles after eating at least some of the meal. The CMTs have a one hour window to give the medication. The portion of the order that states to give after meals either came from a recommendation from the dietician or during the weight meeting; -The DON expects staff to awaken the resident and have some interaction with him/her to make the resident more alert. The staff should not be feeding the resident from out of the resident's line of sight.

Based on observation, interview and record review, the facility failed to ensure staff immediately report allegations of abuse perpetuated by one certified nurse aide (CNA B) towards one resident (Resident #9). The resident complained that CNA B "tried to hurt" him/her and talked to him/her "like a dog." The resident said, a few weeks ago, CNA B twisted his/her left knee . While repositioning the resident in bed, the CNA tended to "slam" him/her into the rail which possibly caused bruising to the resident's right arm. One night, when the resident repeatedly asked for pain medication, CNA B told the resident to leave the call light alone and moved the call light out of the resident's reach. Staff also failed to immediately notify the administrator when multiple staff were aware of the allegations, at least two weeks prior; failed to complete a thorough investigation of the allegations of abuse and failed to implement the steps, as outlined in the facility's policy, following an allegation of abuse in order to protect the resident from further incidences. The deficient practice had the potential to affect all residents of the facility. The facility's census was 51. Record review of the facility's Abuse Investigation and Reporting policy, revised 11/2005, showed the following information: -All incidents of alleged or suspected resident maltreatment including mistreatment, neglect, or abuse, and misappropriation of resident property must be reported immediately to the administrator or the administrator designee by a facility employee or immediate supervisor, who will report incidents as required by state law or regulation; -The administrator or the administrator designee will complete an immediate investigation of all alleged or actual incidences of abuse, neglect or misappropriation of property. The investigation should determine whether an incident occurred, to what extent the resident was mistreated, by whom, and the measures needed to protect residents from further incidents. If the resident is able to communicate, the administrator or the administrator designee shall document, in thorough detail, the resident's account of the incident, including a description of the perpetrator; -Identification and investigation of abuse, neglect, or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident; -The Director of Nursing (DON) is responsible for assessing the resident and shall document the findings, including negative findings, if helpful, in the resident's record. If a resident alleges abuse, the resident should be assessed for mood and behavior changes that may indicate the resident was abused, such as fear, isolation, depression, withdrawal or other new signs. Findings will be documented in the resident's record. 1. Record review of Resident #9's monthly nursing summary, 09/07/11 through 10/07/11, completed by facility staff on 10/07/11, showed the following information: -No short or long term memory problems; -Independent decision making ability; -Involved, easily interacts with others; -Happy, pleasant; -Anxious, at times; -Refuses care, at times, and staff were instructed to attempt cares at a later time. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, required to be completed by facility staff, dated 09/19/11, showed the following information: -Was a school teacher; -Cognitively intact; -Mild depression; -No behaviors; -Weighed 282 pounds; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Record review of the care plan, last updated 09/13/11, showed the following information: -The resident will, at times, refuse care; -If refusing care, try again later; -Attempt to redirect any negative behaviors; -Maximum assist of two staff with transfers, toileting and dressing; -Uses walker, with two staff assist, to the bathroom; -Turn every two hours when in bed; -Refuses to turn at night sometimes (staff wrote the intervention on the care plan but did not date when it was added). Record review of the monthly nursing summary, 10/07/11 through 11/07/11, completed by facility staff on 11/07/11, showed the following changes in behavior: -Unhappy, isolates self, at times -Stays alone, does not interact, at times; -Sad, at times; -No change in mood or behavior. During interview on 11/30/11, at 10:07 A.M., during initial tour of the facility, the assistant director of nursing (ADON) said the resident was interviewable and currently received restorative services. When asked about behaviors, the ADON only mentioned non-compliance with turning at night. The resident had pain, but received a scheduled pain medication and his/her pain was controlled. Observation and interview on 12/01/11, at 9:35 A.M., showed the resident sat in a wheelchair, in his/her room, reading the newspaper. -The resident confirmed he/she was a school teacher for a long time and was very strict; -While discussing the resident's pain, the resident said he/she did not think one of the night shift aides, Certified Nurse Aide (CNA) B, liked him/her because the aide tried to hurt him/her and talked to him/her "like a dog." When the resident began talking about the aide, he/she became tearful. -The resident said, a few weeks ago, CNA B twisted his/her left knee; the resident did not know why. -When CNA B repositioned him/her in bed, the CNA tended to slam him/her into the rail, and a few weeks ago he/she even had some bruises on his/her right arm. The resident said one of his/her tablemates (residents who sit at the same dining room table with the resident during meals), asked him/her if he/she fell . The resident said, "no" and asked why his/her tablemate asked. The tablemate said, "because you have bruises on your arm". The resident said he/she did not know he/she had bruises so when he/she finished eating, he/she looked in the mirror. The resident saw faint blue bruising on the outside of his/her right arm. -The resident said he/she used to have pressure sores (areas of damaged skin caused by staying in one position for too long) on his/her buttocks so the staff only will let him/her turn on his/her right side; the side that generally hurts the most. The resident thought CNA B wanted him/her to hurt because he/she would turn the resident off of his/her back onto his/her right side before two hours were up. When he/she is lying on his/her right side, the aide would wait longer than two hours to turn him/her onto his/her back. The resident said "I think (he/she) wants me to hurt." -One night the resident turned on his/her call light and when CNA B entered the room he/she said, in a "snotty tone", "what do you want?" The resident told the CNA he/she wanted a pain pill. About thirty minutes later, the resident turned on his/her call light, (he/she had still not received the requested pain pill) and when CNA B entered the room CNA B said, in a snotty and rude tone, are you still wanting a pain pill? The resident said, yes. CNA B told the resident the nurse was on the phone and would get to him/her when he/she could, then said, "Leave that call light alone!" The CNA moved the resident's call light out of reach. -The resident said CNA B purposely places the call light out of his/her reach. -Another night, the resident said he/she kept telling CNA B there were wrinkles in his/her sheets. CNA B said there were not any wrinkles and the resident did not know what he/she was talking about. The resident said he/she knew there were wrinkles; the resident knows his/her body. -The resident said there have been several instances such as those described. -The resident said he/she had reported CNA B's behavior to a few nurses, LPN C and another who he/she could not remember, and even mentioned it in resident council. The resident said he/she asked other residents present in the resident council meeting if any aides were rough when turning them. The resident said he/she was the only resident present who required assistance turning so no other residents had any problems. -The resident said another resident later said CNA B was awful to him/her. -The resident said he/she told LPN C that CNA B twisted his/her leg and when CNA B assisted the resident to turn, he/she pushed the resident into the rail. The resident said the nurse told him/her to report the above to the DON. The resident did not report to the DON because he/she did not want to cause trouble and did not want CNA B to find out he/she had said something. -The resident said he/she tries not to talk to CNA B so CNA B will not have the opportunity to talk to him/her like a dog. -The resident said, "That one individual has sure made me unhappy." Record review of a nurses' note, dated 10/28/11, at 8:30 P.M., showed the resident chose not to have the turn sheet underneath him/her while in bed because it rolled up underneath him/her and was uncomfortable. The nurse explained to the resident staff would not be able to turn him/her without the turn sheet but the resident still chose not to have it. Record review of a nurses' note, dated 11/26/11, at 3:45 A.M., showed the resident complained of pain, rated a ten (out of a total of ten) in both of his/her legs, with the left leg hurting more than the right leg, after staff turned him/her. During an interview conducted on 12/02/11, at 1:23 P.M., Resident #18 said he/she was one of Resident #9's tablemates. Resident #18 noticed bruises on Resident #9's arm and asked Resident #9 how he/she got the bruises. Resident #9 said a nurse or nurse aide (did not specify) came into his/her room and grabbed him/her. Resident #18 said staff has to assist Resident #9 with everything and it probably gets tiresome but they get paid to take care of us and there is no excuse. During an interview conducted on 12/02/11, at 1:27 P.M., Resident #19 said he/she was one of Resident #9's tablemates. He/she saw bruises on Resident #9. Resident # 9 said he/she was not sure where he/she got the bruises; he/she bumps into things Record review of the "new business" of the resident council notes, dated 11/09/11, and completed by facility staff, showed Resident #9 said the girls are being too rough when he/she is turned at night. They push the resident into the side rail and he/she cannot move his/her arm. During an interview conducted on 12/01/11, 1:26 P.M., the activity director (AD) said he/she just started acting as the activity director last month. The AD said he/she attends the resident council meetings and takes note of any concerns the residents have. The AD writes the concern on the resident council notes then copies the notes and gives them to the appropriate department head. If the concern was related to a nurses' aide, then the AD would give a copy of the notes to the Director of Nursing (DON). When the concern is resolved the department head gives the AD a copy of their resolution, often written on the copy of the resident council notes. The AD said the resident brought up in resident council that the staff was pushing him/her up against the side rail which caused the resident's arm to be positioned against the side rail. The AD said he/she gave the DON a copy of the notes and he/she thought that issue was taken care of. The resident has not said anything further about the incident. During an interview conducted on 12/01/11, at 3:49 P.M., the DON said the AD gave her a copy of the 11/09/11 resident council notes. The DON