Every finding on record at Laurie Care Center

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received ground and pureed diets. The facility census was 41. 1. Review of the facility's Kitchen Weights and Measures policy, revised April 2007, showed food services staff will be trained in proper use of cooking and serving measurements to maintain portion control. Review showed serving utensils used will be consistent with choice of metric or U.S. measure used. Review of the facility's Standardized Recipes policy, revised April 2007, showed standardized recipes shall be developed and used in the preparation of foods. 2. Review of the facility's recipe for ground white chicken chili showed the recipe directed staff to serve eight ounce portions. Observation on 04/23/25 at 11:30 A.M., showed [NAME] G served three residents six ounces of white chicken chili, which was two ounces less than the directed amount. 3. Review of the facility's pureed cornbread/margarine recipe showed the recipe directed staff to prepare four servings by adding four servings of cornbread, three-fourths cup of milk, and one tablespoon plus one teaspoon of margarine. Review showed the recipe directed staff to serve one #10 (3.2 ounces) scoop. Observation on 04/23/25 at 11:48 A.M., showed [NAME] G add five servings of cornbread and an unmeasured amount of milk to a food processor. [NAME] G pureed the cornbread and divided it into three small dessert bowls, which was more than the directed serving size. Observation showed the dessert bowls were placed on the steam table and were served to three residents. Observation showed the recipe set on the prep counter while [NAME] G prepared the cornbread. During an interview on 04/23/25 at 11:43 A.M., [NAME] G said he/she served the ground chili using a six ounce ladle because he/she could not find another eight ounce ladle. [NAME] G said he/she served one ladle plus a little more to make eight ounces. [NAME] G said he/she usually follows the recipes but did not know why he/she didn't follow it today. During an interview on 04/24/25 at 1:35 P.M., the Dietary Manager (DM) said he/she was responsible for ensuring staff were trained on kitchen policies and procedures to include recipes and portion sizes. The DM said all staff preparing meals were responsible for following recipes to include serving sizes when preparing and serving food. The DM said he/she was not aware staff were not following recipes and providing directed portion sizes. The DM said there were plenty of serving utensils available in the kitchen.

45564 Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff also failed to properly wash dishes to prevent cross-contamination and the growth of foodborne pathogens. Facility staff failed to maintain an air gap in one ice machine drain. These failures have the potential to affect all residents. The facility census was 41. 1. Review of the facility's Refrigerators and Freezer policy dated, [DATE], showed: -Information regarding acceptable storage periods for perishable foods are kept in the supervisor's office. A condensed version is posted by each refrigerator and freezer for reference; -All food is appropriately dated to ensure proper rotation by expiration dates; -Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened foods are observed and use by dates are indicated once food is open; -Supervisors are responsible for ensuring food items in the refrigerators and freezers are not past the use by or expiration dates; -Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. Review of the facility's Food Receiving and Storage policy, dated [DATE], showed: -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -All food items to be kept in the refrigerator at the nurse station should be labeled with the use by date; -Beverages must be dated when opened and discarded after twenty-four hours; -Partially eaten food may not be kept in the refrigerator; -Other open containers must be dated and sealed or covered during storage. Observation on [DATE] at 1:06 P.M., showed in the refrigerator on the secured unit contained: -One container of fruit punch dated ,d+[DATE]-,d+[DATE]; -One container of orange juice dated ,d+[DATE]-,d+[DATE]; -One container of Cranberry juice dated ,d+[DATE]-,d+[DATE]; -Several single serve plastic cups with what appears to be different flavors of jello and whipped cream on top of a plastic tray, undated and unlabeled; -An aluminum cake pan half filled with an undated and unlabeled and uncovered product that appears like a cheesecake or other type of cake; -Several plastic small containers of an unknown substance dated ,d+[DATE]; -An undated and unlabeled plastic zipperseal bag with what appears to be slices of oranges; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag. Observation on [DATE] at 08:38 A.M., showed inside the refrigerator on the secured unit contained: -One container of fruit punch dated ,d+[DATE]-,d+[DATE]; -One container of orange juice dated ,d+[DATE]-,d+[DATE]; -One container of cranberry juice dated ,d+[DATE]-,d+[DATE]; -Several single serve plastic cups with what appears to be different flavors of jello and whipped cream on top of a plastic tray, undated and unlabeled; -An aluminum cake pan half filled with an undated and unlabeled and uncovered product that appears like a cheesecake or other type of cake; -Several plastic small containers of an unknown substance dated ,d+[DATE]; -An undated and unlabeled plastic zipperseal bag with what appears to be slices of oranges; -The crisper with a plastic bag that contained a plastic container with a lid that was undated and unlabeled that was stuck to the bottom of the crisper; -Two undated/unlabeled containers of a brown fluid; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag. Observation on [DATE] at 08:20 A.M., showed inside the refrigerator on the secured unit contained: -One container of orange juice dated ,d+[DATE]-,d+[DATE]; -One container of Cranberry juice dated ,d+[DATE]-,d+[DATE]; -Several plastic small containers of an unknown substance dated ,d+[DATE]; -The crisper with a plastic bag that contained a plastic container with a lid that was undated and unlabeled that was stuck to the bottom of the crisper; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag and a plastic bag with what appears to be waffles dated ,d+[DATE]. Observation on [DATE] at 02:35 P.M., showed inside the refrigerator on the secured unit contained: -Two containers of cranberry juice dated ,d+[DATE]-,d+[DATE]; -Several plastic small containers of an unknown substance dated ,d+[DATE]; -The crisper with a plastic bag that contained a plastic container with a lid that was undated and unlabeled that was stuck to the bottom of the crisper; -The freezer contained two plastic containers with lids inside undated and unlabeled plastic bag and a plastic bag with what appears to be waffles dated ,d+[DATE]. During an interview on [DATE] at 02:35 P.M., Certified Nurse Aide (CNA) D said he/she is not sure who cleans the refrigerator but will if he/she notices it needs it. He/She said the staff that put food/fluids into he refrigerator are the ones who need to date or label the items so staff know what it is. He/She said he/she is not sure how long the food is good once it is opened and would still use something such as juice if it was dated ,d+[DATE]. During an interview on [DATE] at 08:52 A.M., CNA E said the only thing he/she does with the refrigerators is get items for the residents and is not sure who is responsible to clean it. He/She said the kitchen staff come down a couple times a week and replaces items and thinks the numbers on the food/fluids are dates but not really sure. He/She said he/she does not track how long items are good for since that is the kitchens job. During an interview on [DATE] at 08:55 A.M., the Dietary Manager (DM) said it has been a debate who is responsible for the refrigerator on the secured unit but believes it fell on dietary. He/She is not sure when it was last cleansed and not sure how often it should be cleansed. Food and fluids should be labeled and dated to ensure food safety and should not use the items after the dates on the food/fluids since that means they are expired and no longer good. He/She said he/she does not do anything with the food or fluids in the refrigerator but thinks there should not be anything in there except a meal for a resident who did not come down right away or some snacks or juice. He/She was not aware of any food or fluids undated or unlabeled in that refrigerator. During an interview on [DATE] at 12:13 P.M., the Director of Nursing said dietary is responsible for dating, labeling and cleaning the refrigerator on the secured unit. He/She said his/her staff is not educated on expiration dates and would expect the kitchen to pull expired food and fluids and if nursing would give out expired foods the resident could get sick. He/She was not aware of any expired food in the refrigerator. During an interview on [DATE] at 12:49 P.M., the administrator said dietary is responsible to check the dates and label the foods and fluids in the refrigerator and would expect any staff clean up any mess in the refrigerators. He/She is not aware of any issues with undated or unlabeled foods in the secured unit refrigerator. The Administrator said the dates indicate a used by date and if the food/fluids are used beyond those dates, it could make the residents sick. 2. Review of the facility's Food Preparation and Service policy, revised [DATE], showed food preparation staff adhere to proper hand hygiene and sanitary practices to prevent the spread of foodborne illness. Review showed food and nutrition services staff were directed to wash hands before serving food, after collecting soiled plates or food waste prior to handling food trays. Review showed gloves are single use items and are discarded after each use. Observation on [DATE] at 12:07 P.M., showed [NAME] G served residents during the noon meal. Observation showed [NAME] G left the serving line, opened the refrigerator door and removed a package of sliced cheese with gloved hands. [NAME] G placed slices of cheese on bread which was on the grill. [NAME] G removed a paper ticket from the meal ticket printer, used a ladle to serve chili and used a gloved hand to add salad to a bowl which was served to a resident. Observation showed [NAME] G used gloved hands to place a bowl of soup in the microwave and removed gloves. [NAME] G then donned new gloves and did not wash his/her hands before using his/her gloved hands to serve another resident salad. Observation on [DATE] at 12:23 P.M., showed [NAME] H used gloved hands to fill three bowls with lettuce and cut tomato which were placed on the salads. [NAME] H rubbed his/her nose with back of his/her gloved hand and cut additional tomatoes which were added to the salads. [NAME] H opened the refrigerator door with his/her gloved hand, removed a bag of shredded cheese and used his/her gloved hand to add cheese to the salads. [NAME] H did not wash his/her hands or change gloves after rubbing his/her nose or touching the refrigerator door handle. Observation on [DATE] at 12:46 P.M., showed [NAME] H opened the refrigerator with gloved hands, remove hamburger patties which were placed on the grill. [NAME] I used gloved hands to add onion to grill and did not wash his/her hands. [NAME] H washed his/her hands, turned the faucet off with wet hands, dried his/her hands and donned gloves. [NAME] H removed his/her right glove, went in the walk in the cooler and retrieved a package of turkey. [NAME] H came out of the cooler and donned the same glove on his/her right hand, grabbed a knife by the blade and cut open the turkey packaging. [NAME] H used his/her gloved hand to remove bread from a bag and did not wash his/her hands. Observation on [DATE] at 12:21 P.M., showed Dietary Aide (DA) I precleaned dirty dishes and placed them on a rack, loaded the dish machine, pulled a rack from the clean side, loaded more dishes to a dirty rack, pulled a clean rack out of the machine, advanced another dirty rack, then removed clean items and placed on drying racks. Observation showed DA I did not wash his/her hands before handling clean kitchen wares. During an interview on [DATE] at 12:30 P.M., DA I said he/she should wash hands when going from dirty to clean, but he/she sanitized hands by submerging them in the sanitizer sink. DA I said he/she did not use running water to wash his/her hands. During an interview on [DATE] at 1:35 P.M., the Dietary Manager (DM) said staff should wash hands when entering the kitchen, after completing dirty tasks, and before and after donning gloves. The DM said staff should turn off the faucet with a paper towel after washing hands. 3. Observation on [DATE] at 3:07 P.M., showed a placard on the dish machine indicated minimum wash and rinse temperatures of 120 degrees Fahrenheit (F). Observation showed an operating instruction sign posted in the dish washing area instructed staff to report to supervisor if machine temperature was lower than 120 degrees F or higher than 160 degrees F. Observation on [DATE] at 3:00 P.M., showed the dish machine maximum temperature reached was 102 degrees F as indicated on the machine thermometer. Observation on [DATE] at 3:05 P.M., showed the maximum temperature was 113 degrees F when checked with a calibrated digital thermometer. Observation on [DATE] at 12:37 P.M., during a dish machine test load showed the maximum water temperature, using a calibrated digital thermometer, was 100 degrees F. During an interview on [DATE] at 3:05 P.M., DA J said the dish machine temperature was usually 100 to 110 degrees F. DA J said the DM told him/her the machine temperature had to be less than 120 degrees F to prevent chlorine breakdown. During an interview on [DATE] at 12:35 P.M., DA I said staff checked the dish machine water temperature before use, but he/she had not checked it yet. DA I said the water temperature should be between 90 and 100 degrees F. During an interview on [DATE] at 1:35 P.M., the Dietary Manager (DM) said he/she believed the dish machine water temperature should be less than 120 degrees Fahrenheit (F). The DM said he/she did not know the machine instructions indicated a minimum water temperature of 120 degrees F. During an interview on [DATE] at 12:20 P.M., the maintenance director said the dish machine water temperature should be 150 degrees F for the wash cycle and 180 degrees F for the rinse cycle. The maintenance director said the dish machine was installed in the past three months so he/she assumed it was working correctly. 4. Observation on [DATE] at 2:45 P.M., showed the end of the ice machine drain was connected to a section of clear plastic tubing which entered a curved white plastic elbow which was connected to the floor drain. Observation showed there was not a gap between the end of the ice machine drain and the floor drain. During an interview on [DATE] at 2:46 P.M., the DM said he/she thought the air gap was taken care of after last survey. The DM said the ice machine was moved some time ago and he/she did not look at the drain after it was moved. During an interview on [DATE] at 12:20 P.M., the maintenance director said he/she was not familiar with the required ice machine drain air gap. During an interview on [DATE] at 3:15 P.M., the administrator said the DM was responsible for traning kitchen staff and ensuring they followed proper hygiene procedures. The administrator said staff should wash hands before touching ready to eat foods, before handling clean dishes, before donning new gloves and after completing a dirty task or touching anything that may be considered dirty. The administrator said staff should turn off the water with a paper towel after washing hands. The administrator said he/she was not sure of the dish machine operating temperature but he/she could look at the machine and find out. The administrator said he/she expected staff to follow the dish machine operating instructions. The administrator said he/she was not aware the dish machine was not running at the proper temperature.The administrator said he/she was of aware of the required ice machine air gap. The administrator said he/she did not know the air gap was missing.

Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff did not complete neurological assessments after unwitnessed falls for seven residents (Resident #13, #19, #21, #23, #28, #35 and #38) of seven sampled residents. The facility census was 41. 1. Review of the facility's policy titled, Assessing Falls, revised 02/24, showed staff are directed as follows: -If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to resident; -Perform neuro checks if indicated: -Resident states head was struck during fall; -If any signs or symptoms present that may indicate a head injury such as pain, bleeding, changes in mental status, or body language indicators. Review of the facility's Post Fall 72-Hour Monitoring Report, showed staff are directed to: -Complete this assessment at the following intervals for follow up for all falls. -A fall that is unwitnessed, or in which the head is struck, requires neurological checks; -Initial assessment, followed by every 15 minutes for one hour, every 30 minutes for two hours, every one hour for two hours and every shift for 72 hours. 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/16/25, showed staff assessed the resident as: -Severe cognitive impairment; -Two or more falls without injury since last MDS; -Dependent of staff for all ADL Cares; -Diagnosis of Dementia. Review of the resident's electronic fall event report, dated 3/07/25, showed staff documented the resident had an unwitnessed fall. The resident was found on the floor on the fall mat on his/her knees leaning over the bed. Review of the resident's electronic fall event report, dated 3/10/25, showed the resident had an unwitnessed fall when staff reported the resident on the floor. Review of the resident's electronic fall event report, dated 4/03/25, showed the resident had an unwitnessed fall when the resident found on the floor mat next to bed. Review of the resident's electronic fall event report, dated 4/11/25, showed the resident had an unwitnessed fall. The resident was found on his/her knees on the fall mat leaning over the bed. Upon nurse arrival, resident was on his back on the floor mat. Review of the resident's Electronic Medical Record (EMR) dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 03/07/25, 03/10/25, 04/03/25, and 04/11/25. 3. Review of Resident #19's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -History of falls one month prior to admission and two to six months prior to admission; -Diagnosis of Atrial fibrillation (irregular heartbeat) and dementia. Review of the resident's electronic fall event report, dated 02/08/25, 02/17/25, 02/24/25, 02/25/25, 03/13/25 and 03/28/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's EMR dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 02/08/25, 02/17/25, 02/24/25, 02/25/25, 03/13/25, or 03/28/25. During an interview on 04/23/25 at 12:13 PM, the Director of Nursing (DON) said he/she could not find documented neurological checks for this resident. 4. Review of Resident #21's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Had two or more non-injury fall since admission; -Had one fall with injury (such as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain pain) since admission. Review of the resident's electronic fall event report, dated 03/22/25 at 7:03 P.M., showed staff documented the resident had an unwitnessed fall. The resident was found on the foot pedals of the wheelchair, it was leaning to the front, and almost turned over. Review of the resident's electronic fall event report, dated 03/23/25 at 3:50 P.M., showed staff documented the resident had a witnessed fall. Staff documented the resident's roommate came out of room yelling for help, Licensed Practical Nurse (LPN) to room to find resident of floor on fall mat. Review of the resident's electronic fall event report, dated 04/03/25 at 1:15 A.M., showed staff documented the resident had an unwitnessed fall. Staff found resident on the fall mat in the floor next to his/her bed with their back against the bed. Staff documented from his/her position, it was not likely that he/she hit head and resident denied hitting their head. Review of the resident's EMR dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 03/22/25, 03/23/25, and 04/03/25. 5. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Two or more falls without injury and one fall with injury since last MDS; -Diagnosis of Traumatic brain injury. Review of the resident's electronic fall event report, dated 01/04/25, showed the resident had an unwitnessed fall when the resident slipped out of bed onto his/her knees. Review of the resident's electronic fall event report, dated 01/16/25, showed the resident had an unwitnessed fall when the resident was found on his/her side in the floor next to bed with his/her head at the opposite end of the bed. Review of the resident's fall event report, dated 02/12/25, showed the resident had an unwitnessed fall. Review of the resident's EMR, dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/04/25, 01/16/25, and 02/12/25. 6. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Two or more falls since prior assessment. -Diagnosis of dementia. Review of the resident's electronic fall event report, dated 02/07/25, 03/02/25, and 03/19/25, showed staff documented the resident had an unwitnessed fall. Review of the resident's EMR, dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 02/07/25, 03/02/25, or 03/19/25. During an interview on 04/23/25 at 12:13 P.M., the DON said he/she could not provide documentation for neurological exams for the falls that occurred on 02/07/25, 03/02/25, or 03/19/25. 7. Review of Resident #35's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Had two or more non-injury falls since admission; -Had two or more falls with injury (such as skin tears, abrasions, lacerations, superficial bruises) since admission. Review of the resident's electronic fall event report, dated 01/23/25, showed staff documented the resident had an unwitnessed fall. The resident found sitting on the floor in his/her bedroom between the bed and his/her wheelchair with his/her back against the wheelchair. Review of the resident's electronic fall event report, dated 03/01/25, showed staff documented the resident had an unwitnessed fall. The resident on the floor in his/her bathroom and said he/she did not hit his/her head. Review of the resident's electronic fall event report, dated 03/07/25, showed staff documented the resident had an unwitnessed fall. The resident on the floor in his/her bathroom. Review of the resident's electronic fall event report, dated 04/18/25, showed staff documented the resident had an unwitnessed fall. The resident found on the floor of his/her bedroom in front of his/her bed. Review of the resident's electronic fall event report, dated 04/22/25, showed staff documented the resident had an unwitnessed fall. The resident found on the floor in his/her bathroom. Review of the resident's EMR, dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/23/25, 03/01/25, 03/07/25, 04/18/25, and 04/22/25. During an interview on 04/24/25 at 12:00 P.M., LPN C said the resident could tell you if he/she hit his/her head but given his/her cognitive ability, the nurse should complete neurological checks on the resident if he/she had an unwitnessed fall. During an interview on 04/23/25 at 1:35 P.M., the DON said staff are still expected to document neurological checks on paper for up to 72 hours after some unwitnessed falls, but staff have not had the need to document neurological checks for the resident recently. 8. Review of Resident #38's Significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Had two or more non-injury fall since admission; -Had one fall with injury (such as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain pain) since admission. Review of the resident's electronic fall event report, dated 01/13/25 at 10:42 A.M., showed staff documented the resident had an unwitnessed fall. Nurse called to memory care unit, resident was found sitting on the floor in the dining room while staff was in shower with another resident. Review of the resident's electronic fall event report, dated 02/24/25 at 11:45 P.M., showed staff documented the resident had a witnessed fall. Staff reported the resident on floor. Resident fell out of bed onto floor. Review of the resident's electronic fall event report, dated 03/28/25 at 7:55 P.M., showed staff documented the resident had an unwitnessed fall. Staff found the resident sitting in the floor beside her bed, resident had a small indentation on his/ her right foot. Review of the resident's EMR dated 01/01/25 through 04/24/25, showed the record did not contain documentation staff completed the neurological checks after the resident's unwitnessed fall on 01/13/25, 02/24/25, and 03/28/25. 9. During an interview on 04/24/25 at 11:52 A.M., LPN C said when a resident falls the nurse is to assess if the resident hit their head. He/She said neurological checks are started when there is an indication that the resident hit their head. He/She said indications like a hematoma, small bruise, or if they are in a position that looks like they hit their head. He/She said if resident is sitting on their buttock upon arrival, they may have not hit their head, but said that he/she really doesn't know for sure if they did or not. He/She said if a resident is not cognitive and able to tell staff if they hit their head then the nurse assesses the position that the resident is in upon arrival. He/She said that he/she questions him/herself a lot about starting neuros because a resident can change positions at any time. He/She said if he/she is unsure then he/she should go ahead and start neurological checks. He/She said if there is a roommate, and they are alert that it would be okay to ask them if resident hit their head during fall plus based on nursing assessment. He/She said they use the post fall 72-hour monitoring report paper form when they do neurological checks. During an interview on 4/24/25 at 12:20 P.M., the DON said the nurse is to do a body assessment after a fall. He/She said if a fall is unwitnessed, then the nurse can ask the resident questions about hitting their head during the fall or if there is an indication that the resident hit their head then neurological checks should be started. He/She said if the resident is not cognitive the nurse should do a more physical assessment to determine if the resident hit their head. He/She said if there is no indication that the resident hit their head then a neurological check does not have to be done. He/She said the post fall 72-hour monitoring report form was not created by the facility and it does not follow the facility policy, but they do use the form to complete their neurological checks. The DON confirmed that a confused resident could change their position after a fall before the nurse arrived to assess, which means staff might not know if resident hit their head or not. The DON said he/she does not 100% agree with the facility policy, but it does state that neurological checks are not needed for unwitnessed falls unless there is indication that resident hit his/her head. During an interview on 4/24/25 at 12:55 P.M., the administrator said nurses are to do a full body assessment after a fall. She said if a fall is unwitnessed and there is an indication that resident hit their head or if the resident says they hit their head, then neurological checks should be started. She said indications that a resident may have hit their head could be a wound, physical appearance, or the position of their body. She said it is possible that non-cognitive resident could changed positions before staff arrived to assess them. She said she relies on the nurse assessment and if they believe that neurological checks should be started. The administrator said staff should not depend on another residents witness of the fall to determine if a resident hit their head. The administrator said if there is not a neurological form for a fall then it was not done. She said she thinks it's a good practice that unwitnessed falls have neurological checks completed. 39644 43327 Surveyor: [NAME], [NAME] 50422

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three (Resident #4, #19, and #21) out of three sampled residents. The facility's census was 41. 1. Review of the facility's Bed Hold/Retention Policy, undated, showed the record did not direct staff to provide a bed hold notification, explains the duration of bed-hold, if any, and the reserve bed payment policy. 2. Review of Resident #4's medical record showed the resident discharged from the facility to the hospital on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 3. Review of Resident #19's medical record showed the resident discharged from the facility on 12/31/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 4. Review of Resident #21's medical record showed the resident discharged from the facility on 03/15/25 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 5. During an interview on 04/24/25 at 12:00 P.M., Licensed Practical Nurse (LPN) C said the nurse who does the discharge is responsible to give the bed hold policy, and check the box in the electronic medical record (EMR) under the discharge summary saying you gave it. LPN said he/she was not aware they should keep them on file to show it was given. During an interview on 04/24/24 at 12:38 P.M., the Director of Nursing (DON) said the nurse is responsible for this at the time of discharge. The nurses will make a note that it was done, but they don't retain a copy of what is given. The DON said this is a new policy the facility just started, and is unsure what it states. The DON said there is no way to for sure to tell if or when it is given to the resident or their reresentative due to it is just check marked in the system as given. During an interview on 04/24/25 at 1:04 P.M. the administrator said the nurse who discharges the resident should be completing the bed hold information at time of discharge. The administrator said she was not aware the policy did not contain the required information, and did not think about the benefit of this notification being kept on file.

