Every finding on record at Lee's Summit Place

On 5/26/26, the Administrator was notified of the past noncompliance which took place on 5/11/26. The resident's physician was notified of the error. The Director of Nursing (DON) provided facility staff training on 5/11/26 with return demonstration provided. The deficiency was corrected on 5/11/26. Review of facility policy entitled Medication Administration revised 2/7/24 showed:-Medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Identified resident by photo in the Medication Administration Record (MAR).-Review MAR to have identified medication to be administered. -Compare medication with MAR to have verified resident name, medication name, form, dose, route, and time. -Observed resident consumption of medication. 1.Review of Resident #2 admission Record showed the resident admitted to the facility on [DATE] with the following diagnosis:-Essential Hypertension (High Blood Pressure).-Peripheral Vascular Disease (a slow, progressive circulation disorder characterized by narrowed, blocked, or spasmodic blood vessels outside the heart and brain).-Atrial Fibrillation ( a condition where the heart's upper chambers (atria) beat irregularly and out of sync with the lower chambers).-Hyperlipidemia (high levels of lipids (fats), such as cholesterol and triglycerides, in the blood). Review of facility investigation dated 5/11/26 showed:-Resident #2 received the following medications in error:--Allopurinol ( a prescription medication primarily used to prevent gout attacks and kidney stones by lowering uric acid levels in the blood) 100 milligram (mg).--Ascorbic Acid (naturally occurring, water-soluble micronutrient better known as Vitamin C) 500 mg.--Cephalexin (antibiotic used to treat a wide variety of bacterial infections, such as those affecting the skin, respiratory tract, bones, and urinary tract) 500 mg.--Cetirizine (antihistamine used to treat allergy symptoms like sneezing, runny nose, itchy or watery eyes, and hives) 10 mg.--Cholecalciferol ((Vitamin D3) is a naturally occurring, fat-soluble vitamin) 5000 units.--Duloxetine (antidepressant and nerve pain medication) 30 mg.--Kerendia (used to slow the progression of chronic kidney disease (CKD)) 20 mg.--Lamotrigine (prescription medication classified as an anticonvulsant) 200 mg.--Senna-Docusate 8.6 mg-50 mg (stool softener).--Slow Iron Extended Release (supplement) 142 mg.--Torsemide (a loop diuretic, or water pill, that helps your body get rid of excess salt and fluid) 10 mg. --Acetaminophen Extra Strength (pain relief medication) 500 mg.-A root cause analysis of the event.-Witness statement from the nurse involved.-A completed Medication Error Incident Report. Review of Incident Note dated 5/11/26 at 11:09 A.M. showed:-The nurse notified the DON that a resident received medication intended for another resident. The Nurse Practitioner was notified immediately. The resident was immediately assessed Vital signs: blood pressure 159/75 millimeters mercury (mmHg) (normal range 90-120/60-80 mmHg), pulse 60 beats per minute (BPM)(normal range 60-100 BPM), reparations 16 even and unlabored (normal range 12-20), Oxygen saturation 93% on room air (normal range 92-100), blood sugar was 237 (normal range 80-130). Resident was alert and able to verbize needs. The resident complained of nausea and anti-nausea medication administered per NP order. No additional reactions noted no respiratory distress, changes in level of consciousness, chest pain, or alteration in mental status. Following further review of medications administered and out of abundance of precaution NP gave orders to transfer the resident to the hospital for further monitoring. Resident transferred to the hospital in stable condition. Report called to hospital and daughter notified. Review of Witness Statement from Certified Medication Technician (CMT) A dated 5/11/26 showed:-He/She was distracted by another resident when preparing medications for a resident.-As he/she was preparing medications for a resident when another resident interrupted him/her asking for medication.-He/She stopped working on the medications for the current resident and gave the requested medication to the resident who interrupted him/her. -Then went back to doing the medications for the resident he/she had prepared medications for. -He/She then went in and gave the medications to Resident #2.-He/She then came back to the medications cart to sign out the medications and realized he/she gave Resident #2 medications that were meant for another resident. During an interview on 5/26/26 at 10:36 AM, CMT A said:-He/She got distracted during medication pass when another resident interrupted him/her during medication pass. -He/She stopped working on the medication for one resident and gave the resident that had interrupted him/her the mediation the resident was requesting. -He/She finished preparing the medication that was to be given. -He/She went into the wrong room and gave the resident the wrong medications. -He/She thought she knew the resident who he/she was giving medications too. -He/She did not follow the five rights of medication administration (right patient, right medication, right dose, right route, and right time).-He/She came back out to the medication cart to chart medication given and then realized she gave Resident #2 the wrong medication that belonged to another resident. -When he/she realized the error he/she notified the DON and the doctor. -The doctor said to give the resident his/her correct medication, and to monitor the resident, and send the resident to the hospital in case the resident had a serious reaction. -The resident did not have any serious reactions to receiving the wrong medication but was sent to the hospital just in case for more detailed monitoring. -He/She was reeducated on the five rights of medication administration by the DON, as well as all staff, and did a new medication pass competency to show he/she could safely pass medication. During an interview on 5/26/26 at 12:03 PM, Licensed Practical Nurse (LPN) A said:-When you gave medication you verified the resident by the picture of the resident on the Medication Administration Record (MAR) to ensure you had the correct resident. -Once you verified the picture on the MAR matched the resident you were doing medications for you then followed the five rights of medication administration. -When the five rights of medication administration were followed no residents would get the wrong medications. -He/She heard a resident had gotten the wrong meds.-The residents had no sever adverse reactions but was sent to the hospital for precautions. -The medication error was preventable. -After the incident all the staff received education on medication administration, five rights of medication administration, and staff were observed to ensure medication pass done properly and followed the five rights of medication administration.During an interview on 5/26/26 at 12:20 P.M., CMT B said:-He/she followed the five rights of medication administration to ensure that medication errors were prevented. -If a resident was interrupting him/her you finished preparing the medications for the resident you were getting medications for, and resident that interrupted you would have told that you would be with next once these medications for the resident you were working on was done and focus on the meds and tell the resident that was interrupting you to wait nicely. -There was training on medication administration and how to ensure there were no medication errors, and observation on medication administration. During an interview on 5/26/26 at 12:47 P.M., DON said:-It was his/her expectation that nurses and CMT's would follow facility policy.-It was his/her expectation that staff passing medications would have followed the five rights of medication administration. -It was his/her expectation that when staff were preparing medication to be given to a resident, that if another resident interrupted the staff during that process that the staff would have told the resident that the staff were preparing another residents medication, and when the staff were done with that residents medication then the staff could help that resident. -If the staff had followed the five rights of medication administration, then the medication error would not have happened. -When he/she was notified of the mediation error he/she ensured the doctor was notified and the family were notified. -The resident that had received the wrong medication had no adverse reactions but was sent to the hospital for further monitoring out of precaution. -The facility now has signs on the medication cart that showed medication pass was in progress and to please do not disturb. During an interview on 6/2/26 at 4:08 P.M., the physician said:-He/She would have expected the resident to have received the correct medication, and not another resident's medication. -He/She would have expected staff that passed medications to have followed facility policy. -He/She would have expected the staff passing medications to have followed the five rights of medication administration. -He/She believed had staff doing medication administration had followed facility policy, and the five rights of medication administration then a medication error would not have happened. -He/She believed the Nurse Practitioner followed the correct interventions for the medication error by having the resident sent to the hospital due to the medications that were given. 3012182