asked the resident which staff member was rough and the resident described CNA B. The DON said she came to the facility, during the night shift, she thought on 11/10/11, to talk to the night shift staff. She talked to CNA B who said he/she was trying to get along with the resident. The resident had complained about him/her (CNA B) before, therefore, he/she did not go into the resident's room by himself/herself. The DON said he/she did not remember the resident ever complaining about CNA B before. The DON said she talked with Nurse Aide (NA) I, briefly, and talked to the charge nurse, LPN F, at length, about the resident's complaint. Neither staff member had observed any problems between CNA B and the resident. However, the DON said she did not expect NA I to say anything because the night shift staff was "tight" and would cover for each other. The DON said although the night shift staff was close, she thought LPN F would report any problems with a staff members' job performance. The DON said the resident was noncompliant with cares, mostly turning, because turning was uncomfortable for the resident. He/she said the resident is large and "covers the bed." The DON thought the resident did not like CNA B because CNA B made him/her turn. After the DON talked with the staff, she waited outside the resident's door as staff, including CNA B, performed cares on the resident. The DON said CNA B was "good." After the staff left the resident's room the DON asked the resident if the care performed by the staff that just left the room was okay and the resident said, yes. The DON said she "was kind of hoping (the resident) would say no so (she) would know for sure (the resident) was making things up a little." The DON did not talk to any other staff related to the resident's concerns. Record review of the DON's copy of the 11/09/11 resident council notes, showed the DON documented on 11/09/11 she spoke with CNA B who said he/she was trying very hard to get along with the resident and he/she does not provide care alone so he/she will have a witness performing the resident's cares. The DON did not document other staff interviews or any other information related to the investigation of the allegation of abuse. During an interview conducted on 12/02/11, at 10:50 A.M., LPN F (night shift charge nurse) said the DON had not discussed, with him/her, any conflict between the resident and CNA B. During an interview conducted on 12/02/11, at 3:50 P.M., NA I (night shift CNA) said no one had talked to him/her about a conflict between CNA B and the resident. During an interview conducted on 12/01/11, at 4:35 P.M., the DON said she felt the problem regarding CNA B was resolved because the resident had not said anything else about it. The DON thought the resident "got it out of (his/her) system." During an interview conducted on 12/01/11, at 5:00 P.M., the administrator said she reviewed the 11/09/11 resident council notes and told the DON she needed to investigate the allegation. The administrator said the DON told her she talked with the resident, CNA B, the charge nurse and other CNAs who worked on the night shift. The administrator said the resident had some noncompliance on the night shift but during the day he/she was fine. She knew the resident had pain and was sure the pain had something to do with his/her noncompliance (not wanting to turn at night), that and he/she just does not want to. The administrator had faith in CNA B and CNA B was a good aide; he/she just states fact, is [MEDICATION NAME], and tells the resident he/she needs to turn. The administrator thought the resident's noncompliance caused the resident to say staff was too rough. Staff did not investigate the resident's allegation any further. The administrator said if this allegation was made by any other resident, she would have been "on top of it" and completed the investigation herself. During an interview conducted on 12/01/11, at 8:10 P.M., CNA B (night shift CNA) said he/she had known the resident a long time; the resident was the CNA's school teacher. He/she said all residents have people they get along with better than others. The CNA said one resident does not care for him/her because the resident does not like to turn or get out of bed. When the resident was admitted he/she had a lot of pressure sores so the CNA told the DON and the charge nurse the resident needed to turn. The CNA asks the resident if he/she wants to turn and if the resident refuses, the CNA tells the charge nurse. Usually the charge nurse is able to get the resident to turn. Every now and then the resident refuses to turn; he/she does not care for it and it probably causes him/her pain. CNA B said if you touch the resident's legs he/she says it hurts. The resident had not specifically told the CNA he/she twisted his/her knee, but in order to turn the resident; you have to raise his/her leg straight up. The CNA said the resident had complained about him/her to the charge nurse and said CNA B was making him/her turn. Because the resident complained, the CNA chose to not care for the resident alone. CNA B said he/she knew of at least one time (besides the statement on the resident council notes) the resident had complained about him/her, LPN F was in the room. The resident complained CNA B made him/her turn. The CNA said the DON did talk to him/her about both complaints. During an interview conducted on 12/02/11, at 11:30 A.M., LPN G (night shift charge nurse) said he/she had seen CNA B enter the resident's room without another staff member. During an interview conducted on 12/01/11, at 6:33 P.M., LPN C (evening shift charge nurse) said if the facility had a possible problem that residents were not treated right, the facility has two staff members go into that resident's room together so there is a witness to what is being done. If a resident told the LPN an aide was being