Based on record review and interview, facility staff failed to complete a Comprehensive Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool, for three residents (Resident #12, #28, and #37) out of five sampled residents who had either improvements and/or declines in condition. The facility census was 41. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0, dated October 2024, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -A significant change in status assessment (SCSA) is appropriate when there is a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline in two weeks; -A significant change is any decline in two or more of the following: decision making has changed; presence of a resident mood item no previously reported by the resident or staff and /or an increase in symptom frequency in Section E; changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since last assessment; any decline in an Activities of Daily Living (ADL) physicial functioning area where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual functioning; residents incontinence patters changes or placement of indwelling catheter; emergence of unplanned weight loss, emergence of a new pressure ulcer at stage II (partial-thickness skin loss) or higher, a new unstageable pressure ulcer/injury (depth and extent of the tissue damage cannot be determined ), a new deep tissue injury or worsening in pressure ulcer status (where the skin remains intact, but the underlying tissues are damaged); -A significant change is any improvement in two or more of the following: any improvement in ADL physical functioning area where a resident is newly coded independent, set up or clean-up assistance, or supervision or touching assistance since last assessment and dates does not reflect normal fluctuations in that individuals functioning; a decrease in areas where behavioral symptoms are coded as being present and/or the frequency of a symptom decreases; resident's decision making improves; and the resident's incontinence pattern improves; -A significant change assessment must be completed within 14 days after a determination has been made that a significant change in status has occurred and submitted within 14 days of the care plan completion date. 2. Review of Resident #12's Annual MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Mood severity code of one (score ranges between 0 and 27, indicates the potential for depression symptoms); -Rejection of care one to three days; -Did not wander; -Required supervision or for eating, oral hygiene, and wheelchair locomotion 50 feet with two turns; -Dependent on staff for personal hygiene. Review of the resident's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Mood severity score of 0; -Did not reject care; -Wandered one to three days; -Required set up or touch for eating and wheelchair locomotion 50 feet with two turns; -Required partial to moderate assistance for oral hygiene; -Required substantial to maximal assistance for personal hygiene. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment for improvements and declines in two or more areas of function. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said the resident waxes and wanes (mental status shifts back and forth) so that is why a significant change was not done on her. He/She said the decision to make the resident a significant change was not discussed or documented for this resident. 3. Review of Resident #28's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -No social isolation; -Verbal behaviors one to three days; -No psychosis; -Delusions present; -No functional limitations; -Required supervision for eating, lying to sitting, wheelchair locomotion 50 feet with two turns and 150 feet; -Required substantial to maximum assistance for oral hygiene, lower body dressing, putting on and removing footwear, and toilet transfers; -No weight loss. Review of the resident's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Sometimes socially isolative; -No verbal behaviors; -Psychosis present; -No delusions; -Functional limitation of range of motion to one lower extremity; -Required set up assistance for eating, lying to sitting, wheel chair locomotion 50 feet with two turns and 150 feet; -Required supervision for oral hygiene; -Required set up or touch for eating and wheelchair locomotion 50 feet with two turns; -Required partial to moderate assistance for putting on and removing footwear, lower body dressing, and toilet transfers; -Weight loss. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment for improvements and declines in two or more areas of function. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said the resident should have a significant change of status MDS completed but must have missed it. 4. Review of Resident #37's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Physical behavior directed toward others one to three days; -No rejection of care; -Required supervision for oral hygiene, rolling from left to right, sitting to lying, lying to sitting, sit to standing, and chair to bed to chair transfers; -Required partial to moderate assistance for toilet hygiene, showers/baths, lower and upper body dressing, and tub/shower transfers; -Frequently incontinent of bowel. Review of the resident's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -No physical behaviors; -Rejection of care one to three days; -Required set up assistance for oral hygiene, rolling from left to right, sitting to lying, lying to sitting, sit to standing, and chair to bed to chair transfers; -Required supervision or touching for toilet hygiene, shower/baths, lower and upper body dressing, and tub/shower transfers; -Continent of bowel. Review of the resident's medical record showed facility staff did not complete a significant change in status assessment for improvements and/or declines in two or more areas of function. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said he/she did not know why a significant change MDS was not completed for this resident and should have discussed it. 5. During an interview on 04/24/25 at 08:32 A.M., the MDS Coordinator said a significant change is a change in a residents condition that lasts longer than two weeks. If a significant change is observed, he/she takes the information to the Interdisciplinary team (IDT) to discuss and determine if there is a true significant change. He/She said the decision is not documented in the medical record. He/She said it is his/her responsibility to ensure the MDS assessments are completed by use of the RAI manual. During an interview on 04/24/25 at 12:13 P.M., the Director of Nursing (DON) said he/she does not know a lot about the MDS. He/She said a significant change is a decline in function such as transfers, more assistance with activities of daily living, or a change from the prior MDS assessment. The MDS Coordinator is responsible to ensure significant change of status MDS assessments are completed. He/She said the IDT does not discuss if a resident is a significant change of status for a MDS assessment. During an interview on 04/24/25 at 12:49 P.M., the administrator said a significant change of status assessment would include new wounds, changes in activities of daily living, and changes in weights. He/She said the MDS nurse is responsible to ensure the significant change of status MDS assessments are completed by use of the RAI manual. There should be a note in the medical record if a decision is made by staff to not complete a SCSA. He/She was not aware of residents that did not have a SCSA completed.

Based on interviews and record review, facility staff failed to complete a baseline care plan within 48 hours of admission and failed to provide the resident and/or the resident's representative with a copy of the baseline care plan for two residents (Resident #3, and #192) out of two sampled residents. The facility's census was 41. 1. Review of the facility's policy titled, Care Plans-Baseline, dated 12/2016, showed: -To assure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary restrictions. 2. Review of Resident #3's electronic medical record (EMR), showed staff documented the resident admitted to the facility on [DATE]. The EMR did not contain documentation staff completed a baseline care plan within 48 hours of admission or provided a summary of the baseline care plan to the resident and/or his/her representative. During an interview on 04/24/25 at 12:14 P.M., the Director of Nursing (DON) said he/she was not sure why staff did not complete a baseline care plan for the resident after admission and was not sure how it got missed by him/her. During an interview on 04/24/25 at 12:58 P.M., the Care Plan Coordinator (CPC) said he/she was not sure why staff did not complete a baseline care plan for the resident, and he/she did not provide a summary of the baseline care plan to the resident or his/her representative. 3. Review of Resident #192's EMR, showed staff documented the resident admitted to the facility on [DATE]. The EMR did not contain documentation staff completed a baseline care plan within 48 hours of admission or provided a summary of the baseline care plan to the resident and/or his/her representative. During an interview on 04/21/25 at 12:01 P.M., the resident said he/she had concerns staff had not administered all the medications the physician prescribed for him/her at the facility. He/She said his/her spouse requested staff provide him/her with a list of medications staff administered to the resident since his/her admission and was still waiting for the medication list. During an interview on 04/23/25 at 1:31 P.M., the DON said he/she was not sure why the charge nurse did not initiate or complete the resident's baseline care plan within 48 hours of his/her admission. He/She said he/she had not had a chance to follow up. During an interview on 04/24/25 at 12:00 P.M., Licensed Practical Nurse (LPN) C said he/she was the charge nurse responsible to initiate the resident's baseline care plan after admission and was not sure why he/she did not complete the baseline care plan or communicate to the oncoming nurse that the baseline care plan was not completed. During an interview on 04/24/25 at 12:58 P.M., the CPC said he/she was not sure why staff did not complete a baseline care plan for the resident, and he/she had not provided a summary of the baseline care plan to the resident or his/her representative. 4. During an interview on 04/24/25 at 12:14 P.M., the DON said baseline care plans are used to let the Certified Nurse Assistant (CNA)s know a resident's prior level of care, current diet, transfer status, etcetera. He/She said the charge nurse is responsible to complete the baseline care plan within 48 hours of admission and either the DON or Assistant DON (ADON) is responsible to check within 72 hours to ensure it was completed. During an interview on 04/24/25 at 12:49 P.M., the administrator said baseline care plans are used to help direct a resident's care, the admission nurse is responsible to complete the baseline care plan within 48 hours after a resident is admitted to the facility, and the DON/ADON is responsible to check within 72 hours to ensure it was completed. During an interview on 04/24/25 at 12:58 P.M., the CPC said baseline care plans are used to give direct care staff an idea of each resident's care needs before a full/comprehensive assessment is completed. He/She said the charge nurse is responsible to complete the baseline care plan within 48 hours of a resident's admission, and the DON checks within 72 hours to ensure the baseline care plan was completed. He/She said he/she often initiates the comprehensive assessment within a few days after admission, and is usually responsible to give the resident or his/her representative a signed copy of the care plan summary. During an interview on 04/24/25 at 1:13 P.M., CNA A said the nurses complete residents' care plans, the CNAs access the care plans via the EMR and use the care plans to get information on a resident's diet, how to transfer, and special precautions.

Based on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner, when staff failed to discard expired medications from one of one sampled medication storage room, and failed to remove and discard expired and improperly labeled medications from one of two sampled medication carts. The facility's census was 41. 1. Review of the facility's policy titled, Insulin Administration, dated 09/2014, showed if opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). Review of the facility's policy titled, Storage of Medications, dated 04/2019, showed discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. Observation on 04/21/25 at 10:35 A.M., showed the medication storage room contained: -One bottle of Gerilanta (medication used to treat heartburn) with an expiration date of 04/2024; -Three tubes of Diclofenac Sodium Topical Gel (medication used to relieve pain from arthritis) with an expiration date of 11/2024. During an interview on 04/21/25 at 10:38 A.M., Certified Medication Technician (CMT) B said the CMTs and nurses are responsible to check and remove expired medications from the medication storage room, but he/she was not sure of a schedule to do so. He/She said he/she was not sure why items expired from 2024 were still inside the medication storage room. During an interview on 04/22/15 at 10:40 A.M., Licensed Practical Nurse (LPN) C said the CMTs and nurses are responsible to discard expired medications from the medication storage room periodically but there was not a set schedule. He/She said the expired Gerilanta and pain creams just got missed. During an interview on 04/24/25 at 12:14 P.M., the Director of Nursing (DON) said the nurses and either the assistant DON (ADON) or himself/herself is responsible to check for expired medications in the medication storage room. He/She said he/she is responsible to ensure expired medications were removed from the medication room and he/she was not sure why expired medications from 2024 were still inside the medication storage room. During an interview on 04/24/25 at 12:49 P.M., the administrator said the nurses and ADON are responsible to remove expired medications from the medication storage room, the DON and pharmacist to ensure it gets done, but he/she was overall responsible. 3. Review of Lantus Insulin Pen Instruction insert, dated 06/2023, shows Lantus Insulin pens can only be used up to 28 days after it's first use. After 28 days throw the opened Lantus pen away, even if it still has insulin left in it. Review of Novolog Insulin Pen Instruction insert, dated 10/2023, shows Novolog insulin pens should be thrown away after 28 days of opening, even if it still has insulin left in it. Review of Semeglee Insulin Pen Instruction insert, dated 11/2023, shows Semeglee insulin pens should be thrown away after 28 days of opening, even if it still has insulin left in it. Observation on 04/21/25 at 10:20 A.M., showed Station One Medication Cart contained: -One Novolog insulin (medication to lower blood sugar) pen opened and undated; -One Novolog insulin pen opened, undated, and did not have a resident's name; -One Lantus insulin pen opened and undated; -One Semglee insulin pen opened, undated, and did not have a resident's name; -One bottle of Allergy Relief eye drops, opened with an expiration date of 03/2025; -One bottle of Chewable Antacid tablets with an expiration date of 02/2025, opened. During an interview on 04/21/25 at 10:25 A.M., CMT B said insulin pens should be labeled with the resident's name so staff knows who the insulin belongs to. He/She said the CMT or the nurse is responsible to label the insulin with the open date, and the insulin expires 28 days after opening. He/She said the CMTs are responsible to discard expired medications from the carts and remove/discard the insulins that were either undated or missing a resident's name. The CMT said he/she was not sure if anyone double checks to ensure expired medications or improperly labeled insulin pens are removed from the carts. During an interview on 04/22/15 at 10:40 A.M., LPN C said the CMTs are responsible to remove and discard expired medications from the medication carts. He/She said the pharmacist usually labels the pens with the resident's name, the CMT should place a sticker on the pen with the open date, and the insulin expires 28 days after opening. He/She said the CMT should discard the insulins that were either undated or missing a resident's name. During an interview on 04/24/25 at 12:14 P.M., the DON said insulin pens should have a resident's name on it, the CMT or nurse should date the pen when opened prior to placing in the medication cart, and the insulin expires 28 days after opening. He/She said the CMTs should check for expired medications prior to each administration, discard and replace the medication, and the ADON/DON checks the carts randomly. He/She said he/she was responsible to ensure expired medications were removed from the mediation cart and was not aware improperly labeled insulin pens and expired medications were stored inside the medication cart. During an interview on 04/24/25 at 12:49 P.M., the administrator said he/she expects insulin pens to have a resident's name on it, staff should label the pen with the open date, and the insulin expires per the manufacturer recommendations. He/She said the nurse or CMT is responsible to check for expired medications prior to each administration and discard as necessary from the medication carts, the DON to ensure it gets done, and he/she was ultimately responsible.