Based on observation, interview and record review, the facility failed to follow the facility's policies; failed to ensure prevention and treatment of pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); failed to identify individuals at risk for developing pressure injuries; failed to assess, monitor, and measure the wounds at least weekly and document the findings; failed to observe for changes in the pressure injury that could indicate a change in the treatment; failed to implement the interventions on the residents plan of care; and failed to follow physician's orders for the treatment of pressure injuries for two sampled residents (Resident #26 and #307) out of 12 sampled residents. The facility census was 48 residents. Review of the facility policy titled Comprehensive Care Plan, dated 9/1/21, showed: -It was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will describe any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. -The facility would attempt alternate methods for refusal of treatment and services and document such attempts in the clinical records, including discussion with the resident and/or resident representative. Review of the facility policy titled Medical Provider Orders, dated 4/7/22, showed: -The facility used uniformed guidelines for the ordering and following of medical provider orders. -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contained all required elements. -Staff would follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. -If an order did not contain all of the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order. -Written transfer orders (sent with a resident by a hospital or other health care facility) would be implemented without further validation, if It was signed and dated by the resident's current attending medical provider, unless the order was unclear or incomplete, or the date signed is different from the date of admission. -If a transfer order was unsigned, signed by a different medical provider, or the date was other than the admitted , the receiving nurse should verify the order with the current attending medical provider. Review of the facility policy titled Skin Assessment, dated 9/1/22, showed: -It was the facility's policy to perform a full body skin assessment as part of the facility systematic approach to pressure injury prevention and management. -A full body, or head to toe skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. -The skin assessment may also be performed after a change of condition or after any newly identified pressure injury. -Documentation of the skin assessment included: Date and time of the skin assessment, the staff members name, and the staff members position title. -Documentation of the skin assessment included observations (skin condition, how the resident tolerated the procedure, etc.) -Documentation of the skin assessment included the type of wound. -Documentation of the skin assessment included description of the wound (measurement, color, type of tissue in wound bed, drainage, odor, pain). -Documentation of the skin assessment included if resident refused assessment and why. 1. Review of Resident #26's admission record showed: -The resident had a diagnosis of cognitive deficit (a problem or impairment in one or more aspects of a person's mental abilities, such as memory, attention, or problem-solving). -There was no diagnosis of pressure injury and/or any other skin wounds on the resident's admission record. Review of the resident's care plan dated 2/20/25, showed: -The resident had potential for impairment to skin integrity. -The resident would maintain or develop clean and intact skin by the review date. Review of the resident's Physician Order Sheet (POS) dated 2/21/25, showed weekly skin assessments were to be performed every Friday. Review of the resident's Admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/24/25 showed the resident: -Had moderate cognitive impairment. -Was at risk for developing pressure injury. -Did not have any pressure injuries, or any other skin problems. -Did not have any skin or ulcer/wound treatments. Review of the resident's weekly nursing skin assessment dated [DATE], showed: -A pressure injury on the resident's right outer ankle. --There were no measurements documented. --There was no description documented. -An area of discoloration on the resident's left outer ankle. --There were no measurements documented. --There was not description documented. Review of the resident's skin monitoring: Comprehensive Certified Nurse Assistant (CNA) shower review sheet dated 3/14/25, showed no wounds or other skin concerns were documented. Review of the resident's weekly nursing skin assessment dated [DATE], showed no documentation and/or description of the resident's pressure injuries. Review of the resident's skin monitoring: Comprehensive CNA shower review sheet dated 3/24/25, showed no wounds or other skin concerns were documented. Review of the resident's Initial outside wound company evaluation and management summary dated 3/25/25, showed: -The resident presented with wounds on his/her left lateral ankle, left lateral (outer) heel; and right lateral ankle. -Left lateral ankle measured 0.6 centimeters (cm) X 1.7 cm X Not measurable. --The dressing treatment plan was to apply skin prep once daily for 30 days. ---This was an unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) -Left lateral heel measured 0.6 cm X 1.5 cm X Not measurable. --The dressing treatment plan was to apply skin prep once daily for 30 days. ---This was an unstageable pressure injury. -Right lateral ankle measured 1.1 cm X 1.0 cm X Not measurable. --The dressing treatment plan was to apply betadine once daily for 30 days. ---This was an unstageable pressure injury. --NOTE: The wound care company evaluated the resident 13 days after the left lateral ankle and the right lateral ankle were found. Review of the resident's Treatment Administration Record (TAR) dated March 2025 showed: -The left lateral ankle and left lateral heel treatment was: apply skin prep every shift, two times a day to start on 3/30/25. --The treatment started five days after the wound care company evaluated the wound and was 18 days after recognizing the pressure injuries. -NOTE: There were no orders that addressed the right lateral ankle. Review of the resident's weekly nursing skin assessment dated [DATE], showed no observation and/or description of the resident's pressure injuries. Review of the resident's skin monitoring: Comprehensive CNA shower review sheet dated 3/28/25, showed no wounds or other skin concerns were documented. Review of the resident's POS dated 3/30/25, showed: -Treatment to the left lateral ankle and left lateral heel was to apply skin prep every shift, two times a day. -NOTE: There were no orders that addressed the resident's right lateral ankle. Review of the resident's weekly wound assessment dated [DATE], showed: -The resident had a facility acquired pressure injury on his/her right lateral ankle. --The date of onset for the pressure injury was 3/12/25. --The wound measured 1.1 cm in length X 1.0 cm in width X undetermined depth. -The resident had a facility acquired pressure wound on his/her left lateral ankle. --The date of onset for the pressure injury was 3/12/25. --The wound measured 0.6 cm in length X 1.7 cm in width X undetermined depth. -NOTE: The right lateral ankle was not assessed, Review of the resident's skin monitoring: Comprehensive CNA shower review sheet dated 3/31/25, showed no wounds or other skin concerns were documented. Review of the resident's weekly nursing skin assessment dated [DATE], showed no observation and/or description of the resident's pressure injuries. Observation on 4/3/25 at 11:49 A.M. of wound care with Licensed Practical Nurse (LPN) A and Registered Nurse (RN) A showed: -The resident had three wounds on his/her left lateral ankle. -Gauze was in between the resident's socks and his/her left lateral ankle. -There was no wound dressing and/or bandages in place on the resident's left lateral ankle. -RN A placed skin prep on all three wounds on the resident's left lateral ankle. -RN A placed a dressing over the three wounds on the resident's left lateral ankle. --NOTE: No wound care was completed on the resident's right lateral ankle. During an interview on 4/3/25 at 11:49 A.M. LPN A and RN A said the wound care for the resident was complete. During an interview on 4/3/25 at 11:49 A.M. the resident said RN A may remove the sock from his/her right foot. Observation on 4/3/25 at 11:49 A.M. showed the resident had a pressure injury on his/her right lateral ankle that measured approximately 1.1 cm X 1.0 cm X not measurable. During an interview on 4/3/25 at 11:58 A.M., LPN A said: -He/She was not aware there was a wound on the resident's right lateral ankle. -There were no physician orders for any treatment to the the resident's right lateral ankle. -He/She had not been completing any treatments or medication application on the resident's right lateral ankle. During an interview on 4/3/25 at 12:10 P.M., the resident said the staff had not been doing any type of wound care to his/her right lateral ankle. Observation on 4/7/25 at 9:39 A.M., of wound care with LPN A and the Assistant Director of Nursing (ADON), showed: -A dressing was removed from the resident's right lateral small toe that was dated 4/6/25. -LPN A applied skin prep to the pinpoint sized wound on the outside of the resident's small toe and applied a wound bandage. -An open wound was seen on the resident's right lateral foot. --LPN A measured the wound to the resident's lateral right foot 1.5 cm X 1 cm X non measurable. -An open wound seen on the resident's coccyx (tailbone). --A crumbled up dressing that had no initials or date was removed from the resident;'s coccyx area by the ADON, ---The coccyx wound measured 1.0 cm X 1.0 cm. ---The ADON applied ointment to the coccyx area and left it open to air. The resident was repositioned to his/her back. During an interview on 4/7/25 at 9:48 A.M., LPN A said there were no orders for the coccyx wound. During an interview on 4/7/25 at 10:02 A.M., the resident said: -He/She could not recall when his/her coccyx wound started. -He/She could not recall who placed the wound dressing on the coccyx wound or when it was placed, he/she believed it was the previous shift night nurse. -The coccyx wound was causing him/her some discomfort. Review of the resident's POS dated April 2025 showed no orders for any treatment to the resident's coccyx area. 2. Review of Resident #307's admission record, dated 3/25/25, showed: -The resident was his/her own responsible party. -The resident had a diagnosis of pressure injury to his/her sacral (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) area, Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) . -The resident had a diagnosis of pressure injury at other site, unstageable. -The resident had a diagnosis of cognitive communication deficit. Review of the resident's facility to facility transfer report from the hospital dated 3/25/25, showed: -Left sided ischial tuberosity (the rounded bone that extends from the ischium - the curved bone that makes up the bottom of your pelvis). pressure injury; 4 cm X 2 cm X 4 cm; Stage IV. --Cleanse wound with wound cleanser, pat dry. Pack to depth with Dakin's (A solution that kills germs and prevent their growth in wounds. It can also help dissolve dead tissue- necrosis). 1/4 strength soaked kerlex to depth. Cover with foam adhesive dressing every shift. -Right sided ischial tuberosity pressure injury; 1.5 cm X 1.5 cm X 1 cm; Stage IV. --Cleanse wound with wound cleanser, pat dry. Pack to depth with Dakin's 1/4 strength soaked kerlex to depth. Cover with foam adhesive dressing every shift. -Sacrum pressure injury; 6 cm X 5 cm X 4.5 cm; Stage IV. -- Cleanse wound with wound cleanser, pat dry. Pack to depth with Dakin's 1/4 strength soaked kerlex to depth. Cover with foam adhesive dressing every shift. -Left lateral (outside) knee pressure injury; 1 cm X 0.5 cm X 0.1 cm; Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). --Cleanse wound with wound cleanser, pat dry. Apply Silvadene to wound bed. Apply 1-2 layers of Xeroform gauze to wound. Cover with foam adhesive dressing every shift. -Right sided toe pressure injury; Unstageable. --Cleanse wound with wound cleanser, pat dry. Apply betadine painting to toe. Leave open to air daily. -Contact isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA-a type of bacteria that is resistant to many antibiotics) in the wound. Follow facility guidelines. Review of the resident's admission skin assessment dated [DATE], showed: -The resident had a Stage III pressure injury on his/her right buttock. --There were no measurements documented. -The resident had a Stage III pressure injury on his/her left buttock. --There were no measurements documented. -The resident had a Stage III pressure injury on his/her sacrum. --There were no measurements documented. -The resident had a pressure injury on his/her left knee. --There were no measurements documented. --Described as open and covered with 4X4 for protection. -The resident had a pressure injury on his/her right lower leg (front). --There were no measurements documented. --Described as closed and covered with 4X4 for protection. -There was no mention of the right toe wound. -NOTE: There was no mentioned of the resident's wounds having MRSA. Review of the resident's admission MDS dated [DATE], showed: -One Stage III pressure injury upon admission to the facility. -Three Stage IV pressure injuries upon admission to the facility. -The resident had zero unstageable pressure injuries upon admission to the facility. -NOTE: The right toe wound was not captured on the resident's MDS. Review of the resident's POS dated 3/25/25, showed: -Left Ischial Tuberosity cleanse with wound cleanser, pat dry. Pack with Dakins soaked kerlix (A type of bandage roll made from 100% woven cotton with a unique crinkle-weave pattern) to depth. Cover with foam Dressing every shift (twice per day) and as needed for soiling. -Right ischial tuberosity wound cleanse with wound cleanser, pat dry. Pack with Dakins soaked kerlix to depth. Cover with foam dressing every shift (twice per day) and as needed for Soiling. -Sacrum wound cleanse with wound cleanser, pat dry. Pack with Dakins 1/4 strength soaked kerlex to depth. Cover with foam adhesive every shift (twice per day) and as needed for soiling. -Left lateral knee wound cleanse with wound wash, pat dry. Apply Silvadene to wound bed. Apply a layer of Xeroform to wound bed. Cover with foam adhesive dressing every shift (twice per day) and as needed for soiling. every shift -Right 4th toe wound. Cleanse wound with wound wash, pat dry. Apply betadine to toe. Leave open to air daily and as needed. -There were no orders for skin assessments. Review of the resident's care plan dated 3/28/25, showed: -An unstageable pressure injury of the left foot, third digit. --The wound was actually on the resident's right fourth digit. -A Stage IV pressure injury of the sacral region. -The resident's left ischial tuberosity, right ischial tuberosity, and left lateral knee were not addressed in the care plan. -There were no updates to the care plan that indicated the resident refused treatments to his/her wounds. Review of the resident's TAR dated April 2025, showed: -Left Ischial Tuberosity wound cleanse with wound cleanser, pat dry. Pack with Dakins soaked kerlix to depth. Cover with foam dressing every shift (twice per day) and as needed for soiling every shift. --The resident refused wound treatment on 4/1/25, 4/2/25, and 4/3/25 on the day shift. -Right ischial tuberosity wound cleanse with wound cleanser, pat dry. Pack with Dakins soaked kerlix to depth. Cover with foam dressing every shift (twice per day) and as needed for soiling every shift. --The resident refused wound treatment on 4/1/25, 4/2/25, and 4/3/25 on the day shift. -Sacrum wound cleanse with wound cleanser, pat dry. Pack with Dakins 1/4 strength soaked kerlex to depth. Cover with foam adhesive every shift (twice per day) and as needed for Soiling every shift. --The resident refused wound treatment on 4/1/25, 4/2/25, and 4/3/25 on the day shift. -Left lateral knee wound cleanse with wound wash, pat dry. Apply Silvadene to wound bed. Apply a layer of Xeroform to wound bed. Cover with foam adhesive dressing every shift (twice per day) and as needed for soiling, every shift. --The resident refused wound treatment on 4/1/25, 4/2/25, and 4/3/25 on the day shift. -Right 4th toe wound cleanse wound with wound wash, pat dry. Apply betadine to toe. Leave open to air daily and as needed. --The resident refused wound treatment on 4/1/25, 4/2/25, and 4/3/25 on the day shift. -NOTE: There were no orders for skin assessments. During an interview on 4/1/25 at 9:45 A.M., the resident said: -Since being admitted staff had not changed the dressings to his/her left and right ischial tuberosities, sacrum and left lateral knee. -Since his/her admission the right toe wound dressing had been changed one time. -He/she has never refused a wound treatment for any of his/her wounds. -He/She was admitted for wound care. -He/She would be able to go home when they were better. -He/She was upset that they were not changing the dressings because that was the whole reason he/she was at the facility. Review of the resident's medical record dated 4/1/25 to 4/3/25 showed: -There was no documentation with any details about the resident's refusal of wound treatments. -There were no skin assessments in the resident's record. -There were no wound measurements in the resident's record. -There were no nursing notes regarding the resident's wounds. During an interview on 4/3/25 at 10:32 A.M., the Medical Director said: -He/She would expect weekly skin assessments to be completed and documented on residents in the facility. -He/She would expect physicians orders to be implemented and documented when completed. During an interview on 4/3/25 at 1:45 P.M., the resident said: -The staff had not been in his/her room today, 4/3/25, to offer or complete wound care. -LPN A asked to change the dressings on 4/2/25 around 4:30 P.M., he/she gave permission. LPN A went to get supplies and did not return until 6:20 P.M. When LPN A came into the resident's room at 6:20 P.M., asked if he/she was ready for the dressings to be changed, he/she responded, yes. LPN A left and never returned to change his/her wound dressings on 4/2/25. -The night shift nurse did not offer or complete the dressing changes throughout the night of 4/2/25. -He would like to have his/her wound dressings changed as soon as possible as they were causing him/her discomfort and were dirty. During an interview on 4/3/25 at 2:15 P.M., LPN A said: -The resident refused his/her wound care treatments today (4/3/25). -He/She forgot to document the refusal in a progress note and should have done so. Observation on 4/3/25 at 3:04 P.M., showed: -LPN A and RN A changed the resident's wound dressings. -LPN A removed the resident's soiled dressing from the sacrum. --The sacrum was a Stage IV wound with visible bone: approximately 6 cm X 5 cm X 4.5 cm. --The dressing was soiled with exudate of numerous color; clear, yellow, and brown. --The dressing was crumbled up and not covering the wound completely. --The dressing did not have any nurse initials or a date. -The left ischial tuberosity and right ischial tuberosity dressings were not covering the wound. --The dressings were soiled with exudate of numerous color; clear, yellow, and brown. --The dressings were partially hanging and partially crumbled up. --The left ischial tuberosity and the right ischial tuberosity were exposed to and in contact with the resident's feces. --Wound dressings for the left ischial tuberosity and the right ischial tuberosity did not have a date or initials. --The left ischial tuberosity was approximately 1.5 cm X 1.5 cm X 1 cm; Stage IV. --The right ischial tuberosity was approximately 4 cm X 2 cm X 4 cm; Stage IV. -Wound care for the left lateral knee was not completed. --The left lateral knee had no dressing and was open to air. --The left lateral knee was approximately 1 cm X 0.5 cm X 0.1 cm. ---Wound care orders for the left lateral knee were cleanse with wound wash, pat dry. Apply Silvadene to wound bed. Apply a layer of Xeroform to wound bed. Cover with foam adhesive dressing every shift (twice per day) and as needed for soiling. Every shift. -Wound care for the right toe was not completed. --The right toe was covered by a dressing with the date of 3/30/25. --Right 4th toe wound. Cleanse wound with wound wash, pat dry. Apply betadine to toe. Leave open to air daily and as needed. -NOTE: There was a strong malodorous smell in the resident's room. During in an interview on 4/3/25 at 4:00 P.M., LPN A said: -The dressings that were on the resident's wounds had not been in stock since sometime last week. -The dressings were currently on back order. 3. During in an interview on 4/7/25 at 1:46 P.M., CNA A said: -The nurses were responsible to complete the weekly skin assessments on the resident's in the facility. -The CNA's were responsible for the bath skin assessments in the facility. -He/She was not sure where the weekly and the bath assessments were documented. -He/She gave his/her bath skin assessments to the charge nurse on duty for his/her shift. -He/She reported skin issues to his/her charge nurse. -He/She could not recall where the wounds were located for Resident #26 and Resident #307. -He/She had never completed a bath skin assessment on Resident #26 or Resident #307. During in an interview on 4/7/25 at 1:49 P.M., LPN A said: -He/She was not sure who was responsible for resident's weekly skin assessments. -The skin assessment duties were handed off from the floor nurses to the ADON recently. -There had been some confusion on who was responsible for weekly skin assessments. -He/She was unsure of who was responsible for the skin assessments from week to week. -Skin assessments were documented in the resident's electronic medical record when completed under the assessment tab. -The previous DON came in and made a lot of changes and caused a lot of confusion. -The new DON started on Monday. -He/She was unsure who was responsible for wound assessments. -Wound assessments should be documented in the resident's electronic medical record. -18 days would be an excessive and unacceptable amount of time for a resident's wounds to not receive wound care or treatments. -The charge nurse who was on duty when a wound was brought to their attention was the one responsible for ensuring that a resident received timely wound care treatment orders. -The physician should be notified within the same shift that a wound was brought to the attention of the charge nurse to receive wound care treatment orders. -When a resident refused wound care treatments, it should be documented on the TAR and in a progress note but sometimes the progress note was bypassed. -He/She was unsure of what the policy was for assessment and treatment of resident's with wounds. During an interview on 4/7/25 at 2:44 P.M., the DON said: -Upon admission the charge nurse was responsible for a complete skin assessment and measurements of any current pressure injuries that the resident may have. -Weekly skin assessments should be completed and documented by the charge nurses on the floor. -Weekly skin assessment should be documented in the resident's electronic medical records under assessments. -If a wound was found on an assessment the nurse should notify the physician as soon as they found the wound but definitely within that shift. -18 days would be an excessive and unacceptable amount of time for a resident's wounds to not receive care and treatment orders. -He/She was unsure of who was responsible for the care plans regarding wounds and wound care or what they were doing before he/she started. -He/She would expect a resident that refused wound care treatments to be care planned for those refusals. -He/She would expect the floor nurses to document in a progress note and notify him/her if a resident refused wound care treatments. -He/She would expect a resident's wounds to be measured upon assessment and documented in the resident's electronic medical record under weekly wound assessments. -The facility did not currently have a MDS Coordinator and one was being shared between another facility. MO00248773