too rough, he/she would talk to the resident and tell the resident to report the problem. The LPN said he/she would report an allegation of abuse the next day. LPN C said a few weeks ago the resident told him/her CNA B talked to him/her hatefully, and then the resident started to cry. The LPN told the resident to report the CNAs behavior to the DON. The LPN said he/she should have reported what the resident said himself/herself, but did not. Record review of the care plan, last updated 12/02/11, showed the following information: -The resident is easily brought to tears; -Will have quicker resolution of tears and less episodes of tearfulness; -When the resident is tearful, stop and listen to what he/she has to say; -Offer support; -Resolve the issue (take steps to resolve issues) when possible such as pain medications; -Encourage the resident to verbalize any concerns/problems with staff. During an interview conducted on 12/02/11, at 10:50 A.M., LPN F (night shift charge nurse) said the resident is reluctant to turn at night and complains of pain in his/her legs. The resident could feel a pea under his/her sheets but staff are good at ensuring the resident's sheets are not wrinkled. The LPN said the resident is a larger person and the bed is narrow. Staff place pillows near the right side rail so the resident does not hit his/her arm on the side rail. LPN F said it is difficult to have different staff care for the resident at night because we only have two aides and a nurse at the facility. During an interview conducted on 12/02/11, at 11:30 A.M., LPN G (night shift charge nurse) said the resident had no behaviors such as making things up. The LPN was not aware of any concerns regarding staff and the resident. The LPN had worked with CNA B. CNA B is nice but kind of loud and has his/her own opinions; CNA B is very direct with the resident. When CNA B is turning the resident in bed, he/she grunts and groans because the resident is large and CNA B is small. The resident may take offense to CNA B's grunts and groans. During an interview conducted on 12/02/11, at 1:37 P.M., CNA M said he/she had not witnessed any problems between staff and residents. The CNA had worked with CNA B and said CNA B was "a little different." CNA B is opinionated and a "know-it-all." CNA B is the team leader but CNA M does not think CNA B acts this way just because he/she is the team leader. During an interview conducted on 12/02/11, at 2:30 P.M., CNA H (night shift CNA) said he/she had not seen any personality conflicts between staff and residents. If CNA H had been off a few days, the resident tells the CNA he/she is glad he/she is back. The resident said some of the other girls are not as patient or take time with him/her. CNA H said a while back, do not remember specifically when, the resident told the CNA that CNA B spoke hateful to him/her. CNA H did not report what the resident told him/her to the charge nurse or administrative staff. CNA H said CNA B did not like the resident because the resident was a mean school teacher. He/she knew this because CNA B told CNA H. He/she had been in the room with CNA B a few times and during those times CNA B really did not have a lot to say to the resident. CNA H usually took care of the resident, when he/she worked, because CNA B did not like the resident. The CNA said when the resident does not want to turn CNA B has appeared angry and aggravated at the resident. CNA B's aggravation is not shown by words but by his/her body language. During an interview conducted on 12/02/11, at 10:00 A.M., the administrator said she talked with the resident and he/she gave the same information to the administrator as the resident did in his/her interview. The administrator said she was disappointed in her DON for not documenting the investigation. The administrator assumed the DON completed a full investigation of the allegation. The administrator reviewed the bath sheets, which would indicate if staff found bruising on the resident, from 11/03-12/1/11 and found no documentation the resident had any bruising. The administrator said the resident was CNA B's school teacher and although CNA B had no problems with him/her (the resident) during school, the resident had a lot of issues concerning CNA B's little sister which caused his/her mother to be at the school a lot. During an interview conducted on 12/02/11, at 12:40 P.M., the physician said other staff had told him the resident was a school teacher and he/she terrorized the kids. The physician said the facility could have done a better investigation. Refer to Complaint number MO

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 12/21/11. Based on interviews, observations and record review completed during the onsite revisit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility had provided in-service training on how to assess pain, use of a numeric pain scale (0-10), identification of non-verbal behaviors related to pain, and pain in dementia residents. The facility in-serviced the staff regarding proper pain related documentation, the need to reassess the resident's pain levels following an intervention and how to document the interventions effect. The facility has nursing staff assess each resident's pain level during each shift and document the results on the resident's MAR. The DON audits the residents pain documentation and interventions weekly. Record review of four resident charts showed staff consistently assessed, monitored and treated resident's identified with pain. One resident complained of severe pain during a wound care treatment. A 45 day revisit will be completed to ensure staff continue to assess, monitor, and treat residents identified with pain. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State Law (Section 198.026.1 RSMo) requiring that prompt remedial action to be taken to address Class I violation.