Based on record review and interview, facility staff did not document a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility or document who is required to complete the assessed competencies and skill sets necessary to provide the level and types of care needed for the resident population. Facility census was 41. 1. Review of the facility's Facility Assessment policy, dated October 2018, showed the assessment should include a breakdown of the training, licensure, education, skill level and measures of competency for all personnel. The policy did not contain direction for documentation or assessment of staffing needs of each unit. Review of the facility assessment, dated 02/04/25 showed: -Sixty full time staff, seven part time staff, three as needed staff for a total of seventy staff; -Dayshift includes: eight Registered Nurse (RN) hours, 10 Licensed Practical Nurse (LPN) hours, 32 Certified Nurse Aide (CNA) hours and eight other hours; -Evening shift includes: three RN hours, 12 LPN hours, 24 CNA hours, and six other hours; -Nightshift includes: six RN hours, two LPN hours and 24 CNA hours; -The facility utilizes a patient and family centered team-based approach to evaluate team members strengths and weaknesses to ensure staff are assigned in the area that will benefit both the staff and the resident the most; -The assessment did not contain documentation on how the facility assessed or will staff each unit of the facility; -The facility provides time and financial resources for our staff to receive education from outside resources and communicate updates to policy modifications effectively to all relevant parties through communication channels such as training sessions, just in time in services, virtual meetings, and written communication; -The education/in-service section documented a list of topics education/in services needed by the staff of the facility. The education/in-service topics did not indicate which staff type, timing and how the education would be completed; -The staff competency section documented a list of assessed competencies needed by staff of the facility. The staff competencies did not indicate which staff type, timing, or how the competencies would be completed. Observation on 04/21/25 at 10:30 A.M., showed the facility had one secured unit, a 200 hall, a 300 hall, a 400 hall, 500 hall, and a 600 hall. Residents did not reside on 400 or 500 hall. During an interview on 04/24/25 at 11:52 A.M., Licensed Practical Nurse (LPN) C said he/she was not sure what a facility assessment was. He/She said he/she is not asked about staffing needs but is verbal to the management if staff is needed. LPN C said he/she is required to attend in house training and complete virtual training. During an interview on 04/24/25 at 12:13 P.M., the Director of Nursing (DON) said he/she is asked about needs of the facility for the facility assessment. He/She determines staffing needs by asking residents, families and the certified nurse aides. The census and ratio of resident to staff is also considered for staffing needs of the facility as a whole and not specific to each unit/hall. The DON said the education and in-services should be mentioned in the facility assessment but is not sure if it is. During an interview on 04/25/25 at 12:49 P.M., the Administrator said the facility assessment should include staffing by acuity for the facility as a whole and not per unit. He/She was not aware staffing should be assessed for each unit and that the education portion of the assessment did not include staff type, how or frequency of training but it should.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1's chest without Resident #1's consent. The facility census was 48. 1. Review of the facility's policy, Abuse Prevention Program, revised December 2016, showed all residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/15/24, showed staff assessed the resident with short and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance and two person assist for transfers, and had diagnoses of dementia (a group of thinking and social symptoms that interferes with daily function), anxiety, and stroke (damage to the brain from interruption of it's blood supply). Review of Resident #1's plan of care, dated 4/01/24, showed staff are directed to monitor and observe the resident's surroundings for his/her safety. Review of Resident #1's nurse's notes, dated 3/29/24, showed the Director of Nursing (DON) documented he/she and the administrator called the resident's durable power of attorney to notify him/her about residents incident with another resident, voicemail left to call Administrator back. Review of Resident #2's Admission MDS, showed staff assessed the resident as severely impaired cognitive skills for daily decision making, required partial assistance and setup only for transfers, and had diagnoses of Alzheimer's and dementia. Review of Resident #2's plan of care, dated 1/24/22, showed staff assessed the residents at risk for behavioral episodes due to cognitive changes related to diagnoses. Review showed staff updated the plan of care on 4/01/24 to address the resident's sexual behavior toward another resident. Review of Resident #2's nurse's notes, dated 3/28/24, showed Licensed Practical Nurse (LPN) A documented he/she walked up 600 hall and saw resident #2 bending over with face near resident #1's chest with shirt pulled over and down a little bit. Residents were separated, and he/she notified the DON and Assistant Director of Nursing (ADON). Review of the facility investigation, dated 3/29/24, showed LPN A reported to the DON and ADON he/she witnessed Resident #2 bending over with his/her face near Resident #1's chest, possibly kissing his/her chest area, and staff separated the residents. Review showed staff documented neither resident could recall the incident. Review of the facility's video footage from 3/29/24 showed Resident #2 walk past Resident #1 in the common area and pull his/her shirt up. Review showed Resident #2 came back and pulled Resident #1's shirt over and down, he/she then leaned down to the resident's chest. Review showed LPN A intervened immediately and seperated the resident's. During an interview on 4/1/24 at 2:17 P.M., Resident #2 said he/she does not remember an incident with another resident. During a phone interview on 4/3/24 at 12:05 P.M., LPN A said he/she was walking up the 600 hallway and saw Resident #2 leaning over Resident #1's chest area. He/She yelled Resident #2's name and he/she stood up and the residents were immediately separated. Resident #1's shirt was pulled to the side and down a little bit, with his/her chest exposed. A skin assessment was performed on Resident #1 and there was no trauma or redness to the area, the resident's behavior did not change and he/she did not remember the incident. He/She interviewed Resident #2 and he/she did not remember the incident. He/She said he/she has never seen Resident #1 have any sexual behaviors. LPN A said Resident #2 can be handsy with personal cares and staff but never witnessed sexual behaviors with other residents. During an interview on 4/1/23 at 12:15 P.M., the DON said he/she was not in the building when the incident between the residents but the LPN responded appropriately by immediately seperating the residents, notifying him/her, and they started the investigation was started. During an interview on 4/1/23 at 12:15 P.M., the administrator said he/she was not in the building when this occured between the two residents but that the LPN responded appropriately by immediately seperating the residents, and notifying the DON. He/She said they started an investigation, notified the proper authorities. The administartor said the one thing he/she did not do was in-services immediately, but the in-service was scheduled for 4/4/24. MO00233963

Based on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. The facility census was 39. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Never leave any food item uncovered and not labeled. Observation on 02/07/23 at 9:45 A.M., showed the reach-in freezer contained a box of waffles opened to the air. Observation on 02/07/23 at 9:47 A.M., showed the reach-in refrigerator contained: -a container of grated cheese opened and undated; -a 32 ounce container of strawberry preserves opened and undated; -a 20 ounce container of strawberry jam opened and undated; -a sliced onion, partially wrapped in plastic, opened to the air and undated. Observation on 02/07/23 at 9:53 A.M., showed the kitchen dry storage area contained: -a 16 ounce container of fennel seeds opened and undated; -a cheese shaker labeled as garlic opened and undated; -a 32 ounce container of browning sauce opened and undated; -a five and 1/4 pound container of garlic powder opened and undated; -a 36 ounce container of celery salt opened and undated; -a 16 ounce container of [NAME] jerk seasoning opened and undated; -a 20 ounce container of salt free seasoning opened and undated; -a six ounce container of rosemary leaf opened and undated; -a one and one-half pound container of Italian seasoning opened and undated. Observation on 02/07/23 at 10:00 A.M., showed the baker's area contained: -a 250 milliliter container of olive oil opened and undated; -a five pound container of ground cinnamon opened and undated; -a one pound container of ground cloves opened and undated; -a one pound container of ground ginger opened and undated; -a 28 ounce container of cream of tarter opened and undated; -a cheese shaker, which contained an unidentifiable white powder, opened to the air, undated and unlabeled. Observation on 02/07/23 at 10:06 A.M., showed the area next to the grill contained an cheese shaker, which contained small unidentifiable yellow flakes, opened to the air, undated and unlabeled. Observation on 02/07/23 at 10:08 A.M., showed the cook's station contained: -a plastic container of frosted flakes cereal opened to the air and undated; -a plastic container of corn flakes cereal opened and undated; -a plastic container of toasted oat O's cereal opened and undated; -three loaves of white bread opened and undated; -a package of hot dog buns opened and undated; -a loaf of rye bread opened and undated. Observation on 02/07/23 at 10:21 A.M., showed the dry goods pantry contained: -a 10 pound bag of semolina pasta tubes opened and undated; -a large bag of small shell pasta opened and undated; -a large bag of fruit whirls opened and undated; -a large bag of toasted oat O's opened and undated; -a large bag of 10 inch linguini dated 10-11 opened to the air. Observation on 02/07/23 at 10:27 A.M., showed the walk-in freezer contained: -a large unidentifiable piece of meat in a plastic resealable bag unlabeled and undated; -a box of beef country fried steak opened to the air; -a box of pork loin fritters opened to the air. Observation on 02/07/23 at 10:32 A.M., showed the walk-in refrigerator contained: -an undated five gallon bucket of kosher deli pickles partially opened to the air with the lid to the container soiled with black debris; -a large plastic bag of an unidentifiable ground meat unlabeled and undated; -a long rectangle metal container covered with aluminum foil, which contained an unidentifiable brown meat-type substance, unlabeled and undated. During an interview on 02/07/23 at 10:41 A.M., the Dietary Manager (DM) said opened food items should have a date received and a date opened. The DM said leftovers should be dated for five days past the original preparation date. Observation on 02/08/23 at 11:33 A.M., showed the walk-in freezer contained: -a case of beef country fried steaks opened to the air; -a chunk of unidentifiable meat in plastic resealable bag unlabeled and undated; -two cases of frozen cookie dough, a case of peas, a five gallon carton of chocolate ice cream, a five-gallon carton of vanilla ice cream, and a case of grape juice concentrate stored on the floor. Observation on 02/08/23 at 11:38 A.M., showed the dry goods pantry contained: -a large plastic bag of linguini noodles dated 10/11 stored on the shelf opened to the air; -a large plastic bag of fettuccini noodles opened and undated; -a large plastic bag of conchigliette pasta shells opened and undated; -a large plastic bag of rigatoni noodles opened and undated. Observation on 02/08/23 at 12:07 P.M., showed the cook's station contained undated plastic storage containers of toasted oat O's, raisin bran, frosted flakes, cornflakes and fruit whirls cereals removed from their original packaging. Observation on 02/08/23 at 12:21 P.M., showed the reach-in refrigerator in the aide's station contained an opened and undated 12 pound container of commercially prepared mustard potato salad and an opened and undated 10 pound container of peeled hard cooked eggs. Observation on 02/08/23 at 12:34 P.M., showed an large unlabeled and undated bulk container in the spice storage area which contained an unidentifiable grain-like substance removed from its original packaging. During an interview 02/08/23 at 12:34 P.M., the DM said the bulk container contained cornmeal and the container should be dated and labeled with the product name. Observation on 02/08/23 at 12:35 P.M., showed the reach-in freezer contained a case of waffles dated 12-9 opened to the air and a plastic bag of hashbrown patties opened to the air and undated. During an interview on 02/08/23 at 12:38 P.M., the DM said opened food items, including the spice containers, should be stored sealed, labeled and dated. The DM said all staff are responsible to ensure food is stored correctly and staff usually go through coolers to look for outdated food items twice a week. The DM said the food delivery truck came in the afternoon of the previous day and, while food should not be stored on the floor, he/she just not had time to put all the food away. During an interview on 02/10/23 at 10:24 A.M., the administrator said opened food items, including the spice containers, should be dated and sealed before they are put away and if a food has been removed from original packaging, staff should also label the package with the product name. The administrator said staff had recently been trained on how to store food properly. 45564

Based on interview and record review, facility staff failed to implement an infection surveillance program that included tracking of organisms responsible for infections and failed to review their Infection Prevention and Control Program (IPCP) on an annual basis. The facility census was 39. 1. Review of the facility's Surveillance for Infections policy, dated September 2017, showed: -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated infections, to guide appropriate interventions and to prevent future infections. Review of the facility's undated Infection Control and Prevention Program Evaluation Policy showed: -The effectiveness of the infection prevention and control program is reviewed no less than annually with findings reported to the QA committee and integrated in the resident safety program; -This review will include an evaluation of results of surveillance findings and analysis to determine opportunities. Review of the facility's undated IPCP showed the record did not contain the following: -A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; -An annual review or update of the program. During an interview on 2/09/23 at 11:32 A.M., the Infection Preventionist (IP) said he/she was new to the position and still learning. He/she said the lab sends culture results, but there was no formal way to monitor trends in infection sources. During an interview on 2/09/23 at 11:34 A.M., the Director of Nursing (DON) said infection control policies should be reviewed and/or updated annually. The DON also said the facility did not get monthly summaries from the lab and the infection prevention staff haven't looked in depth at actual organism results, because they really don't have a mechanism to keep track of specific organisms or infection trends. During an interview on 2/10/23 at 10:18 A.M., the Administrator said he/she did not know the policy on how often infection control and prevention policies should be reviewed. The administrator said the IP should be tracking organisms that are causing infections.