Based on interview and record review, the facility failed to ensure medications were given as ordered when a staff member administered Lorazepam Intensol (a scheduled IV controlled substance medication was used for the management of anxiety disorders (a feeling of fear, dread, and uneasiness) without a physician's order for one supplemental resident (Resident #14) out of 12 residents. The facility census was 48 residents. Review of the facility policy titled Medical Provider Orders, dated 4/7/22, showed: -The facility shall use uniform guidelines for the ordering and following of medical provider orders. -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. -Documentation of medication if using electronic medication record, should be input in the electronic health record (EHR) with instructions per facility policy. -Medical provider orders should be reviewed prior to administration of medication to validate the orders timely. -If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order. Review of the facility policy titled Medication Administration, dated 9/1/22, showed: -For policy explanation and compliance guidelines, staff must review the Medication Administration Record (MAR) to identify medication to be administered and compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time. -Staff must sign the MAR after administration and if the medication is a controlled substance, sign the narcotic book. -Staff must correct any discrepancies and report to the nurse manager. Review of the facility policy titled Controlled Substance Administration & Accountability, dated 9/1/22, showed: -It was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. -The facility would have safeguards in place in order to prevent loss, diversion, or accidental exposure. -In all cases, the dose noted on the usage form must match the dose recorded on the MAR, Controlled Drug Record, or other facility specified form and placed in the patients' medical record. -The Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration. 1. Review of Resident #14's admission record showed: -The resident was admitted to the facility on [DATE]. -The resident was his/her own responsible party. -The resident had a diagnosis of cognitive communication deficit. -NOTE: There was no diagnosis of Anxiety and/or depression listed. Review of the resident's care plan revised on 2/2/25, showed staff were to administer medications as ordered. Document adverse side effects and notify Dr as needed. Review of the resident's MAR dated February 2025 showed: -Lorazepam Concentrate 2 milligram (mg)/milliliter (ml). Give 0.5 ml by mouth every 6 hours as needed for Anxiety to start on 2/3/25 and discontinue on 2/4/25. -Lorazepam Concentrate 2 mg/ml Give 0.5 ml by mouth every 6 hours as needed for Anxiety for 14 Days. With a Start Date of 2/4/25. -There were no staff initials on the resident's MAR to represent administration of Lorazepam Concentrate 2 mg/ml being given to the resident as ordered in February. -On 2/4/25 the resident's MAR was blank and did not have staff initials to show the medication was administered. -On 2/25/25 the resident's MAR had an X, which indicated to not give the medication. Review of the resident's Physician Order Sheet (POS) dated 2/3/25, showed: -Lorazepam Concentrate 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for anxiety to start on 2/3/25. -Lorazepam Concentrate 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for anxiety to discontinued on 2/4/25. -Lorazepam Concentrate 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for anxiety for 14 days to start on 2/4/25. Review of the resident's Controlled Drug Record dated 2/4/25, showed: -Lorazepam Intensol 0.5 ml was administered to the resident on 2/4/25 at 6:00 P.M. -Lorazepam Intensol 0.5 ml was administered to the resident on 2/25/25 at 4:58 P.M. -The resident did not have a physician's order for Lorazepam Intensol on 2/25/25 when the medication was administered. -The resident's Lorazepam Intensol order was discontinued on 2/18/25. During a phone interview on 4/7/25 at 12:06 P.M., the Pharmacist said: -The resident's Lorazepam medication was ordered on 2/3/25 and delivered to the facility on [DATE] at 3:14 A.M. -The resident did not have any record of additional Lorazepam orders by a physician. -He/She would expect a nurse to ensure that a resident had a physicians order for a medication prior to administering a medication to the resident. During in an interview on 4/7/25 at 1:49 P.M., Licensed Practical Nurse (LPN) A said: -He/She was unaware of which staff member administered the resident Lorazepam 0.5 ml on 2/25/25. -He/She would expect a nurse to check a resident's physicians order in the computer prior to administering a resident a PRN medication. -He/She would expect a nurse to compare the physicians order with the MAR to ensure accuracy prior to administering a PRN medication. -He/She would not expect a resident to receive a medication that did not have a physician's order. During an interview on 4/7/25 at 2:44 P.M., the Director of Nursing (DON) said: -He/She would expect a nurse to ensure that that a resident was given a medication that had a physician's order. -He/She would expect a nurse administering a medication to check the resident's physician's order in the electronic medical record to ensure the right patient and ensure the right dose of the medication was being administered. -He/She would not expect a medication that did not have a physician's order to be administered to a resident.