Based on interview and record review, facility staff failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. facility census was 39. 1. Review of the facility's Grievance/Complaint filing policy, revised April 2017, showed staff were directed as follows: - All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response; - Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations a submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint; - The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any, need to be taken.; - The resident, or person filing the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems; - The Administrator, or his or her designee, will make such reports orally within __ working days of the filing of the grievance or complaint with the facility; - A written summary of the investigation will also be provided to the resident, and a copy will be filed in the social services office; - The results of all grievances filed, investigate and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. Review of the facility's Resident Rights policy date, December 2017, shows staff were directed as follows: - Residents may voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Residents have the right to have the facility respond to his or her grievances. Review of the facility records showed the record did not contain grievance reports for a period of no less than three years. During an interview with the resident council on 2/9/23 at 2:07 P.M., the council members said the following: -Staff do not take the time to look at their grievances; -Staff write down their concerns during the council meeting and then they shelve it; -Residents do not get written answers to their grievances; -Residents do not get meeting minutes until the day of the council meeting so they don't know what problems have been addressed; -Staff say they are going to do something about the problem but they don't follow through. During an interview on 2/10/23 at 9:00 A.M., activities assistant (A) said grievances are typed up and given to the department heads. He/she was unsure of what was done by staff after that. During an interview on 2/10/23 at 9:10 A.M., the activity director said they take grievances to the department heads in written form. The residents are then told by the department heads during the next council meeting what will be done. During an interview on 2/10/23 at 9:51 A.M., the director of nursing said resident council can invite staff to their meeting and a response to a grievance is done verbally. They don't do a formal written response with rationale to a grievance. During an interview on 2/10/23 at 9:50 A.M., the administrator said the activities department takes grievances from the resident council to the related department head who will if invited come and tell the members what he response is. This is then entered into the minutes for resident council. 47293

Based on observation, interview, and record review, facility staff failed to provide protective oversight for one resident (Resident #1) when he/she exited the facility without staff knowledge and fell down multiple stairs resulting in swelling and abrasions to the resident's lower extremities. Staff failed to follow their elopement policy when a door alarm sounded. Staff failed to conduct a census check to see if anyone was unaccounted for and the alarm was silenced without staff implementing their elopement procedures. Staff failed to check outside and community members alerted staff the resident was at the bottom of the steps. The facility census was 53. The administrator was notified on 10/06/21 at 8:45 A.M. of an Immediate Jeopardy (IJ) which began on 8/4/21. The IJ was removed on 8/24/21 as confirmed by surveyor onsite verification. 1. Review of the facility's Elopement and Search Policy, dated 12-30-15, showed the purpose is to establish methods for protecting those who are risk to elope and for conducting an organized search for a resident who cannot be located. Review showed the administrator, Director of Nursing (DON), charge nurses, and all facility personnel are responsible. Additional review showed: -All nursing staff are responsible for knowing the general whereabouts of the residents they are assigned to care for; -Employees are instructed in elopement prevention and search protocol during initial orientation and quarterly throughout the year; -Resident who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an alert elopement device (arm or ankle bracelet); -High risk areas include streets, parking lots, wooded areas, ponds or railroads within close proximity of the facility; -The administrator or designated staff member is assigned responsibility of initiating detailed documentation of all actions taken and efforts made to locate the resident. Documentation should be performed immediately after the event or at the time of the event; -The administrator is responsible for notifying the Department of Health and Senior Services; -An Elopement Risk Assessment will be performed and care plan interventions revised in accordance with assessment findings. 2. Review of the facility Policy and Procedure Resident Elopement, undated, showed if at any time a resident who is considered an elopement risk leaves the building unsupervised a staff member will be assigned to continually monitor the resident, the care plan will be updated and the registered nurse (RN) coordinator will put appropriate interventions into place. 3. Review of the facility's Exit Door alarms policy and procedure, revised on 4/23/21, showed: -All exit door are equipped with alarms. When the doors are opened without the code being entered, they alarm to alert staff of the possibility of resident's exiting the building who should not be exiting; -The door alarms sound audibly and all pagers sound as well. The pagers will identify which door has been opened. The computer screens at each nurses station will alarm as well. -Upon hearing an exit door alarm, staff are to immediately respond to the door. If upon arrival you do not see anyone or cannot determine why the alarm has sounded a census check of all residents must be conducted immediately. While (simultaneously) the census check is being conducted a staff personnel must be designated to immediately go outside and check the perimeter of the facility, starting with the front of the building near the road. -If after census check all residents have been accounted for the all clear can be announced via the overhead paging system. -If after the census check any resident(s) are unaccounted for, the elopement code is called via the overhead paging system and the procedure for the elopement is enacted. There is a red Emergency Plan book at each nurses station attached to the wall. All emergency procedures are listed in the books. -Certified Nursing Assistants (CNA's) and Certified Medication Technicians (CMT's) and nurses are to wear pagers at all times while they are working in the facility. Pagers are to be signed out at the beginning of your shift and signed in at the end of your shift. 4. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/21, showed staff assessed the resident as follows: -Severe cognitive impairment; -Unable to walk, locomotion on and off unit (once in wheelchair) supervision only. -Diagnoses of dementia with behavioral disturbance, non traumatic [CONDITION(S)], generalized anxiety order, dizziness. Review of the resident's plan of care, updated 6/19/21, showed staff assessed the resident at risk for elopement related to wandering type behaviors and confusion. Review showed staff documented interventions as follows: -Gently redirect resident if he/she is noted to be attempting to exit the facility; -Ensure that wander alert bracelet is in place and functioning properly; -Check under wander guard during weekly skin checks; -Needs supervision as he/she does wander. Review of the resident's nurses progress note, dated 8/4/21 at 04:27 A.M., showed staff documented the resident fell during shift change report. Review showed staff documented a couple (two people) arrived at the front door and reported there was a resident at the bottom of the stairs outside the building. Review showed nursing staff reported to the area and found the resident sitting on his/her bottom at the bottom of the stairs by the loading dock and the wheelchair remained at the top of the dock. Review showed staff documented staff called 911 since the fall was unwitnessed and they could not properly assess the resident due to the position he/she was in and his/her normal inabilities of non-weight bearing and immobility. Review showed when ambulance personnel arrived, they determined he/she did not need emergency care. Review showed staff assisted the resident back into his wheelchair and brought the resident back into the building. Review showed the administrator and director of nursing (DON) were contacted per phone and advised a full skin check and 15 minute checks for 24 hours. Review showed staff documented several abrasions to both lower extremities, left knee appeared red and swollen. The doctor was notified and ordered x-rays. Review showed staff documented the resident could not give any information as to what had occurred. Staff documented the door alarm by the administration office had reportedly sounded prior to this nurses arrival, thus the resident had accessed an area which is not to be accessed without assistance and he/she could exit the building. Review showed staff documented it is unknown how he/she managed to get down the stairs. Review of the facility door alarm system documentation, dated 8/3/21, showed the alarm triggered at 6:04 P.M. and cleared at 6:36 P.M. Review showed a 32 minute response time. Additional review showed the observation of the first incident was put in the computer at 7:07 P.M. and the first notification to the Administrator at 7:40 P.M., per phone records. During an interview on 8/25/21 at 8:44 A.M., CNA D said the pager alerted staff the administrator exit doors alarmed. CNA D checked, but never went through the doors. He/she just looked through the windows on the doors. The CNA said he/she did not know why the alarm was sounding. There is nothing behind the doors, to his/her knowledge, just a closed hallway. He/she said he/she could not get the code cleared and just went back to work. He/she said he/she did not have time to look for the nurses to alert one of them. The CNA said simply put, this was due to a lack of knowledge on building layout and policy to look for the resident. During an interview on 8/25/21 at 8:44 A.M., Register Nurse (RN) C said the pagers sounded because a door was opened, but he/she did not clear the alarm and had no idea who did clear the alarm. There was one aide on station one and one on station two. The other nurse on duty went home because of a death in the family. He/she said he/she can not recall what he/she was doing as to why he/she could not answer the page and check the doors. He/she said the facility is understaffed and there is a lot of alarm fatigue because it is the same alarm, or page, that goes off for call lights. When a new page comes in, it clears the previous one and you have to manually go back and see if they have been cleared. By the time he/she looked at his/her pager, it could have been very far back. He/she said training on this topic was brief. During an interview on 8/25/21 at 3:04 P.M., RN B said he/she was on the floor to get report closer to 7:00 P.M. He/she said RN C was very overwhelmed because staff had left early. RN B said the phone rang and it was a couple at the front door that said someone was outside on the stairs. RN C ran when he/she heard him/her asking questions because he/she was shocked. RN B said the resident was found at the bottom of the stairs and his/her wheelchair at the top of the stairs. He/she said he/she asked CNA D if the alarms sounded and the CNA replied, yes, for a long time. RN B said he/she never heard an alarm while in the building but had not checked out a pager yet. He/she said RN C said staff at the adjoining building called to let them know the alarm was sounding but RN C did not have time to go check. In addition, RN C said earlier he/she had dropped his/her pager in the trash and set it in the utility room to clean it and never picked it back up. During an interview on 8/24/21 at 3:52 P.M., the administrator said the resident fell down the stairs. She said the resident had gotten out of the doors by the administrator's office. The doors are alarmed and the alarm sounded. She said the resident does not have a history of elopement. She said the incident was right at shift change so staff probably did not hear it, even though everyone has pagers. During an interview on 8/24/21 at 5:06 P.M., the administrator said only the staff member at fault was inserviced for not following the facilities policy. During an interview on 8/25/21 at 9:11 A.M., the former DON/MDS Coordinator said the staff did not follow the policy and procedure set by the facility and no one is ever too busy to check the alarm. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 872

Based on observation, interview, and record review, facility staff failed to maintain personal medical information in a manner to protect five residents' privacy (Residents #1, #2, #3, #4, and #5). The facility census was 40. 1. Review of the facility's Admission Agreement, undated, showed staff are directed as follows: -A resident has the right to personal privacy and confidentiality of his or her personal and clinical records; -Personal privacy shall include accommodations, medical treatment, written and telephone communications, personal care, and visits and meetings with family and resident groups. 2. Review of the facility's Administering Medications Policy, revised April 2019, showed the medication cart and/or Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Observation on 6/08/21 at 8:27 A.M., showed Certified Med Tech (CMT) A prepared Resident #1's medication and entered his/her room to administer the medication. Further observation showed the computer with the resident's Electronic Health Record (EHR) open, faced out toward the hall, and visible to visitors. 4. Observation on 6/08/21 at 8:35 A.M., showed CMT A prepared Resident #2's medication and entered his/her room to administer the medication. Further observation showed the computer with the resident's EHR open, faced out toward the hall, and visible to visitors. 5. Observation on 6/08/21 at 8:43 A.M., showed CMT A prepared Resident #3's medication and entered his/her room to administer the medication. Further observation showed the computer with the resident's EHR open, faced out toward the hall, and visible to residents and visitors. Additional observation showed staff and residents passed by and looked at the open EHR. 6. Observation on 6/08/21 at 8:52 A.M., showed CMT A prepared Resident #4's medication and left the special care unit to obtain applesauce from the skilled unit. Further observation showed the computer with the resident's EHR open, faced out toward the hall, and visible to residents and visitors. 7. Observation on 6/08/21 at 9:10 A.M., showed CMT A prepared Resident #5's medication and entered his/her room to administer the medication. Further observation showed the computer with the resident's EHR open, faced out toward the hall, and visible to residents and visitors. 8. During an interview on 6/08/21 at 9:35 A.M., CMT A said anytime you leave the medication cart you are expected to close the resident's medical record and he/she didn't know why he/she didn't do that. During an interview on 6/09/21 at 1:32 P.M., the Director of Nursing (DON) said there is a button on their software that says, walk away and he/she expects the staff to push that anytime they walk away from the computer. MO 093

Based on interview and record review facility staff failed to ensure a comprehensive plan of care was developed and implemented for one resident (Resident # 6) out of three sampled residents. The facility census was 48. 1. Review of the Facility's Care Plans Comprehensive Person-Centered Policy, revised December 2016, showed staff are directed that the comprehensive, person-centered care plan is to be developed within 7 days of the completion of the required comprehensive assessment Minimum Data Set (MDS). 2. Review of Resident # 6's comprehensive admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on one person assistance with toileting, personal hygiene, an bathing; -Required extensive, two person assistance with bed mobility; -Required extensive, one person assistance with dressing, and eating; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed it did not contain a comprehensive care plan. During an interview on 6/09/2021 at 1:32 P.M., the Director of Nursing (DON) said he/she is responsible for the MDS assessments for all residents. The DON said he/she thought the resident's care plan had been completed but that he/she also did not find it in the resident's medical record. He/She had reached out to someone in corporate because they were updating care plans and changing the format they were using and they didn't find it either. During an interview on 6/11/2021 at 3:11 P.M., the Administrator said he/she expects staff to follow their policy to complete comprehensive care plans for all residents. MO 093

Based on observation, interview, and record review, facility staff failed to provide protective oversight for one resident (Resident #1) who left the facility while nursing staff was giving the shift-change report and did not see the alert on the computer screen, and nurse aide staff were providing direct resident care and either did not hear the alert or were unable to check the alert at that time. The facility census was 53. 1. Review of the facility's Elopement and Search Policy, dated 12-30-15, showed the purpose is to establish methods for protecting those who are risk to elope and for conducting an organized search for a resident who cannot be located. Review showed the adminstrator, Director of Nursing (DON), charge nurses, and all facility personnel are responsible. Additional review showed: -All nursing staff are responsible for knowing the general whereabouts of the residents they are assigned to care for; -Employees are instructed in elopment prevention and search protocol during inital orientation and quarterly throughout the year; -Resident who have been identified as cognitvely impaired and who have been assessed as an elopement risk wil be provided with an alert elopment device (arm or ankle bracelet); -High risk areas include streets, parking lots, wooded areas, ponds or railroads within close proximity of the facility; -The administrator or designated staff member is assigned responsibility of initiating detailed documentation of all actions taken and efforts made to locate the resident. Documentation should be performed immediately after the event or at the time of the event; -The administrator is responsible for notifyng the Department of Health and Senior Services; -An Elopement Risk Assessment will be performed and care plan interventions revised in accordance with assessment findings. 2. Review of the facility Policy and Procedure specifically for Resident Elopement, undated, showed if at any time a resident who is considered an elopement risk leaves the building unsupervised a staff member will be assigned to continually monitor the resident, the care plan will be updated and the registered nurse (RN) coorddinator will put appropriate interventions into place. 3. Review of the Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/21, showed staff assessed the resident as follows: -Severe cognitive impairment; -Able to walk independently for short distances, with use of wheelchair encouraged; -Diagnoses of: Dementia, alzheimers disease, anxiety and depression. Review of the resident's plan of care, updated 01/31/21, showed staff assessed the resident at risk for elopement related to wandering type behaviors and confusion. Reviewed showed staff documented interventions as follows: -Gently redirect resident if he/she is noted to be wondering toward exit; -Ensure that wander alert bracelet is functioning properly; -Be aware that family does not want resident walking the distance of the dining room; -Ensure wander alert bracelet is placed on ankle. Review of the resident's nursing progress note, dated 4/22/21 at 01:40 A.M., showed staff documented at approximately 7:00 P.M. on 4/21, staff from the adjoining facility reported the resident had been noticed by a passerby on the road mobilizing her wheelchair close to the road in front of facility. Staff documented the staff from the adjoining facility quickly went to the location and brought the resident safely back inside the facility. Review showed staff brought the resident back to the facility and assessed the resident. Review showed staff documented the resident did not have injuries. The administrator was notified. Staff documented 15-minute checks were instituted and resident placed into the memory care unit overnight. The resident's responsible party was notified per telephone. During an interview on 4/26/21 at 2:43 P.M., Registered Nurse (RN) D said when a wander alert bracelet gets too close to an exit the alarm goes off and identifies which door a resident is near. The alarm is sent to the nurse aides' pagers and to the desktop computer at station one and the overhead screen on station two. He/She said this incident with Resident #1 was during report so he/she did not see the page come across overhead computer screen. The wander alert bracelet does lock the door but if the resident holds the door bar long enough it will open for fire safety. He/She said pagers were still newer to the facility but only aides wear the pagers not nurses. During an inteview on 4/26/21 at 3:13 P.M., the administrator said nurses do not wear the pagers, but are alerted by the computer at station one and the monitor screen at nursing station two. During an interview on 4/26/21 at 4:28 P.M., Nurse Aide (NA) A said when his/her pager went off he/she was getting residents settled after dinner, he/she was the only aide on station two side. The aide said he/she did not see or hear the pager sound and if he/she had, it would have been assumed that it was the break room and would not have checked it. During an interview on 4/26/21 at 4:46 P.M., with NA B said when his/her pager went off on the night of the incident he/she was with a resident providing direct care. When the NA was finished he/she said she went and checked the door but did not open it and did not see anyone outside. During an interview on 4/27/21 at 3:34 P.M., RN F said he/she had recieved report from Licensed Practical Nurse (LPN) G at station one and was getting report at station two from RN D and did not see the monitor with the alert. The RN said he/she started vitals and then got a call from an aide at the adjoining facility saying a resident got out. The RN said fifteen minute checks were immediately implemented. During an interview on 5/12/21 at 4:42 P.M., RN D said there is a little sound on the computer and overhead monitor if they are turned up. It is a small tone once and then does not sound again. It does sound again on the pagers though. RN D said he/she is not sure why the sound is not turned up. During an interview on 4/26/21 at 1:32 P.M., The Administrator said the facility has suggested to family before the resident needs to be on a locked memory care unit due to wandering tendencies. MO 542

Based on observation, interview and record review, the facility staff failed to follow infection control protocols for COVID-19 when staff did not properly wear face masks while in the facility. The census was 66. Review of the Centers for Disease Control and Prevention (CDC) recommendation dated 5/21/20, showed in order to prevent the spread of COVID-19, facility staff are to ensure all healthcare personnel (HCP) wear a facemask or cloth face covering for source control while in the facility. Additional review of the CDC recommendation titled How to Wear Face Coverings Correctly dated 5/22/20, showed staff are to place it over their nose and mouth and secure it under their chin. 1. Observation on 05/27/20 at 10:03 A.M., showed the Director of Nursing's (DON) face mask did not cover his/her nose while he/she was in a resident care area. Observation on 05/27/20 at 10:27 A.M., showed Certified Medical Technician (CMT) A wore his/her mask incorrectly while leaving a resident's room. He/She did not properly place the face mask over both mouth and nose to ensure infectious agents could not be transmitted. Observation on 05/27/20 at 10:47 A.M., showed Licensed Practical Nurse (LPN) B wore his/her mask incorrectly while in residential areas. He/She did not properly place the face mask over both mouth and nose to ensure infectious agents could not be transmitted. Observation on 05/27/20 at 11:08 A.M., showed CMT A continued to wear his/her mask incorrectly. He/she did not properly place the face mask over both mouth and nose to ensure infectious agents could not be transmitted. Observation on 05/27/20 at 11:23 A.M., showed LPN B continued to wear his/her mask around his/her neck. He/She did not properly place the face mask over his/her mouth while in residential areas. 2. During an interview on 05/27/20 at 10:50 A.M., LPN C said staff should wear a mask at all times except in the break room or outside. He/She said the face mask should cover the nose and the mouth. During an interview on 05/27/20 at 11:09 A.M., the administrator said staff are to wear a mask at all times and the mask should cover the nose and the mouth.

Based on observation, interview, and record review, facility staff failed to provide adequate monitoring to ensure safety to prevent accidents and failed to consistently implement and modify care plan interventions as necessary, in accordance with current standards of practice for two residents, (Residents #64 and #40). The facility's census was 82. Review of the facility's Falls and Fall risk, Managing policy, revised March 2018, showed staff are to identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. Additionally, staff are to implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls and if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 1. Review of Resident #64's Quarterly Assessment Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -History of falls; -Active [DIAGNOSES REDACTED].>-Past [DIAGNOSES REDACTED].>-Sustained two or more falls; -Moderately cognitively impaired; -Required supervision and one person assist for transfers; -Ambulates in room and corridor independently; -Required limited assistance and one person physical assist for toileting; -Occasionally incontinent of urine. Review of the resident's fall risk assessment dated [DATE], showed staff assessed the resident as at high risk for falls with a score of 15. Review of the resident's nurses' notes dated 1/06/2020, showed staff documented the resident sustained [REDACTED]. Review of the resident's care plan, updated 01/06/2020, showed staff assessed the resident's risk for falls due to weakness, impaired mobility, and dementia and added the new direction for staff to educate the resident to ambulate with assistance to decrease the fall risk. Review of the resident's nurses' notes dated 01/14/2020, showed staff documented the resident sustained [REDACTED]. Additional review of the resident's care plan showed staff did not update the care plan with interventions to prevent falls. Review of the resident's nurses' notes dated [DATE]20, showed staff documented the resident's family member voiced concerns with recent falls and wondered about the need for a wheelchair. Additional review of the resident's care plan showed staff did not update the care plan with interventions to prevent falls after the fall. Review of the resident's nurses' notes dated 01/16/2020, showed staff documented the nursing supervisor observed the resident with his/her upper body on the bed and knees barely touching the floor beside his/her bed. Additionally, staff documented the resident complained of dizziness and lowered himself/herself to the floor. Additional review of the resident's care plan showed staff did not update the care plan with interventions to prevent falls after the fall. Review of the resident's nurses' notes dated 0[DATE]20, showed staff documented they found the resident on his/her knees in front of the rocking chair in his/her room. Additional review of the resident's care plan showed staff did not update the care plan with interventions to prevent falls after the fall. Review of the resident's nurses' notes dated 01/31/2020, showed staff documented they heard a crash in the resident's room and found him/her on floor. Additional review of the resident's care plan showed staff did not update the care plan with interventions to prevent falls after the fall. Review of resident's nurses' notes dated 02/03/2020, showed staff documented they were called to the resident's room and found the resident on the floor, with his/her legs outstretched in front. Staff documented the resident's pants were around his/her ankles. Additional documentation showed the resident received a skin tear to his/her right elbow. Additional review of the resident's care plan showed staff did not update the care plan with interventions to prevent falls after the fall. Review of resident's nurses' notes dated 02/08/2020, showed staff documented they found the resident on the floor in his/her room with his/her nose bleeding, a slight deviation, and his/her right eye puffed up. Additional documentation showed the resident with extreme agitation, combative and swinging at staff, and complained he/she couldn't see. Staff sent the resident to the emergency room for an evaluation. Review of the resident's nurses' notes dated 02/08/2020, showed staff documented the resident received multiple facial fractures. Review of the resident's nurses' notes dated 02/09/2020, showed staff documented the resident has a right orbital non displaced fracture as well as a sinus fracture. During an interview on [DATE]20 at 12:29 P.M., Certified Nursing Assistant (CNA) C said in the event they need a nurse to come to the memory unit, they call the nurse on the wireless phone and talk to him/her or go find him/her on the floor outside of the unit. He/She said it depends on the scenario how long it takes the nurse on duty to report to the unit. CNA C said nursing staff rarely come back to the unit. The CNA said they used to send a staff person to the unit when one staff took a break, but this unit is out of sight, out of mind. CNA C said there is only one staff present at night. CNA C said there has been issues before with falls with the resident while someone was on break. During an interview on 02/12/2020 at 11:32 A.M., CNA B said the resident fell about a week ago and is still in the hospital. CNA B said he/she works evenings and stayed over because there wasn't any staff to cover next shift. CNA B said the staffing issues are bad and he/she is the only CNA on the floor. 2. Review of Resident #40's care plan, dated 05/02/2019, showed staff assessed the resident's risk for falls due to weakness and dementia. Staff did not plan interventions to promote safety for the resident. Review of the resident's updated care plan, dated 12/12/19, showed staff planned to assist the resident up and down the hall two times daily for strength, but did not add interventions to promote safety from falls. Review of the resident's quarterly assessment MDS, dated [DATE], showed staff assessed the resident as: -History of falls; -Active [DIAGNOSES REDACTED].>-Weakness; -Moderately cognitively impaired; -Required limited assistance and one person assist for transfers; -Ambulates in room and corridor independently; -Not steady while walking, but able to stabilize self; -Required extensive assistance and one person physical assist for toileting; -Continent of bowel and bladder with occasional incontinent episodes. Review of the resident's nurses' notes, dated [DATE], showed staff documented they were called to the memory care unit and found the resident on his/her buttocks with legs outstretched, a laceration to his/her left eye with bruising and swelling. Review of the resident's nurses' notes, dated [DATE], showed the resident received a head injury, possible facial fracture and five sutures. During an interview on 02/07/2020 at 09:47 A.M., CNA A said he/she is the only CNA on the floor right now, and unfortunately it happens a lot when there is only one of them on the floor. During an observation on 02/07/20 at 9:48 A.M., showed CNA A entered the resident's room and assist him/her to the bathroom. Additional observation showed another resident going into three different residents' rooms, not belonging to him/her. CNA A said he/she was the only staff on the memory care unit when the resident fell yesterday. He/She said another staff person was scheduled, but was pulled to another unit of the facility.

Based on interview and record review, the facility failed to have a complete facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility census was 82. 1. Review of the facility's Resident Census and Conditions of Residents form, dated 02/11/20, showed the following resident characteristics: -Indwelling or external catheters: five residents; -Occasionally or frequently incontinent of bladder: 65 residents; -Occasionally or frequently incontinent of bowel: 48 residents; -In a chair all or most of time: 68 residents; -With contractures: 7 contractures; -Documented signs and symptoms of depression: 28 residents; -Documented psychiatric Diagnosis: [REDACTED].>-Dementia or Alzheimer ' s disease: 48 residents; -Behavioral healthcare needs: 22 residents; -Pressure Ulcers: 17 residents; -Hospice Care: 5 residents; -Ostomy Care: 1 resident; -Injections: 16 residents; -Mechanically altered diets: 23 residents; -Rehabilitative Services: 24 residents; -Receiving psychoactive medications: [REDACTED] -Receiving antipsychotic medications: [REDACTED] -Receiving antianxiety: 23 residents; -Receiving antidepressant medications: [REDACTED] -Pain management program: 56 residents; and -Unplanned significant weight lass/gain: 6 residents. Review of facility's Facility Assessment 2020, undated, showed the facility did not complete a thorough facility assessment identifying the needs and type of population of residents residing within the facility. Further review showed the facility assessment did not contain the resident population, staff competencies, physical environment, equipment, services, staffing levels, evaluation of diseases, conditions, physical, functional or cognitive status, acuity level required/needed to care for the facility's population.