Based on observation, interview and record review, the facility failed to assess the resident's ability and capacity for self-care of his/her catheter (a tube passed through the urethra into the bladder to drain urine); failed to provide the resident with infection control education for self-administration of his/her catheter to help prevent infection; failed to capture the resident's self-catheter care on his/her admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning); and failed to include the resident's self-care on his/her baseline care plan for one sampled resident (Resident # 307), out of 12 sampled residents. The facility census was 48 residents. A policy was requested and not received at the time of exit. 1. Review of Resident #307's admission record, dated 3/25/25, showed he/she admitted with the following diagnoses: -Cognitive communication deficit. -Neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). -Paraplegia (partial or complete paralysis of the lower half of the body, specifically the legs and feet). Review of the resident's facility to facility transfer report from the hospital dated 3/25/25, showed: -The resident was treated with antibiotics in the hospital prior to admission to the facility for a Urinary [NAME] Infection (UTI). -The resident's urine culture in the hospital was positive for Proteus mirabilis (a Gram-negative bacterium which is most frequently a pathogen of the urinary tract, particularly in patients undergoing long-term catheterization). -The hospital physician stated that the resident required increased and continuous education regarding the sterile straight catheter procedure (A sterile straight catheter procedure involves inserting a sterile, thin tube (a straight catheter) into the urethra to drain urine from the bladder, followed by immediate removal of the catheter. It's a medical procedure designed to minimize the risk of infection, using sterile gloves, equipment, and techniques throughout). Review of the resident's admission MDS dated [DATE], showed: -In Section H - Bladder and Bowel; the resident did not perform intermittent catheterization. -In Section H - Bladder and Bowel; the resident did not have an internal or external catheter. Review of the resident's Physician Order Sheet (POS) dated 3/25/25, showed: -A physician's order for the resident to straight catheterize self when needed. -NOTE: There were no directions specified for the catheter order in the directions section. Review of the resident's care plan dated 3/28/25, showed: -The resident had an Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) self-care deficit. -There was no mention of the resident's self-catheterization or the need for infection control education. Review of the resident's Treatment Administration Record (TAR) dated March 2025 showed: -Enhanced barrier precautions for straight catheterization required. -There was no mention of education or monitoring the resident's straight catheterization. -There was no mention of assessing and monitoring for symptoms and or prevention of a urinary tract infection. During an interview on 4/1/25 at 9:45 A.M., the resident said: -He/She performed self-catheterization. -He/She was not educated by the facility staff about how to safely and accurately perform self-catheterization. -He/She had never been educated by the facility staff on using the sterile technique while performing self-catheterization to help prevent infection. -He/She recently recovered from an infection of the urinary tract. Review of the resident's electronic medical record on 4/2/25, showed: -No documentation, assessments, or progress notes of the resident's self-catheterization. -No documentation about his/her risk for urinary tract infection. During an interview on 4/3/25 at 1:45 P.M., the resident said: -The facility provided his/her catheters. -He/She kept his/her catheters in his/her bedside table. -He/She did not use gloves or aseptic wipes when he/she performed self-catheterization. Observation on 4/3/25 at 1:45 P.M. showed: -The resident had two catheters in his/her resident's bedside table. -There were no sterile supplies (aseptic wipes) or gloves. -There were no aseptic wipes in the resident's room. -The gloves hanging near the resident's door on the wall were clean, not sterile. Observation on 4/3/25 at 3:04 P.M., showed Licensed Practical Nurse (LPN) A opened the resident's bedside table drawer and saw the resident had two catheters and told the resident that he/she would bring him/her more catheters. During an interview on 4/7/25 at 1:46 P.M., Certified Nursing Assistant (CNA) A said: -He/She was not aware that the resident performed self-catheterization. -He/She had never assisted the resident in performing self-catheterization. -He/She was not educated on the resident's history of urinary tract infections. -He/She was unaware if the resident received education from the nursing staff on the sterile technique and proper procedure for self-catheterization. During an interview on 4/7/25 at 1:49 P.M., LPN A said: -He/She was aware that the resident performed self-catheterization. -He/She had never assisted the resident with the self-catheterization. -He/She had not educated the resident on the proper aseptic technique for self-catheterization. -He/She was not aware if the resident received education from other nursing staff on the proper aseptic technique for self-catheterization. -The nursing staff were responsible for educating residents on the proper aseptic technique for self-catheterization. -The nursing staff were responsible for ensuring that a resident who performed self-catheterization was care planned for the self-care. -The facility did not currently have an in house MDS Coordinator. -The MDS Coordinator that created the residents care plans and kept the residents care plans updated was working two different facilities at the same time. During an interview on 4/7/25 at 2:44 P.M., the Director of Nursing (DON) said: -He/She was not very familiar with the resident and the resident's self-catheter situation. -He/She would expect a resident to have a self-care assessment completed on admission to ensure safe and aseptic self-catheterization. -He/She would expect a resident's care plan to reflect self-catheterization and education on the procedure. -He/She would expect a resident's admission MDS to capture intermittent catheterization for a resident who performed self-catheterization.

Based on observation, interview and record review, the facility failed to ensure accurate documentation on the narcotic count sheets; and failed to dispose of Lorazepam Intensol (a controlled substance used to treat anxiety) per professional standards and facility policy for one supplemental resident (Resident #14). The facility census was 48 residents. Review of the facility policy titled Controlled Substance Administration & Accountability, dated [DATE], showed: -It was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. -The facility would have safeguards in place in order to prevent loss, diversion, or accidental exposure. -Where an automated patient profiling systems is not utilized, the Director of Nursing (DON), charge nurse, and other designee and the consultant pharmacist discuss all additions or deletions to the areas stock supply. -All controlled substances (schedule II, III, IV, and V) are accounted for. -All controlled substances obtained from a non-automated medication cart or cabinet are recorded on a designated usage form. Written documentation must be clearly legible with all applicable information provided. -In all cases, the dose noted on the usage form must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patients' medical record. -The Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration. -The controlled drug record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient specific narcotic dispensed from the pharmacy. -Areas without automated dispensing systems utilize a paper system for 24-hour recording of controlled substance use. -Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the drug disposition record, controlled drug record, or via the automated dispensing system. -For inventory verification, two licensed nurses or per state regulations account for all controlled substances at the end of each shift. -Any discrepancy in the count of controlled substances is resolved by the end of the shift during which it is discovered. 1. Review of Resident #14's admission record showed: -The resident was admitted to the facility on [DATE]. -The resident was his/her own responsible party. -The resident had a diagnosis of cognitive communication deficit. -NOTE: There was no diagnosis of Anxiety and/or depression listed. Review of the resident's Physician Order Sheet (POS) dated [DATE], showed: -Lorazepam Intensol 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for anxiety to start on [DATE]. -Lorazepam Intensol 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for anxiety to discontinued on [DATE]. -Lorazepam Intensol 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for Anxiety for 14 days to start on [DATE]. Review of the resident's Controlled Drug Record dated [DATE], showed: -Lorazepam Intensol 0.5 ml was administered to the resident on [DATE] at 6:00 P.M. -Lorazepam Intensol 0.5 ml was administered to the resident on [DATE] at 4:58 P.M. Review of the resident's MAR dated February 2025 showed: -Lorazepam Intensol 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for Anxiety to start on [DATE] and discontinue on [DATE]. -Lorazepam Intensol 2 mg/ml. Give 0.5 ml by mouth every 6 hours as needed for Anxiety for 14 Days. With a Start Date of [DATE]. Review on [DATE] at 10:25 A.M., showed: -The resident's-controlled drug record for Lorazepam Intensol 2 mg/ml was in the ,d+[DATE] hall narcotic count sheet book. --The resident's controlled record log was started on [DATE]. --The resident's controlled record log showed that on [DATE] at 6:00 P.M., Lorazepam 0.5 ml was administered and left a remaining amount of 29.5 ml of Lorazepam. --The resident's controlled record log showed that on [DATE] at 4:58 P.M., Lorazepam Intensol 0.5 ml was administered and left a remaining amount of 29 ml of Lorazepam. ---There was no other documentation on the resident's controlled record log. -The resident's Lorazepam Intensol 2 mg/ml was not in the medication carts, and was not in the medication refrigerator. During an interview on [DATE] at 10:32 A.M., Licensed Practical Nurse (LPN) A said: -The staff had not been completing the medication narcotic count sheets as they should have on a regular basis. -He/She was unaware where the previous medication narcotic count sheets were. -He/She thought the previous sheets were in the management office with the DON. -He/She destroyed the Lorazepam Intensol last week with the DON. -He/She did not document the destruction of the Lorazepam Intensol in the resident's electronic medical record. -He/She did not document the Lorazepam Intensol destruction on the resident's controlled drug record. -The process for a controlled substance being destroyed by facility staff required two nurses. -Once a controlled substance was destroyed by the two nurses, the two nurses both had to document the destruction on the resident's controlled drug record. -He/She knew the correct procedure to destroy controlled substances when the resident's Lorazepam Intensol was being destroyed by himself/herself and the DON, but they did not have the resident's controlled drug record handy at the time. During an interview on [DATE] at 10:45 A.M., DON said: -Staff have not been completing the medication narcotic count sheets like they were supposed to. -He/She destroyed the resident's Lorazepam Intensol with LPN A one day last week, but he/she could not recall the exact date. -He/She and LPN A destroyed the Lorazepam Intensol because it was expired. -He/She did not document the destruction of the Lorazepam Intensol in the resident's electronic medical record. -He/She did not document the destruction of the Lorazepam Intensol on the resident's controlled drug record. -He/She and LPN A should have documented on the resident's controlled drug record when they destroyed the resident's Lorazepam Intensol. -He/She would expect the staff to follow the facility policy when destroying a controlled substance. -He/She would expect staff to document on a resident's controlled drug record when the resident's medication was destroyed. -He/She would expect the resident's controlled drug record to be pulled from the facility's narcotic logbook once destruction was complete. 2. Review of the ,d+[DATE] hall medication cart narcotic count sheets dated [DATE] to [DATE], showed: -There was no documentation from [DATE] to [DATE] on the narcotic count sheet. -Six out of 46 opportunities the oncoming nurse did not sign the count sheet. -Seven out of 46 opportunities the off going nurse did not sign the count sheet. -46 out of 46 opportunities there was no documentation of the narcotic total count. Review of the 200 hall medication cart narcotic count sheets dated [DATE] to [DATE], showed: -Two out of 40 opportunities the oncoming nurse did not sign the count sheet. -Three out of 40 opportunities the off going nurse did not sign the count sheet. -40 out of 40 opportunities there was no documentation of the narcotic total count. -There was no documentation for [DATE] and [DATE] on the narcotic count sheet. Review of the ,d+[DATE] hall medication cart narcotic count sheets dated [DATE] to [DATE], showed: -12 out of 54 opportunities the oncoming nurse did not sign the count sheet. -15 out of 54 opportunities the off going nurse did not sign the count sheet. -44 out of 54 opportunities there was no documentation of the narcotic total count. -There was no documentation for [DATE] and [DATE] on the narcotic count sheet. Review of the 200 hall medication cart narcotic count sheets dated [DATE] to [DATE], showed: -Two out of 56 opportunities the oncoming nurse did not sign the count sheet. -Four out of 56 opportunities the off going nurse did not sign the count sheet. -50 out of 56 opportunities there was no documentation of the narcotic total count. Review of the ,d+[DATE] hall medication cart narcotic count sheets dated [DATE] to [DATE], showed: -Four out of 22 opportunities the oncoming nurse did not sign the count sheet. -Five out of 22 opportunities the off going nurse did not sign the count sheet. -19 out of 22 opportunities there was no documentation of the narcotic total count. Review of the 200 hall medication cart narcotic count sheets dated [DATE] to [DATE], showed: -Four out of four opportunities there was no documentation of the narcotic total count. During in an interview on [DATE] at 1:49 P.M., LPN A said: -The oncoming and the off going nurse should both be signing the facility's medication cart narcotic count sheet at the change of each shift. -The oncoming nurse and the off going nurse should both be counting the total narcotic count and documenting that number on the facility's medication cart narcotic count sheet at the change of each shift. During an interview on [DATE] at 2:44 P.M., the DON said: -He/She was aware that they facility staff was not following the policy for completing the medication cart narcotic count sheets. -He/She would expect the medication cart narcotic count sheets be completed per the facility policy.