Based on observation and interview, the facility failed to ensure adequate nursing department staffing was in place to meet the needs for 10 residents (Resident #8, #30, #39, #42, #43, # 44, # 70, #[AGE], #81, and #82) The facility census was 82. 1. Review of Resident #30's quarterly minimum data set (MDS), a federally mandated assessment tool used to plan care, dated 12/2/19, showed facility staff assessed the resident as follows: -BI[CONDITION] of 15; -Limited, one person assist with mobility, dressing and transfer; -Extensive, one person assist with bathing; -Wheelchair use. During an interview on [DATE] at 11:37 A.M., showed the resident said, We don't have enough aides for this hall, I haven't had a shower since last Saturday. I didn't go to breakfast because I smell too bad to go. We have to wait a long time for staff to answer the call lights. 2. Review of Resident #82's quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -BI[CONDITION] of 15; -Extensive, one person assist with locomotion and bathing; -Extensive, two person assist with mobility, transfers and toileting. During an interview on [DATE] at 02:09 P.M., the resident said, There is not enough aides. I didn't get my shower last night, there is only one aide on nights after 10:00 P.M. for all four halls. They have a nurse assistant (NA) but they can't do much. 3. Review of Resident #44's admission MDS, dated [DATE], showed facility staff assessed the resident as follows: -BI[CONDITION] of 15; -Supervision, with one person assist with mobility, transfers, ambulation and hygiene; Review of the resident's nurses' notes dated [DATE], showed staff documented staff entered the resident's bathroom to find the resident sitting on the toilet with blood on floor and without shoes or socks on his/her feet. Additional documentation showed the residnet said he/she hit his/her head and he/she used the call light because he/she needed to use the bathroom, but he/she decided he/she could no longer wait and walked to bathroom by himself/herself. Review of the resident's nurses' notes dated 01/28/20, showed staff documented the resident had an unwitnessed fall, the emergency light in bathroom was going off. Additional documentation showed the resident reported getting up to use bathroom and lost his/her balance. 4. Review of Resident #70's quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Limited, two person assist with bathing; -Extensive, one person assist with locomotion and eating; -Extensive, two person assist with mobility, transfer, dressing and hygiene; -Total, two person assist with toileting; -Use of a wheelchair. Observation on [DATE] at 08:00 A.M., showed the resident sat in the dining room with food in front of him/her with no assistance from staff. Additionally staff fed other residents at the table. 5. Review of Resident #[AGE]'s MDS, dated [DATE], showed staff assessed the resident has a BI[CONDITION] of 15, required extensive assistance from one staff person to toilet and dress and supervision and oversight from staff to transfer. During an interview on [DATE] at 1:07 P.M., the resident said there is not enough staff to assist the residents. He/She said he/she is not supposed to transfer by himself/herself, but will sometimes do so because he/she waits too long for staff to answer his/her call light. The resident said staff come in and turn off the call light, say they will be right back and then don't come back at all. He/She said he/she has had accidents because of waiting too long for staff assistance. 6. During an interview on [DATE] at 09:40 A.M., Resident #42 said it is a struggle sometimes to get assistance because there is not enough staff and he/she said he/she thinks the problem is keeping adequate help. The resident said when he/she uses the call light it can take 10 minutes to never. He/She said staff will come in the room to turn the light off and tell you they will come back and they never come back. 7. Review of Resident # 81's quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Extensive, one person assist with eating and hygiene; -Extensive, two person assist with mobility, transfer and dressing; -Total, one person assist with locomotion; -Total, two person assist with toileting and bathing; -Wheelchair use. Observation on [DATE] at 08:00 A.M., showed the resident sat in the dining room with food in front of him/her with no assistance from staff. Additionally staff fed other residents at the table. Observation on [DATE] at 08:15 A.M., showed the resident's food temperature was 98 degrees before staff assisted the resident with eating. 8. Review of Resident #8's quarterly MDS, dated [DATE] showed facility staff assessed the resident as follows: -Extensive, one person assist with locomotion, eating and hygiene; -Extensive, two person assist mobility, transfer, dressing and toileting; -Total, one person assist with bathing; -Wheelchair use. Observation on [DATE] at 08:00 A.M., showed the resident in the dining room with food in front of him/her. Staff did not assist the resident to eat while they fed other residents at the table. Additional observation at 8:15 A.M., showed the resident's food temperature was 98 degrees Fahrenheit when staff began to assist him/her. Observation on [DATE] at 08:05 A.M., showed certified nursing assistant (CNA) D sat in the dining room and assisted Resident #39 and Resident #43 to eat. Additional observation showed the CNA left the table and went to another table to assist Resident #81 and Resident #8. The CNA went back and forth between all the residents in order to assist them to eat. 9. During an interview on [DATE]20 at 12:29 P.M., CNA C said in an event they need a nurse to come to the memory care unit (MCU), they call the nurse on the wireless phone and talk to him/her or go find him/her on the floor outside of the unit, it depends on the scenario how long it takes the nurse on duty to report to the unit. CNA C said nursing staff rarely come back to the unit. The CNA said they used to send an additional aide to the unit while one is gone, but this unit is out of sight, out of mind. CNA C said there is only one staff present at night. CNA C said there has been issues before with falls with residents while someone was on break. During an interview on 02/07/2020 at 09:47 A.M. CNA A said he/she is the only CNA on the floor right now, and unfortunately it happens a lot when there is only one of them on the floor. Observation at this time showed the CNA assisted a residnet to the bathroom. While this occurred, another resident wandered in and out of three residents' rooms, not belonging to him/her. CNA A said when the resident fell yesterday there was only one staff person on the unit at that time because the other staff person was pulled to another unit. During an interview on 02/12/2020 at 11:32 A.M. CNA B said he/she had to stay over because there wasn't any staff to cover the next shift. CNA B said staffing is bad and he/she is the only staff on the unit at this time because the other staff person was pulled to another unit in the facility. MO [AGE]6 MO 637