Based on observation, interview, and record review, the facility failed to keep the kitchen and Dry Storage (DS) room floors clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food; and to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination), in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 13 residents with a licensed capacity for 60 residents at the time of the survey. 1. Review of the meal times provided by the Dietary Manager (DM) on 9/5/23 at 8:48 A.M. showed that breakfast was served at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:30 P.M. Observation on 9/5/23 between 8:48 A.M. and 9:17 A.M. during the initial kitchen inspection showed the following: -There was a large amount of unknown residue on the manual can opener blade. -There were grease drips along the lower edge of a metal barrier under the range hood that hung over the stove. -The red, blue, and green cutting boards were excessively scored to the point of plastic bits flaking off. -On the bottom shelf of a rack by the stove was a 1 gallon (gal.) jug of soy sauce approximately (app.) 1/4 full with a label which read, Refrigerate After Opening for Quality. -There was a butter pod under the south rack in the kitchen, and cardboard and paper trash under the racks in the DS room. Observation on 9/5/23 between 11:27 A.M. and 11:43 A.M. during the kitchen inspection showed the following: -There was a large amount of unknown residue on the manual can opener blade. -There were grease drips along the lower edge of a metal barrier under the range hood that hung over the stove. -The red, blue, and green cutting boards were excessively scored to the point of plastic bits flaking off. -On the bottom shelf of a rack by the stove was a 1 gal. jug of soy sauce app. 1/4 full with a label which read, Refrigerate After Opening for Quality. -There was a butter pod under the south rack in the kitchen and cardboard and paper trash under the racks in the DS room. Observation on 9/6/23 between 10:12 A.M. and 10:29 A.M. during the follow-up kitchen inspection showed the following: -There was a large amount of unknown residue on the manual can opener blade. -There were grease drips along the lower edge of a metal barrier under the range hood that hung over the stove. -The red, blue, and green cutting boards were excessively scored to the point of plastic bits flaking off. -On the bottom shelf of a rack by the stove was a 1 gal. jug of soy sauce app. 1/4 full with a label which read, Refrigerate After Opening for Quality. -There was a butter pod under the south rack in the kitchen and cardboard and paper trash under the racks in the DS. Review of the maintenance paperwork provided by the Director of Maintenance (DOM) showed the last professional range hood cleaning was performed on 6/5/23 with the next one due in December. Observations during the kitchen range hood inspection with the Regional Maintenance Director (RMD) on 9/6/23 at 1:22 P.M. showed the range hood baffles (metal filters that capture grease droplets from rising hot air and condenses them to drain into a filter tray, which drastically reduces the risk of spreading flames should a fire occur on the cooking surface, and with the intent of reducing food contamination) appeared overly greasy and were so to the touch. During an interview on 9/6/23 at 1:27 P.M. the DOM said that the dietary staff were responsible for cleaning the range hood baffles. During an interview on 9/7/23 at 10:29 A.M. the DM said the following: -All dietary staff were responsible for cleaning the floors throughout the day, at the end of the night, and as needed. -He/She would expect that if a food stuff label read it was to be stored at a certain temperature that it would be. -Dietary staff knew to report damaged food preparation items to him/her or put them in the office. -He/she would expect food to be free of foreign substances. -Food preparation items should be ran through the dishwasher after each use. -A professional company cleaned the range hood quarterly and they did it as needed.

Based on observation, interview and record review, the facility failed to provide an annual dental exam for two sampled residents (Resident #2 and Resident #5) and to provide a dental consult for one sampled resident (Resident #12) who wanted to be evaluated for possible extractions of his/her teeth so he/she could obtain dentures out of nine sampled residents. The facility census was 13 residents. Review of the facility's dental services policy revised on 9/1/22 showed: -It was the policy of the facility to assist residents in obtaining routine and emergency dental care. -The dental needs were to be identified through the physical assessment and Minimum Data Set (MDS-a federally required assessment tool completed by facility staff for care planning) assessment process and addressed in each resident's plan of care. -Oral/dental status should be documented according to assessment findings. -Residents and/or resident representative were notified of dental services available during the admission process. -The Social Services Director maintained contact information for providers of dental services that were available to facility residents. -The facility would assist the resident with making dental appointments and arranging transportation to and from the dental services location as needed. -All information regarding dental services would be documented in the resident's medical record. 1. Review of Resident #2's entry tracking form showed he/she admitted to the facility on [DATE]. Review of the resident's dental records showed: -The resident had a dental cleaning on 7/20/21. -The resident had some teeth extracted on 11/18/21. -No documentation of dental visits after 11/18/21. Review of the resident's oral/dental section of the facility's all-inclusive quarterly screen dated 11/10/22 showed: -Date of last dental exam was left blank. -The resident had natural teeth that were in good condition. -The resident did not have dentures, partials or implants. Review of the resident's oral/dental section of the facility's all-inclusive readmission form dated 2/22/23 showed: -The date of last dental exam was left blank. -The resident had natural teeth that were in fair condition. -The resident did not have dentures, partials or implants. Review of the resident's significant change MDS dated [DATE] showed staff assessment of the resident showed the resident had no dental issues. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Was cognitively intact. -Required set up assistance with hygiene. Review of the resident's care plan dated 8/24/23 showed: -The resident required set-up assistance with personal hygiene/oral care. -It did not include anything else regarding the resident's teeth or dental needs. Review of the resident's Physician's Order Sheet (POS) dated September 2023 showed an order dated 8/4/22 for dental services to be provided by facility selected provider. During an interview and observation on 9/5/23 at 10:31 A.M.,showed: -The resident said he/she had not seen a dentist in a long time, over a year and he/she would like to have a cleaning. -The resident had some build-up on his/her teeth. During an interview on 9/8/23 at 9:48 A.M., Licensed Practical Nurse (LPN) A said there was an assessment where the nurses asked all the necessary questions including dental and then the Social Worker was responsible for setting up the dental appointments. During an interview on 9/8/23 at 12:37 P.M., the Director of Nursing (DON) said: -The Social Worker was supposed to track when annual dental appointments were due. -Their Social Worker was no longer employed there as of the previous week. -All residents should have an annual dental appointment if they wanted one. 2. Review of Resident #12's entry tracking form showed he/she admitted to the facility on [DATE]. Review of the resident's dietary profile dated 6/14/23 showed the resident: -Received a mechanical soft diet (A texture-modified diet that restricts foods that are difficult to chew or swallow. Foods are finely chopped, blended, or ground to make them smaller, softer, and easier to chew. It differs from a pureed diet, which includes foods that require no chewing). -Requested a mechanical soft texture due to only having a few teeth left. -Ate independently without staff assistance. Review of the resident's physician's history and physical note dated 6/16/23 did not include anything regarding the resident's teeth or oral condition. Review of the resident's dental/nutrition section of the all-inclusive admission with baseline care plans dated 6/15/23 showed: -The resident was on a regular, mechanical soft diet. -The resident did not wear dentures. -The date of last dental exam was left blank. -The resident had some natural teeth that were in fair condition. -The resident did not have dentures, partials or implants. -The resident was independent with daily oral/dental care. Review of the resident's admission/baseline care plan dated 6/15/23 showed: -The resident had some natural teeth. -A number of teeth were missing. -The resident's teeth were in fair condition. -The resident had a nutritional problem or potential nutritional problem related to being on a mechanically altered diet for chewing. -The resident had significant weight loss in the hospital (prior to his/her admission to the facility). -The resident was at risk for malnutrition and further weight loss. -Instructions to provide and serve the resident's diet as ordered: (updated to) regular diet, regular texture and regular/thin consistency liquids consistency. Review of the resident's admission MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Was cognitively intact. -Required set-up assistance with eating. -Had no dental issues. Review of the resident's nutritional assessment dated [DATE] showed the resident received a regular, mechanically altered diet. During an interview on 9/5/23 at 11:12 A.M., the resident said: -He/she had a lot of teeth extracted about five or six years ago. -It was hard for him/her to chew. -He/she was on a soft diet but he/she couldn't stand it so he/she talked to the doctor and his/her diet was changed back to regular consistency and he/she was doing better. -He/she needed a dentist because he/she thought the rest of his/her teeth needed to be pulled so he/she could have dentures. Observation on 9/6/23 at 12:27 P.M. of the resident's mouth showed the resident had eight front teeth on the bottom, no teeth on the top right and a partial on the left top. Review of the resident's progress notes showed no dental progress notes and no notes about dental needs. During an interview on 9/8/23 at 9:48 A.M., LPN A said: -There's an admission assessment where the nurse asked all the necessary questions including dental and then the Social Worker was responsible for setting up the dental appointments. -The resident had not told him/her that he/she needed any dental work. During an interview on 9/8/23 at 12:37 P.M., the DON said: -The admitting nurse was responsible for assessing the resident for any dental needs, documenting it in the all-inclusive assessment and following-up with DON or the Social Worker. -Their Social Worker was no longer employed there as of the previous week. -He/She was not aware the resident wanted his/her teeth pulled so he/she could have dentures. 39469 3. Review of Resident #5's face sheet showed he/she was admitted to the facility with the following diagnoses: -Cognitive communication deficit (an acquired communication deficit after a brain injury). -Depressive disorder (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities). -Bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs). -Dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's care plan dated 9/20/21 showed: -He/she had oral/dental health problems related to poor oral hygiene. -Staff were to coordinate arrangements for dental care, transportation as needed/as ordered. -Staff were to monitor/document/report as needed any signs or symptoms of oral/dental problems needing attention. Review of the resident's last dental exam dated 11/17/21 showed: -The Dentist had done a full mouth x ray on 11/11/21. -He/she had recommended that the resident have tooth number #13 extracted. -The resident had declined treatment until the tooth became symptomatic. -He/she would monitor for now. Review of the resident's annual MDS dated [DATE] showed his/Her Brief Interview for Mental Status (BIMS) score was 10 out of 15 indicating he/she was moderately cognitively impaired. During an interview on 9/5/23 at 3:45 P.M. the resident said: -He/she had not seen the Dentist for two years. -He/she had nice teeth and would like to to keep his/her teeth well. -He/she had told the staff he/she wanted to see the Dentist but nothing had happened. During an interview on 9/5/23 at 3:50 P.M. LPN C said: -He/she did not know when the Dentist was at the facility last. -He/she did not know when the resident had last seen the Dentist. -He/she did not know if the resident had dentures or his/her own teeth. -Social Services was responsible for making dental appointments. -He/she could not remember if the resident had asked to see a Dentist. -The facility was between Social Workers right now. -He/she verified the last documentation of a dental visit was on 2/12/21. -He/she did not know how often the residents were supposed to see a Dentist. During an interview on 9/7/23 at 10:30 A.M. Certified Medication Technician (CMT) A said: -The residents should see the Dentist annually. -The Social Worker made up a list and the Dentist saw who was on the list. -A new Social Worker was just starting this week. During an interview on 9/8/23 at 12:37 P.M. the DON said: -The Nurse was responsible to have assessed the residents teeth. -The Nurse or the Social Worker would schedule a dental appointment. -The Social Worker was to have ensured the residents were seen by the Dentist annually. -They had a new Social Worker who just started that week.