Based on observation, interview and record review facility staff failed to properly propel a resident in a wheelchair, which resulted in a fall with a major injury for one resident (Resident #12). Facility staff also failed to do an entrapment assessment for 12 residents with side rails (Residents #1, #2, #3, #4, #5, #7, #8, #9, #11, #12, #13, and #14). Facility census was 82. 1. Review of the facility policy Propelling Resident in Wheelchairs, dated 7/31/12, showed the policy directed staff to place foot rests on wheelchairs to propel residents. Foot rests will then be stored in the resident room or in the foot rest bag holder on the back of the wheelchair. 2. Review of Resident #12's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/31/16 showed staff assessed resident as follows: -Moderate cognitive impairment; -Usually understood others; -Required extensive assistance for bed mobility, locomotion, and transfers; -Did not ambulate; -Balance unsteady from seated position to standing and can only stabilize with assistance; -Balance unsteady from bed to wheelchair, and can only stabilize with assistance; -Fall with no injury; -Fall with injury. Review of the resident's care plan, last updated 3/14/17, showed staff documented: -2/25/17 the resident was found at the foot of his/her bed with his/her wheel chair hung up on the bed, the resident had a large hematoma on his/her forehead -3/13/17 the resident was sent to the hospital to get staples after a fall from his/her wheelchair, the resident hit his/her head. Review of Post Hall Huddle Form, dated 3/13/17 at 2030 (8:30 P.M.), showed staff documented staff propelled the resident in his/her wheelchair, the leg rests were not on the wheelchair, the resident fell out of the chair on his/her head, went to the hospital for a laceration, staples were placed. At Root Cause of fall determined: Foot rest not in place, Certified Nursing Assistant (CNA) education needed regarding foot rests must be in place when wheeling residents in wheelchair. Review of Nurses Note dated 3/13/17, show the staff documented the resident fell forward from his/her chair, hitting the top right side of his/her head on the floor. Resident's head was profusely bleeding from a 1 to 1 1/2 inch jagged laceration not approximated. Further review showed the resident left by ambulance at 8:51 P.M Observation on 3/14/17 at 2:46 P.M., showed the resident propelled himself/herself down the hall in his/her wheelchair. Additional observation showed the resident with a laceration to the top of his/her head with four staples. He/She had a large area of yellow and deep purple bruising on the left side of his/her face. During an interview on 3/16/17 at 6:30 A.M., CNA O said on 3/13/17, he/she propelled the resident in his/her wheelchair, and the resident fell forward out of the chair quickly. The CNA said he/she did not have the foot rests on the wheelchair. The CNA said he/she could not see the resident's feet and did not know if the resident put them down while he/she propelled the wheelchair. The CNA said he/she did not think ahead to get the foot rests out of the room and said he/she should have. The CNA said he/she did not remember if anyone had inserviced him/her about use of footrests on resident wheelchairs before the resident fell . During an interview on 3/16/17 at 10:35 A.M., Registered Nurse (RN) Q said staff are expected to ensure the residents' feet are safe on foot rests before they propel wheelchairs. The RN said it is not safe to propel a resident without the foot rests. During an interview on 3/16/17 at 11:05 A.M., the director of nursing (DON) said staff determined the resident's fall occurred because staff propelled the resident in the wheelchair without foot rests. The DON said he/she will inservice the staff member before he/she comes in for his/her shift tonight. The DON said he/she did not remember if he/she had inserviced the CNA about when to use footrests before this. 2. Review of the facility Bed Safety Policy, dated December 2007, showed staff are directed: -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of the regular bed safety program to identify risks and problems including potential entrapment risks; -Review that gaps within the bed system are within the dimensions established by the FDA (Food and Drug Administration); -Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; -Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; -Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. Further review of the facility Bed Safety Policy, dated December 2007, showed staff are directed to do the following: -The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA (Quality Assurance) Committee for appropriate actions. Copies of the inspection results and QA committee recommendations shall be maintained by the Administrator and/or Safety Committee; -If side rails are used, there shall be an interdisciplinary assessment of the residient, consultation with the Attending Physician, and input from the residient and/or legal representative. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Set up assist for transfers, independent with bed mobility; -Ambulation only once or twice during look back period. Review of the resident's POS, dated 3/2017, showed an order for [REDACTED]. Review of the resident's care plan dated 3/14/17 showed the care plan did not contain documentation about the use of a side rail. Further review showed the resident's medical record did not contain a bed rail entrapment assessment. Observation on 3/14/17 at 2:39 P.M., showed the resident in his/her wheelchair in his/her room with a 1/4 bed rail to the left side of his/her bed, on the upper part of the bed. Observation on 3/15/17 at 10:15 A.M., showed CNA D put the bed rail in the lowered position, and the resident got into bed by him/herself. 4. Review of Residient's #2's MDS, a federally mandated assessment instrument, dated 1/9/17, showed staff assessed the residient as cognitively intact and needs limited assistance of one staff for bed mobility. Review of the resident's care plan, dated 1/25/17, showed staff are directed the residient required supervision to total assist of one to two people for the resident's activities of daily living. Further review showed the residient required extensive assist of one and at times two staff for bed mobility and dressing and is able to assist using side rails and trapeze bar. The resident used 1/4 side rails at the head of the resident's bed to assist with bed mobility and to use the bed controls and a full body mechanical lift with two staff for transfers. Review of the resident's chart showed no entrapment assessment for the side rails on the resident's bed. Observation on 3/14/17 at 12:16 P.M., showed the residient in bed with top two quarter side rails up. Observation 3/14/17 at 2:04 P.M., showed the residient in bed with his/her top two quarter side rails up. Observation on 3/15/17 at 8:44 A.M., showed the residient in bed with his/her top two quarter side rails up. Observation on 3/15/17 at 11:34 A.M., showed the resident in bed with his/her top two quarter side rails up. Observation showed Licensed Practical Nurse (LPN) A entered the room and assisted the residient to roll to his/her side in bed. Observation showed the residient used the side rails to assist and turn in bed. Observation on 3/15/17 at 12:24 P.M., showed the resident in bed with his/her top two quarter side rails up. 5. Review of Resident #3's MDS, dated [DATE], showed staff assessed the residient as the following: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility and dressing; -Required total assistance of of two or more staff for transfers and toileting. Review of the residient's care plan, dated 3/14/17, showed staff are directed the residient required assist of one and at times two with activities of daily living. The residient required extensive assistance of one staff for side to side and assist of two staff with moving up in bed for bed mobility, a full body mechanical lift with two staff for transfers. Staff are directed to use the two upper side rails to assist with positioning and bed mobility due to weakness to promote independence with bed mobility. Further review of the residents care plan, updated 3/14/17, showed the facility staff documented on 12/17/16 the resident was found on the floor next to his/her bed. Staff noted an increased in confusion. Review of the resident's POS, undated, showed the physician ordered quarter side rails for increased mobility. Review of the residient's nurses progress notes, dated 12/17/16, showed staff documented the resident's alarm was sounding and residient was on the floor at the end of the bed. The residient stated I tried to walk over there, pointing to the end of his/her bed Review of the resident's medical record showed no entrapment assessments for side rails on the resident's bed. Observation on 3/14/17 at 1:44 P.M., showed the resident in bed. with the top two quarter side rails up. Observation showed CNA D and CNA E provided incontinent care to the residient. CNA E and CNA D turned the residient side to side in bed during care. Observation showed the resident did not use the side rails to assist to turn. Observation showed the residient's right side rail with a gap between the residient's side rail and mattress and the resident's right side rail loose. During an interview on 3/14/17 at 1:41 P.M., CNA E and CNA D said the resident uses the side rails because he/she will fall out of bed. CNA E and CNA D said the residient does not really use the side rails for bed mobility, sometimes he/she will grab the bars when staff turn the residient. CNA E and CNA D said the residient does not have good body control and the residient's leg sometimes falls out of bed, and the residient can not get his/her leg back into bed by him/her self. Observation on 3/15/17 at 9:23 A.M., showed the resident in bed with the top two quarter side rails up. CNA F turned the residient to his/her side. Observation showed the residient did not grab the bar to assist to turn. During an interview on 3/15/17 at 9:23 A.M., CNA F said the residient uses the side rails because he/she would fall out of bed. CNA F said he/she has seen the residient come out the side of the bed and try to stand up. Observation on 3/16/17 at 5:30 A.M., showed the residient in bed with the top two quarter side rails up. During an interview on 3/16/17 at 11:27 A.M., the DON said the resident uses the side rails for mobility in bed and does sometimes grab the bars when staff turn the resident to his/her sides in bed. The DON said the resident has not fallen out of bed before, but has gotten up out of bed and then fallen. The DON said if the resident's leg falls out of bed, the residient could not get his/her leg back in bed by him/her self. 6. Review of Resident #4's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Extensive assistance of two staff for bed mobility; -Dependent on two staff for transfers; -Did not ambulate; -Dependent on staff for locomotion -Balance from surface to surface unsteady, can only stabilize with help. Review of the resident's POS, dated 3/2017, showed an order for [REDACTED]. Review of the resident's care plan, dated 1/25/17, showed staff documented on 3/8/16 the resident rolled out of bed and staff found the resident on the floor next to the bed with his/her legs bent underneath his/her body and his/her right arm between the bed frame and the side-rail. Further review showed staff are directed the resident uses both upper side-rails on the bed to assist with positioning and bed mobility due to weakness and to promote independence with bed mobility. Further review showed the resident uses a full body mechanical lift with assistance of two staff for transfers. Further review showed the resident's medical record did not contain a bed rail entrapment assessment. Observation on 3/14/17 at 1:05 P.M., showed CNA J and NA I turned the resident in his/her bed during the provision of care. The resident kept his/her arms folded on his/her chest when turned and did not touch the bed rails. During an interview on 3/14/17 at 1:24 P.M., Nurse Aid (NA) I said the resident cannot turn himself/herself or help the staff to turn him/her. Observation on 3/15/17 at 2:40 P.M., showed CNA H and CNA M turned the resident in his/her bed during the provision of care, the resident did not use the bed rails. 7. Review of Resident #5's most recent MDS, dated [DATE] showed staff assessed the resident as: -Severely cognitively impaired. -Extensive assistance with bed mobility, physical assistance of two or more. -Total dependence with transfers. -Only able to stabilize with human assistance when transferring. Review of the resident's POS, dated 05/08/13 through 03/16/17 showed one-fourth side rails as needed to increase bed mobility. Review of the resident's care plan, dated 01/25/17 showed staff are directed to provide one-fourth side rails at the head of the bed to assist with bed mobility. Further review of the resident's medical record showed the record did not contain documentation of an entrapment assessment. Observation on 3/15/17 at 2:55 P.M., showed the resident in bed with top two-quarter side rails up. Observation showed CNA B and CNA C provided care and assisted the resident to turn in his/her bed. Observation showed the resident did not use the side rails to assist in turning in bed. 8. Review of Resident #7's quarterly MDS, dated [DATE] showed staff assessed resident as follows: -Severe cognitive impairment; -Extensive assistance bed mobility; -Extensive assistance for transfers; -Limited assistance of one to ambulate; -Limited assistance for locomotion; -Balance unsteady, only stabilizes with assistance. Review of the resident's physicians orders, dated 3/2017, showed an order for [REDACTED]. Further review showed the resident's medical record did not contain a bed rail entrapment assessment. Observation on 3/16/17 at 5:57 A.M., showed the resident's bed with one quarter side rails up and the resident's other side rail next to the wall. 9. Review of Resident #8's most recent MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired. -Extensive assistance with bed mobility, physical assistance of two or more. -Extensive assistance of two or more with transfers. -Only able to stabilize with human assistance when transferring. Review of the resident's POS, dated 07/10/15 through 03/16/17 showed an order for [REDACTED]. Review of the resident's care plan, dated 02/09/17 showed staff are directed to provide upper rails to assist with repositioning and mobility due to weakness and to promote independence with bed mobility. Further review of the resident's medical record showed the record did not contain documentation of an entrapment assessment. 10. Review of Resident #9's most recent MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with bed mobility; -Independent with transfers; -Steady during transfers. Review of the resident's POS, dated 07/09/13 through 03/16/17 showed an order for [REDACTED]. Review of the resident's care plan, dated 01/02/17 showed staff are directed to provide side rails to assist with positioning and mobility due to weakness and to promote independence with bed mobility. Further review of the resident's record showed the record did not contain documentation of an entrapment assessment. 11. Review of Resident #11's most recent MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Extensive assistance with staff providing weight-bearing support while in bed; -Limited assistance with guided maneuvering of limbs by staff with transfers; -Not steady, but able to stabilize without human assistance when transferring. Review of the resident's POS, dated 07/16/15 through 03/16/17 showed an order for [REDACTED]. Review of the resident's care plan, dated 01/12/17 showed staff are directed to provide side rails to assist with turning and positioning. Further review of the resident's record showed the record did not contain documentation of an entrapment assessment. 12. Review of Resident #12's annual MDS, dated [DATE], showed staff assessed resident as follows: -Moderate cognitive impairment; -Extensive assistance for bed mobility; -Extensive assistance for transfers; -Did not ambulate; -Extensive assistance for locomotion -Balance unsteady from seated position to standing can only stabilize with assistance; -Balance unsteady from bed to wheelchair, can only stabilize with assistance. Review of the resident's POS, dated 3/2017, showed an order for [REDACTED]. Review of the resident's care plan, last updated 3/14/17 , showed the resident uses two upper side-rails to assist with positioning and bed mobility because of weakness and to promote independence with bed mobility. Further review showed the resident's medical record did not contain a bed rail entrapment assessment. Observation on 3/15/17 at 12:17 P.M., showed the resident's bed with the top two quarter side rails up. 13. Review of Resident #13's quarterly MDS, dated [DATE], showed staff assessed resident as follows: -Severe cognitive impairment; -Limited assistance for bed mobility; -Limited assistance for transfers; -Supervision to ambulate; -Independent for locomotion -Balance unsteady but can steady self. Review of the resident's POS, dated 3/2017, showed the documentation did not contain an order for [REDACTED]. Review of the resident's care plan, last updated 3/10/17, showed the documentation did not contain direction for the use bed rails. Further review showed the resident's medical record did not contain a bed rail entrapment assessment. Observation on 3/15/17 at 12:17 P.M., showed the resident in bed with the top two quarter side rails up, large space between bed rail and mattress. Observation showed fall mats were on the left side of the bed on the floor. 14. Review of Resident's #14's MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment and extensive assistance of two or more staff for bed mobility and transfers. Review of the resident's care plan, dated 3/14/17, showed staff are directed the resident required one assist for bed mobility and two assist and a full body mechanical lift for transfers. Further review showed the resident used the upper two side rails on the resident's bed to assist with positioning and bed mobility due to weakness to promote independence with bed mobility. Review of the resident's POS, undated, showed the physician ordered upper quarter side rails up while in bed. Review of the resident's chart showed no entrapment assessment for the side rails on the resident's bed. 15. During an interview on 3/16/17 at 6:38 A.M. the DON said facility staff do not complete entrapment assessments and nobody measures the mattresses and checks the space between the side rails and the mattress. The DON said the requirement started in November and just have not implemented it yet. 16. During an interview on 3/16/17 at 9:20 A.M., the Maintenance Supervisor said all resident's beds come with factory rails to match the beds. He/She said nursing staff is in charge of whether the side rails are used. He/She said the nurses obtain a physician's order prior to side rails use. He/She said because the side rails are factory matched with the beds, there is no side to side adjustment on the bed rails. He/She said the only adjustment on the bed rails was a height adjustment. 17. During an interview on 03/16/17 at 9:21 A.M., CNA B said staff use side rails so the residents don't fall out of bed. Some residents use them to pull themselves up in bed. Resident #4 uses side rails to prevent falls out of the bed. He/she has not observed Resident #4 use side rails for mobility. Residents #5 and #8 use side rails for bed mobility. 18. During an interview on 03/16/17 at 9:29 A.M., RN G said side rails are used for bed mobility and assistance with transfers. Residents #4, #5, #8 use side rails for mobility and might not be able to get up without them. Staff have to lower Resident #4's side rails to transfer him/her out of bed. 19. During an interview on 03/16/17 at 9:36 A.M., CNA H said side rails are used to keep residents from rolling out of bed. Staff use side rails for Residents #4 and #5 to prevent falls out of bed. Resident #8 uses side rails for mobility. 20. During an interview on 03/16/17 at 10:15 A.M., CNA P said side rails are used for different reasons. Staff use side rails for Residents #13 because he/she moves in his/her sleep so they keep him/her from rolling out of bed. He/She cannot put her own feet in the bed but can get up without help. The CNA said that Resident #11 uses the bed rail as a handle to get his/herself up without assistance. The CNA said Resident #7 used the bed rail to get up but has been weak lately and staff have to help her and put her feet in the bed when she gets in bed. The CNA said Resident #12 uses bed rails for safety to keep him/her from falling, he/she cannot put own feet in the bed, and he/she cannot get up without help. Resident #14 has bed rails because he/she feels like he/she is falling so it gives him/her something to hold onto, he/she cannot put his/her own feet into bed. Resident #3 will hold his/her bed rail when he/she is turned in bed, yesterday he/she got her leg off the bed and creamed because it hurt, he/she was stuck. 21. During an interview on 03/16/17 at 10:35 A.M., RN Q said side rails are used for bed mobility and assistance with transfers. Staff use side rails for Residents #13 to help him/her turn his/her self, sometimes he/She cannot put her own feet in the bed. The RN said that Resident #11 uses the bed rail as a handle to get his/herself up without assistance, the resident can not get legs into bed his/her self. The RN said Resident #7 used the bed rail to get up but has been sick, and staff have to help him/her more, and put his/her feet in the bed when he/she gets in bed. The RN said that Resident #12 uses the bed rail to sit up, he/she cannot put his/her own feet in the bed, and he/she cannot get up without help. Resident #14 has bed rails to hold his/herself over, he/she cannot put his/her own feet into bed or turn his/herself. Resident #3 will hold his/her bed rail when he/she is turned in bed, he/she cannot put his/her own feet into bed or turn his/herself.

Based on interview and record review the facility staff failed to notify one resident's (Resident #1) physician about a change in condition of a surgical incisions on the resident's left thigh and calf, in a timely manner. Staff recorded a change in the amount and color of drainage to the calf incision, and that the edges of the thigh incision pulled apart, but failed to notify the physician of these identified changes. The incision on the resident's calf became infected requiring antibiotic treatment. The facility census was 32. 1. Review of Resident #1's Admission assessment dated [DATE] showed staff recorded the resident had a chest incision and left leg incision (thigh and calf). Staff did not record further assessment or the condition of the incisions on admission. Review of the resident's Physician order [REDACTED]. -Coronary Artery Bypass Graft (CABG) times four (surgery to bypass blocked arteries to the heart), [MEDICAL CONDITION], Depression. Review of the resident's nurses notes dated 6/15/11 (6 A.M. to 6 P.M.) showed staff recorded, "left lower leg serosanguinous (blood tinged clear fluid) drainage moderate amount seeping thru incision. Pressure dressing on and wrapped." Review of the POS [REDACTED]. Review of a Temporary Plan of Care dated 6/17/11 showed staff planned to assess the incisions daily and "dress as ordered." Review of the resident's Treatment Administration Record (TAR) dated 6/14/11 - 6/28/11 showed staff signed they completed the dressing change from 6/17 through 6/23. Review showed staff did not sign they completed the dressing change on 6/24 and 6/25. Staff recorded the resident was on a leave of absence on 6/26. Staff did not sign they completed the treatment on 6/27. Review of a nurses note dated 6/20/11 (7:00 A.M. to 3:00 P.M.) showed staff recorded the chest wound edges were approximated (to bring together), no drainage or redness was noted. The left thigh incision's edges were not approximated. Staff recorded they applied steri-strips to the thigh incision. Additionally, staff recorded the left calf incision had a "large amount" of serosanguinous drainage. Staff recorded they applied a pressure dressing. Staff did not record they notified the resident's physician of the changes in the condition of the wound or the addition of the steri-strips and pressure bandage to the wound. Review of a nurses note dated 6/22/11 (7:00 A.M. to 3:00 P.M.) showed staff recorded, "left leg incision bloody drainage noted." Review did not show the staff informed the resident's physician of the "bloody drainage." Review of a nurses note dated 6/24/11 (7:00 A.M. to 3:00 P.M.) showed staff recorded the thigh incision was slightly red, the edges were not approximated, and they applied steri strips. Review showed staff did not record they notified the resident's physician of the changes. Review of a Physician order [REDACTED]. Review of a nurses note dated 6/27/11 (no time noted) showed staff recorded, "left lower extremity incision infected. Yellow drainage noted new order Keflex. Incision cultured." During a interview on 7/8/11 at 2:20 P.M. Licensed Practical Nurse (LPN) A said, the incision on the resident's inner leg became red and the edges of the wound were not approximated. LPN A said he/she did not contact the resident's physician about the changes he/she assessed in the wound. LPN A said the physician ordered an antibiotic on 6/27/11. During a interview on 7/8/11 at 2:30 P.M. the Director of Nursing said she would expect staff to contact the physician when any change is noted in the wound. During a interview on 7/11/11 at 2:00 P.M. the resident's physician said he would expect the staff to contact him/her with changes in a incision that had dehisced (pulled apart) when noted. MO 273