Based on observation, interview and record review, the facility failed to perform hand hygiene during cares for one sampled resident (Resident #12); to ensure nursing staff were cleansing their hands during medication pass, did not sanitize a pair of scissors used to open an sealed package counting a narcotic, and picked a tray lid up off of the floor without cleansing hands for one sampled resident (Resident #10) out of nine sampled residents and to follow their policy to complete testing to screen new employees and residents for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two out of ten sampled new employees. The facility census was 13 residents. Review of the facility's hand hygiene policy dated 9/1/21 showed: -All staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. -Hand hygiene should be conducted after removing gloves. 1. Review of Resident #12's care plan dated 6/15/23 showed: -The resident had bladder incontinence. -Instructions to provide hygiene care after each incontinence episode. -Instructions to provide preventive skin care. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/20/23 showed the following staff assessment of the resident: -Cognitively intact. -Required limited assistance of one person with toileting and hygiene. -Occasionally incontinent of urine and continent of bowel. -No skin issues. Review of the resident's Physician's Order Sheet (POS) dated September 2023 showed a physician's order to apply barrier cream to the resident's buttocks (either of the two round fleshy parts that form the lower rear area of a human trunk), cover with gauze (per resident request to keep cream off of pants) every shift and as needed. Observation and interview on 9/6/23 at 10:00 A.M. with Licensed Practical Nurse (LPN) A showed: -He/she washed his/her hands, applied gloves and applied ointment on the resident's buttocks. -He/she took off his/her gloves, left the room to get 4 x 4 gauze to cover ointment per the residents request. -He/she did not wash his/her hands before applying gauze to the resident's buttocks. -He/she took off his/her gloves and did not wash his/her hands before leaving the room. -He/she said he/she should have washed his/her hands after glove changes before applying new gloves. During an interview on 9/8/23 at 12:37 P.M., the Director of Nursing (DON) said employees' hands should be washed before putting on new gloves and after glove changes. 39469 2. Review of Resident #10's Admission MDS dated [DATE] showed: -He/She was admitted to the facility on [DATE]. -He/She had a complex medical history. -He/she was cognitively intact. Review of the resident's POS dated September 2023 showed he/she had an order for Lidocaine (medication used to decrease pain) patch 5 percent (%) to have been applied daily to his/her left knee. Observation of medication pass on 9/7/23 at 8:15 A.M. with LPN A showed: -He/she cut open the package containing the medicated patch without cleansing the scissors that were in a drawer in the medication cart. -He/she applied the medication patch to the resident. -He/she returned the scissors to the drawer in the medication cart without sanitizing them after opening the package containing the pain patch. -He/she picked up the lid of the resident's meal tray from the floor with his/her bare hands. -He/she did not cleanse his/her hands. -He/she left the room without cleansing his/her hands. -He/she put on gloves without cleansing his/her hands. -He/she proceeded to bleach wipe the top of the medication cart. During an interview on 9/7/23 at 9:00 A.M. LPN A said: -He/she should have cleansed his/her hands before and after applying gloves. -He/she should have cleansed his/her hands after picking anything up off of the floor. -He/she should have used an alcohol pad to clean the scissors before and after using them. During an interview on 9/7/23 at 10:30 A.M. Certified Medication Technician (CMT) A said: -Staff should clean the scissors before and after using them to open a medication package like a patch. -Staff should wash their hands before and after wearing gloves. -Staff should wash their hands after picking anything up off of the floor. -The facility provided education on hand hygiene almost every month. -The DON or Infection Preventionist was responsible for ensuring good hand hygiene was done by the staff. During an interview on 9/8/23 at 12:37 P.M. the DON said: -Staff should have washed their hands when entering a room. -Staff should have washed their hands whenever they take off their gloves. -Staff should have washed their hands if they had picked something up off of the floor. -Staff should have cleaned the scissors with an alcohol wipe before and after using them. -Staff was educated about hand washing a couple of times a week by the Assistant Director of Nursing (ADON). -They had reviewed hand hygiene during the skills fair a couple of weeks ago. -He/she was ultimately responsible for ensuring staff practiced good hand hygiene. 3. Review of the facility's employee TB testing policy dated 9/1/21 showed: -At the time of employment, all new staff shall undergo pre-placement screening for TB, including an individual risk assessment, TB symptoms screen and a TB test. -All new staff shall receive two TB Skin Tests (TST) given two weeks apart unless: --A previously positive TST or positive TB blood test was reported. --Evidence of completion of adequate therapy for active TB was reported. --Two negative TSTs within the past twelve months, the more recent within the last three months. -All initial and follow-up TSTs should be interpreted 48 to 72 hours after administration. -An attachment to the policy included a flow chart from the Missouri Department of Health and Senior Services that showed if a new employee had documentation of a one-step TST with negative results within the past year that they should administer a second-step TST within one to three weeks of beginning employment. Review of the Long Term Care Infection Prevention and Control Manual, Chapter 5, Vaccinations and TB testing, created by the Quality Improvement Program for Missouri (QIPMO), dated February 2022 and the Missouri Department of Health rule 19 CSR 20-20.100, paragraph three dated 2/28/22 showed: -All new long-term care facility employees who work ten or more hours per week should have the first of two TSTs within one month prior to starting employment in the facility. -The results of the TSTs should be read within 48 to 72 hours from administration. -If the initial TST result was zero to nine millimeters (mm) induration, the second test should be administered as soon as possible within three weeks after employment begins, unless documentation was provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year. Review of the facility's list of employees hired since the facility's last survey showed: -Employee A was hired on 6/26/23. -Employee B was hired on 6/23/23. Review of Employee A's TB screening showed: -A prior TST that was administered on 10/27/22 and read on 10/29/22 and the results were 0 mm (negative). -No additional TSTs. -No individual risk assessment or TB symptoms screening. Review of Employee B's TB screening showed: -A prior TST that was administered on 12/19/22 and read on 12/21/22 and the results were 0 mm (negative). -No additional TSTs. -No individual risk assessment or TB symptoms screening. During an interview on 9/7/23 at 8:19 A.M., the DON said: -He/she or the Assistant DON were in charge of TSTs for employees. -They usually did the TST when offering them a job and they would tell the new employee to come back in two to three days to have it read. -They were supposed to do a two-step TST if the employee had no TST in the past year. -Employee A and B should have had another TST.

Based on observation, interview, and record review, the facility failed to ensure residents' private records were kept private during a medication pass by not ensuring the computer screen was not visible to anyone walking by the computer on top of the medication cart while the nurse administered medications inside of the residents' room for two sampled residents (Resident #5 and Resident #11) and one supplemental resident (Resident # 10) out of nine sampled residents. The facility census was 13 residents. Review of the facility's policy, Medication Administration, dated 9/1/22 showed: -Medications were to have been administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Provide privacy. 1. Review of Resident 5's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Cognitive communication deficit (a disorder in which a person has difficulty communicating as a result of a brain injury). -Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). -Bipolar disorder (a disorder associated with episodes of manic highs and depressive lows). -Dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 8/7/23 showed his/her Brief Interview for Mental Status (BIMS) score was 10 out of 15 indicating he/she was moderately cognitively impaired. Observation on 9/7/23 at 7:15 A.M. of the medication pass with Licensed Practical Nurse (LPN) A showed: -The nurse went into the resident's room to administer six medications to the resident. -He/she had left the screen on the computer open for two minutes with the resident's information clearly visible. -One staff member walked by the computer within two feet of the computer screen. 2. Review of Resident #10's Admission MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she had a complex medical history. -His/her BIMS score was 15 out of 15 indicating he/she was cognitively intact. Observation on 9/7/23 at 7:45 A.M. with LPN A showed: -The nurse went into the resident's room to administer one medication patch to the resident. -He/she had left the screen on the computer open for four minutes with the resident's information clearly visible. -Two staff members walked by the computer within two feet of the computer screen. -Three residents walked by the computer within two feet of the computer screen. 3. Review of Resident #11's Admission MDS dated [DATE] showed: -He/she was admitted on [DATE] with the following diagnoses: -Fractures (a complete or partial break in the bone). -Obstructive Uropathy (a condition in which the flow of urine is blocked causing it to back up into the kidneys). -Cerberbal Vascular Accident (CVA -damage to the brain from interruption of its blood supply). -His/Her BIMS score was 00 out of 15 indicating he/she was severely cognitively impaired. Observation on 9/7/23 at 8:26 A.M. with LPN A showed: -The nurse went into the resident's room to administer two medications to the resident. -He/she had left the screen on the computer open for three minutes with the resident's information clearly visible. -One resident walked by the computer within two feet of the computer screen. 4. During an interview on 9/7/23 at 12:30 P.M. LPN A said: -When staff were passing medications, they should have minimized the screen on the computer so anyone passing by could not have seen the resident's information. -The facility had provided education on keeping the residents information private. During an interview on 9/7/23 at 1:00 P.M. Certified Medication Technician (CMT) A said: -Nursing should have minimized the screen if not in front of it when passing medications so no one passing by was able to see the resident's private medical information. -The facility had given them education on ensuring the residents information stayed private. -The Director of Nursing (DON) was ultimately responsible to ensure nursing was ensuring residents' information stayed private. During an interview on 9/8/23 at 12:37 P.M. the DON said: -Nursing was to use the Hide Screen tab on the computer to ensure the medical information of the resident stayed private. -Ensuring residents' information stayed private was covered during orientation. -Privacy was inserviced with the staff at least annually. -Staff was observed during morning rounds to ensure the computer screens were hidden with no resident information visible. -He/she was ultimately responsible to ensure that staff was not leaving the computer screens open with resident information visible to anyone walking by the medication cart.

Based on interview and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans (a document that specified health care and supported needs and outlined how the facility met resident requirements) for one sampled resident (Resident #269) out of nine sampled residents. This practice had the potential to effect the resident's safety and physical well-being. The facility census was 13 residents. Review of the facility's Comprehensive Care Plans Policy, dated 9/1/2021, showed: -It was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident. -The comprehensive care plan described the services that were furnished to attain or maintain the resident's highest practicable physical well-being. -The comprehensive care plan was prepared by the interdisciplinary team which included: --The attending physician. --A Registered Nurse (RN). --A nurse aide. --A member of the food and nutrition services staff. --The resident and the resident representative. --Other appropriate staff or professionals. -The comprehensive assessment was reviewed and revised by the interdisciplinary team. 1. Review of Resident #269's face sheet, undated, showed he/she had the following diagnoses: -Stroke. -Hemiplegia and hemiparesis (lack of ability to move or control the muscles in the affected body part). -Generalized muscle weakness. -Alcohol abuse. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/23, showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in care planning decisions. --This showed the resident was cognitively intact. -The resident required extensive assistance with transferring (how a resident moves to and from surfaces including from bed to wheel chair, chair, standing, toilet) with two staff persons providing weight bearing support. - The resident required maximal assistance with showering/bathing self. Review of the resident's care plan, dated 8/28/23, showed the resident required a mechanical lift for transfers, requiring two staff members. During an interview on 9/5/23 at 10:08 A.M., the resident said: -He/she received a bath/shower twice a week in the shower room. -Staff did not put him/her in a mechanical lift. -Staff just wheeled him/her down to the shower room and helped him/her as needed. During an interview on 9/6/23 at 10:23 A.M., Certified Medication Technician (CMT) A said: -The resident did not require a mechanical lift. -The resident had supervision during bathing. During an interview on 9/6/23 at 1:50 P.M., Licensed Practical Nurse (LPN) A said: -The resident no longer required a mechanical lift. -He/She needed to use one when he/she first was admitted . -His/Her weight bearing improved and no longer needed a mechanical lift. During an interview on 9/7/23 at 6:47 A.M., Certified Nursing Assistant (CNA) B said: -The resident did not require a mechanical lift. -The resident used it when he/she first got to the facility. -The resident no longer required maximum assist. -The resident was able to stand and pivot. During an interview on 9/7/23 at 6:57 A.M., LPN B said: -He/she believed the resident used a mechanical lift. -He/she worked nights and the resident did not usually need to be up at night. -He/she did not get the resident up. During an interview on 9/7/23 at 10:43 A.M., the Director of Nursing (DON) said: -The resident did not use a mechanical lift. -The resident used a mechanical lift when he/she was first admitted . -The Kardex (a filing system for nursing records and orders) stated the resident was an extensive assist. During an interview on 9/7/23 at 1:25 P.M., the DON said: -The care plan should be updated as orders were changed. -He/she was able to go in and update care plans as necessary. -Some changes did not require a full care plan meeting. -If the resident no longer required a mechanical lift he/she would expect the care plan to be updated.

Based on interview and record review, the facility failed to document information regarding the resident's personal belongings for one sampled closed record resident (Resident #15) out of two sampled closed records. The facility census was 13 residents. Review of the facility's resident personal belongings policy revised 9/1/22 showed:-All resident personal belongings would be inventoried at the time of admission and documentation kept in the medical record. -Additional possessions brought in during the duration of the individual's stay would be added to the existing personal belongings inventory listing. -Following the discharge of a resident, all personal belongings would be given to the designated resident representative. -The inventory of personal belongings should be reviewed at time of discharge by Social Services and the resident's representative. -The recipient of the resident's personal belongings would sign-off with their legal signature acknowledging receipt of all personal belongings presented. 1. Review of Resident #15's entry tracking form showed he/she admitted to the facility on [DATE]. Review of the resident's long-term care facility to hospital transfer note dated 7/2/23 showed he/she was discharged to the hospital. Review of the resident's discharge assessment showed he/she was discharged from the facility on 7/2/23 and was not expected to return to the facility. Review of the resident's medical records showed no documentation regarding the resident's personal belongings. During an interview on 9/8/23 at 9:48 A.M., Licensed Practical Nurse (LPN) C said: -During the admission process, the nurses and/or Certified Nursing Assistants (CNA)s were supposed to document the resident's personal belongings on a paper form. -When the resident discharged from the facility, nursing staff were to document where the resident's belongings went upon/after discharge. During an interview on 9/8/23 at 12:37 P.M., the Director of Nursing (DON) said: -Their Social Worker was no longer employed there as of the previous week. -The CNAs have an inventory sheet they were supposed to fill out to put belongings on when residents bring in personal items. -The nurse should document what belongings the resident and/or their representative took with them and have them sign the inventory sheet upon discharge.

Based on observation, interview and record review, the facility failed to follow physician orders by not providing supervision for one sampled resident (Resident #269) out of nine sampled residents while the resident was alone in his/her wheelchair in his/her room. The facility census was 13 residents. Review of the facility's Medical Provider Orders policy, dated 4/7/22, showed: -The facility used uniform guidelines for the ordering and following of medical provider orders. -Medical provider orders were reviewed prior to administration of medication and/or treatment to validate the orders contained all required elements. -Staff should follow all valid medical provider orders timely unless there was an emergency that temporarily delayed the implementation of the order. Review of the facility's Incidents and Accidents policy, dated 9/1/22, showed: -The purpose of the policy was to ensure appropriate and immediate interventions were implemented and corrective actions taken to prevent recurrences and improve the management of resident care. 1. Review of Resident #269's face sheet, undated, showed he/she had the following diagnoses: -Stroke with hemiplegia and hemiparesis (the inability to move or control the muscles in the affected body part). -Generalized muscle weakness. -Difficulty walking. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/23, showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --This showed the resident was cognitively intact. -The resident required extensive assistance with transferring (how a resident moves to and from surfaces including from bed to wheel chair, chair, standing, toilet) with two staff persons providing weight bearing support. Review of the resident's physician order summary, dated 8/24/23, showed: -The resident was not to be in his/her wheelchair unsupervised. -When in room, ensure the resident was in his/her recliner. -Ensure Dycem (material used to help stabilize objects, hold objects firmly in place, or to provide a better grip) was in wheelchair at all times. Review of the resident's Care Plan dated 8/26/23, showed: -On 8/17/23 the resident slid from his/her wheelchair without injury. -On 8/22/23 the resident had an unwitnessed fall in the activity room without injury. -On 8/26/23 the resident slid from his/her wheelchair, no injury noted. Observation on 9/5/23 at 11:13 A.M. showed the resident was in his/her room in his/her wheelchair without supervision. During an interview on 9/6/23 at 10:23 A.M., Certified Medication Technician (CMT) A said: -The resident had a Dycem pad in the wheelchair. -The pad went on top of the cushion. -It helped the resident from sliding out of the wheelchair. -The resident needed supervision while in his/her wheelchair. -A Certified Nurse Assistant (CNA) or nurse supervised the resident. -The resident was not supposed to be left in the wheelchair. -The resident should have been in his/her recliner if in his/her room. During an interview on 9/6/23 at 1:50 P.M., Licensed Practical Nurse (LPN) A said: -The resident slid out of the wheelchair two to three times. -The resident was provided a Dycem pad and educated on call light use. -Currently the resident was able to be in wheelchair unsupervised. Observation from 9/7/23 from 6:35 A.M. to 6:45 A.M., showed the resident was in his/her room in his/her wheelchair, watching TV, unsupervised. During an interview on 9/7/23 at 6:47 A.M., CNA B said: -The resident had a Dycem pad on his/her wheelchair cushion. -The resident was safe to be in his/her wheelchair on his/her own but staff kept an eye on him/her. -The resident tried to get up on his/her own. -He/she made sure the resident's call light was within reach and other items needed were close to the resident. -He/she checked on the resident every 10 to 15 minutes when the resident was in his/her room. -The resident did not like to be in his/her recliner. -He/she knew the resident should be in his/her recliner. During an interview on 9/7/23 at 6:57 A.M., LPN B said: -When the resident was in his/her room and not in bed, he/she was supposed to be in the recliner to prevent falls. -The recliner helped position him/her better. -The resident was usually very cooperative about sitting in the recliner. -The resident required supervision while in the wheelchair. -Supervision meant the resident was within eye sight. Observation on 9/7/23 at 10:25 A.M. showed: -The resident was seen leaving his/her room in his/her wheelchair. -No staff were present in the area. During an interview on 9/7/23 at 10:43 A.M., the Director of Nursing (DON) said: -The resident had a Dycem pad between him/herself and the cushion on the wheelchair. -Nurses were responsible for ensuring the Dycem pad was in place. -There was no need for the resident to be in his/her recliner when in his/her room. During an interview on 9/7/23 at 1:36 P.M., the resident's physician said: -The resident had issues of being impulsive and attempted to do activities he/she was not capable of, such as transfers. -The resident was at high risk for falls if left in the wheelchair unsupervised. -He/she preferred for the resident to be supervised if the resident was in his/her wheelchair, or in a common area where staff could have him/her in eye sight. -He/she did not want the resident in his/her wheelchair without supervision. -He/she expected staff to follow physician orders.

Based on observation, interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one sampled resident (Resident #68) who was the only resident receiving dialysis that resided at the facility. The facility census was 13 residents. Review of the facility's dialysis policy revised 9/1/22 showed: -There should be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. -The facility staff should coordinate and collaborate with the dialysis facility to assure that documentation requirements were met to assure that treatments are provided as ordered. 1. Review of Resident #68's all-inclusive admission with baseline care plans dated 9/3/23 showed the reason for the resident's admission was to receive therapy, cares and dialysis. Review of the resident's Physician's Order Sheet dated September 2023 showed: -The resident was to receive dialysis from 5:00 A.M. to 9:00 A.M. -The resident's dialysis days were Monday, Wednesday and Friday. Review of the resident's dialysis communication form dated 9/4/23 showed: -The dialysis center information section included areas to document pre- and post-dialysis weight, vital signs, dialysis start time and end time, fluid removed, meal/snack intake, shunt location/status, new doctor's orders and additional information. -The information section from the dialysis center was left blank. During an interview on 9/5/23 at 2:30 P.M. the resident said: -He/she just came to the facility the evening of 9/1/23. -He/she went to dialysis once (on 9/4/23) since being admitted to the facility. -The dialysis center took his/her weight before and after dialysis when he/she was there the day before. -He/she was unsure if the dialysis center sent his/her weight or anything else to the facility. -The facility van took him/her to dialysis and he/she was there at 5:00 A.M. Observation on 9/6/23 at 9:56 A.M. showed the resident was being pushed into the building in his/her wheelchair (after returning from dialysis). Review of the resident's dialysis communication form dated 9/6/23 showed: -The dialysis center information section included areas to document pre- and post-dialysis weight, vital signs, dialysis start time and end time, fluid removed, meal/snack intake, shunt location/status, new doctor's orders and additional information. -The information section from the dialysis center was not completed. During an interview on 9/6/23 at 2:59 P.M., Licensed Practical Nurse (LPN) A said: -The dialysis center was supposed to fill out the middle part (titled dialysis center information) of the dialysis communication form and send it back to the facility with the resident after dialysis. -It was the responsibility of the nurse on duty to call the dialysis center and get the weights and information if the dialysis communication form did not come back with the resident after dialysis. During an interview on 9/8/23 12:37 P.M., the Director of Nursing (DON) said: -Nursing had not obtained weights from the dialysis center for Monday and Wednesday until the state surveyor requested the information. -They filled out the pre-dialysis information on the dialysis communication form, they made a copy and sent the form with the resident to the dialysis clinic. -The dialysis center was supposed to fill out the center section of the dialysis communication form and send it back to the facility. -When the resident returned to the facility, nursing staff were supposed to fill out the post-dialysis information section. -If the dialysis center did not fill out their section or send the form back to the facility, the nurse should call the dialysis center and request the form with the information completed.

Based on interview and record review, the facility failed to provide pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for one sampled resident (Resident #268) out of five residents sampled for immunizations. The facility census was 13 residents. Review of the facility's Pneumococcal Vaccine Policy, dated 9/1/2021, showed: -It was the facility's policy to offer residents immunizations against pneumococcal disease in accordance with current Center for Disease Control (CDC-the nation's health protection agency responsible for controlling the introduction and spread of infectious diseases) guidelines and recommendations. -Each resident was assessed for pneumococcal immunization upon admission. -Each resident was offered the pneumococcal immunization unless medically contraindicated or the resident was already immunized. -Vaccinations were offered to residents [AGE] years or older, according to CDC guidelines. -The resident's medical record included documentation that indicated the following: --The resident or resident representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization. --The resident received the pneumococcal immunization or did not receive the immunization due medical contraindication or refusal. Review of the CDC guidelines for the pneumococcal vaccine, dated 9/11/23, showed people age 65 or older who previously received the pneumococcal polysaccharide vaccine (PPV23) should receive one dose of PPV23 at least 1 year after the PPV23 dose. 1. Review of resident #268's face sheet, undated, showed: -The resident was over age 65. -The resident's diagnoses included cellulitis (swelling of connective tissue under the skin), muscle weakness, and atrial fibrillation (an irregular and often very rapid heart). Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/9/23, showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions. --This showed that the resident cognitively intact. Review of the resident's electronic health record (EHR), undated, showed no pneumonia vaccines were noted. Review of the resident's State Immunization Record, dated 9/6/23, showed the resident last received the PPV23 on 10/23/2018. During an interview on 9/6/23 at 1:50 P.M., Licensed Practical Nurse (LPN) A said the Director of Nursing (DON) tracked resident immunizations. During an interview on 9/6/23 at 2:16 P.M., the Assistant Director of Nursing (ADON) said: -Immunizations for new admissions are tracked by the DON. -That included flu and pneumonia vaccines. -Vaccines were to be documented in the immunizations tab in the EHR. During an interview on 9/7/23 at 10:43 A.M., the DON said: -He/she used a phone application (app) from the CDC that showed vaccine guidelines for specific age groups. -He/she utilized those guidelines when offering vaccines to new residents. -He/she tracked when the vaccines were offered and which residents refused them. Review of the resident's Physician Order Summary, dated 9/8/23, showed the resident did not have an order for a pneumococcal vaccine. During an interview on 9/8/23 12:37 P.M., the DON said: -The facility offered immunizations to all new residents, including the pneumonia vaccine. -Education was provided if the resident refused. -This should have been documented in the medical record. -The resident should have had a pneumonia vaccine. -The facility did not have any pneumonia vaccines available. -The facility normally kept pneumonia vaccines on hand.

Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to Vendor B and Vendor C who provided necessary services to the residents and Vendor C who maintained the lawn care and snow removal services. The facility census was 18 residents. 1. Record review of the Vendor B door disconnect notice dated 4/13/23 showed a balance of $3964.95 for the skilled portion of the building. Record review of Vendor C disconnect notice dated 4/21/23 showed a balance of $10,573 was past due and payment was due upon receipt and before 5/9/23. During an interview on 5/2/23 at 10:15 A.M., the Administrator said: -He/she had received a shut off notice for the the facility gas utility and a late notice of the facility electric. -The business office forward all notices and bills received at the facility to the corporate office. During an interview on 5/2/23 at 10:51 A.M., the Business Office Manager (BOM) said: -If the facility received a bill or any notice directly delivered to the facility, it was scanned into the computer and sent electronically to corporate office. -He/she had no access to any report to ensure payment was made. -In the last month two notices were received at the facility door, one from the electric utility and one form the gas utility, both notices were sent directly to the corporate office. -Most all billing statements and or notices go directly to the corporation. During an interview on 5/2/23 at 12:24 P.M., the Maintenance Director said: -No lawn care has been provided as Vendor A had not been paid for their services. -The lawn care recently done was by the corporate Maintenance Director. During an interview on 5/2/23 at 1:00 P.M., Vendor B said the facility paid $3964.95 on 4/17/23 and had an current balance of $1896.66 as of this day on the scheduled utility bill. During an interview on 5/3/23 at 10:33 AM Vendor A said: -He/she had provided lawn care and snow removal in 2022. -The facility owed a balance of $1050 and payment had not been received. -He/she would resume services once a payment was received. During an interview on 5/2/23 at 1:15 P.M., the facility Third Party Accounts Payable said: -The facility had instituted a new program called [NAME], where an email was provided to vendors so the facility could directly approve the payment that the vendor submits directly. -Utility companies have had portals set up. -Payment was made to Vendor B last month after the shut off notice was received and they facility balance was what was currently due. -The last payment made to Vendor C was on 3/13/23. His/her office would make payment for the outstanding balance of $10.573.65 this day. -The delayed payments were in response to the vendors not having a steady time of the month to do a check run and before the new [NAME] system invoices were lost. -The facility had the money available to pay the bills. During an interview on 5/2/23 at 2:10 P.M., the Administrator said he/she had access to [NAME], however when he/she had logged in there was nothing there. [NAME] had not been set up or he/she had not been trained how to adequately use it. MO00217746

Based on observation, interview, and record review, facility staff failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 14 residents. Record review of the facility policy Nurse Staffing Posting Information revised 5/1/22 showed: -The daily staffing sheet would be posted on a daily basis and contain the following information: --The facility name. --The current date. --The census. --The total number of hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and Certified Nurses Assistants (CNA's). -The information would be clear and in a readable format. -The information would be in a prominent place readily accessible to residents and visitors. 1. Observation on 5/2/22 at 5:40 A.M. showed a staffing sheet posted on the table in the front lobby area dated 4/6/22. Observations on 5/3/22 at 8:50 A.M. and 11:04 A.M. showed no staffing posted at the front entrance area or nurses station. Observations on 5/4/22 at 7:17 A.M. and 11:04 A.M. showed no staffing posted at the front entrance area or the nurses station. During an interview on 5/4/22 at 7:53 A.M. RN A said: -The Director of Nursing (DON) was responsible for posting the staffing hours. -The DON was no longer employed and the staffing had not been posted recently. During an interview on 5/4/22 at 10:12 A.M. the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -The DON had been posting the staffing and this was no longer being completed. -There was no DON at this time. During an interview on 5/5/22 at 10:59 A.M. the Administrator said: -The staffing should be posted daily in-house. -The former DON was completing the staffing posting and this had not been completed since he/she left. -The staffing posted should contain nurses, CNA hours and the resident census. -The staffing levels should be posted and visible for all visitors and residents.

Based on observation, interview, and record review, the facility failed to keep the dry storage floor clean; failed to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to keep trash and garbage receptacles lidded; and to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 14 residents with a licensed capacity for 60 residents. 1. Observations during the initial kitchen inspection on 5/2/22 between 9:26 A.M. and 10:18 A.M. showed the following: -The dry storage room had numerous plastic lids, dried drips, paper debris, and a leaf on the floor under storage racks. -The microwave had an excessive build-up of food splatters on the upper inside, with some also on the sides and inner side of the door. -A light bulb with socket inside the reach-in refrigerator by the stove was hanging down loose from the inner top by its wires and resting on two cantaloupes. -An unlidded large garbage can, approximately 4/5 full with food scraps on top, had its lid in between the middle food preparation table and steam table. -Another large garbage can in the dishwashing area was unlidded with its lid tucked between the wall and a rinsing table. -A floor-standing fan by the Dietary Manager's office had excess amounts of lint built-up on the front and back of its fan finger guard. -The oven had a scrap of foil inside on the bottom. -The brown, blue, and red cutting boards were heavily scored with plastic bits flaking off. -The manual can opener had food debris built-up on the right side of the blade. -On a hanging utensil rack over the middle food preparation table was a ladle that had dried streaks in the bowl and a small brown-handled spatula that had chips on the white scraper end. -An approximately 21 inch (in.) square ceiling vent cover with an abundance of lint built-up on its louvers (a set of angled slats or flat strips fixed at regular intervals in a vent, shutter, or screen to allow air to pass through), located over the reach-in refrigerator by the stove, was hanging down approximately 1 in. on its southwest corner allowing excess lint to escape into the kitchen. -A two-slice black toaster on the east side of the stove area had crumbs on the top and inside, and the crumb tray underneath was completely full. Observations during the follow-up kitchen inspection on 5/3/22 at 11:56 A.M. showed all of the conditions observed above on 5/2/22 still existed. Observations outside the facility on 5/4/22 at 8:57 A.M. showed the right lid of a dumpster located in a wooden enclosure was left open. Observations on 5/4/22 at 11:07 A.M. showed the right lid of the dumpster located in a wooden enclosure was still left open. During an interview on 5/4/22 at 1:52 P.M., the Dietary Manager said the following: -All kitchen staff were responsible for cleaning and sweeping the kitchen's floors every day. -Damaged food preparation items are replaced whenever they are brought to his/her attention. -All food should be free from contamination by foreign particles. -The cook, or whoever uses them, is responsible for cleaning food preparation equipment like the toaster and microwave after each use and as needed. -The procedure for the disposal of garbage is that after food preparation any leftover scraps are discarded into one of the two large kitchen garbage cans and when they are full the bag liner is taken out to be put in the dumpster. Observations on 5/4/22 at 1:55 P.M. showed both of the kitchen large garbage cans were unlidded with their lids stored in the same spots as seen previously. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. -In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.

Based on interview and record review, the facility failed to have a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment updated annually and complete to show the current resident population and needs. A total of 8 residents were sampled. The facility census was 14 residents. Record review of the facility's Facility Assessment policy revised 5/1/22 showed: -The facility conducted and documented a facility wide assessment to determine what resources were necessary to care for the residents competently during both day-today operations and emergencies. -The facility assessment would be reviewed and updated whenever there was, or the facility plans for, any change that would require a substantial modification to any part of the assessment or at a minimum, annually. 1. Record review of the Facility Assessment Tool dated 3/30/20 and updated 2/28/22 showed: -This was the guide to complete a facility assessment. -There was limited information regarding all areas required. -This was not a completed facility assessment. During an interview on 5/3/22 at 10:05 A.M. the Administrator said: -He/she was new and there were some things that were not completed. -The last facility assessment was completed in 2020. -The previous Administrator did not update the facility assessment. -He/she was working on an updated assessment now. During an interview on 5/4/22 at 1:19 P.M. the Administrator said: -The previous Administrator should have updated the facility assessment annually and as needed. -The facility was only accepting skilled therapy short-stay residents as of 9/2021. -The facility assessment should have reflected the current population of the residents. -The facility assessment was vague and not as detailed as it should be. -The facility assessment needed to be completely re-done.

Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility; failed to follow facility policy to ensure staff completed employee [CONDITION(S)] (TB-a potentially serious infectious bacterial disease that mainly affects the lungs) testing according to professional standards for three employees (Employee D, E, and F) out of eight sampled employees; failed to ensure infection control practices to prevent possible cross-contamination during the medication pass when staff did not properly sanitize the glucometer (a meter used to check blood sugar levels) between residents and did not wash and/or sanitize hands between glove changes for one sampled resident (Resident #8) and one supplemental resident (Resident #5), failed to ensure oxygen and nebulizer tubing were properly stored between use for one sampled resident (Resident #7), and failed to complete resident [CONDITION(S)] screening/testing annually and upon admission for four sampled residents (Resident #2, #8, #117, and #265) out of eight sampled residents. The facility census was 14 residents. 1. Observations during the Life Safety Code (LSC) room inspections with the Maintenance Director on 5/3/22 between 9:34 A.M. and 11:13 A.M. showed the following: -Each resident room had its own bathroom with a sink and toilet; those on 100 and 300 halls included a shower. -There were two bath houses located on the 200 Hall. -There were two water heaters for the facility. -The kitchen had sinks, a janitor's closet with a place to rinse mops, and a dishwashing area with a low-temperature dish washing machine. Record review of the facility's disaster manual entitled Master Emergency Book, last reviewed and updated on 12/12/18 and obtained from the nurse's station, showed an absence of any documentation that followed CMS's requirements for a waterborne pathogen program such as, but not limited to: -A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard. -A completed Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system with a written explanation of the water flow throughout the facility. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing [CONDITION(S)] (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other waterborne pathogens. -A program and/or flowchart that identified and indicated specific potential risk areas of growth within the building. -Assessments of each individual area's potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 5/5/22 at 10:18 A.M., the Maintenance Director said the following: -He/she was hired at this facility a little over two months ago. -He/she had not worked in a Skilled Nursing Facility for quite a while. -He/she was unaware of the requirement for a waterborne pathogen program. During an interview on 5/5/22 at 10:27 A.M., the Regional Maintenance Director said he/she had asked a previous Maintenance Director that worked there now in Medical Records, if they had any such documentation and they thought they had and went to look. Record review of the facility's waterborne pathogen program paperwork provided by the Regional Maintenance Director showed a 23-page CDC document entitled Legionella Environmental Assessment Form, with numerous pages of questions to answer and charts to complete, none of which were filled out. During an interview on 5/5/22 at 11:44 A.M., the Administrator said the following: -He/she started working at this facility about eight weeks prior. -He/she did not know the Legionella paperwork was not filled out. 2. Record review of the facility's Employee TB Testing policy, dated 5/1/22, showed: -The facility should follow the state or local requirements for TB testing. -At the time of employment, all new staff should receive the two step TB skin test given two weeks apart. -Each TB test should be read 48-72 hours after administration of the TB skin test. Record review of the Centers for Disease Control and Prevention (CDC) website, updated 3/8/2021, showed: -The TB skin test is performed by injecting a small amount of fluid (called [MEDICATION(S)]) into the skin on the lower part of the arm. -A person given the [MEDICATION(S)] skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm. -Results should be documented in millimeters (mm). -A second skin test should be administered one to three weeks later. -The test should be read 48 to 72 hours after administration. -The results should be documented in mm. 3. Record review of Employee D's personnel file showed: -Employee D was hired on 11/24/21. -The first TB test was administered on 11/18/21 and the results of the TB test were read on 11/20/21. -The second step was administered on 11/22/21 and the results of the TB test were read on 11/24/21. -The second skin test was administer four days after the first TB skin test. 4. Record review of Employee E's personnel file showed: -Employee E was hired on 11/17/21. -The first TB test was administered on 11/14/21 and the results of the TB test were read on 11/15/21. -The second step was administered on 11/30/21 and the results of the TB test were read on 12/2/21. -The second skin test was administer six days after the first TB skin test and the first step was read in 24 hours. 5. Record review of Employee F's personnel file showed: -Employee F was hired on 1/25/22. -The first TB test was administered on 1/17/22 and the results of the TB test were read on 1/19/22. -The second step was administered on 1/24/22 and the results of the TB test were read on 1/26/22. -The second skin test was administer five days after the first TB skin test. During an interview on 5/3/22 at 1:54 P.M., the Human Resources Director said: -The employee TB skin testing was completed by a nurse but at this time the Administrator was completing these. -The first TB test was administered and read within 48-72 hours later. -The second TB test should be administered 14 to 21 days after the first step and read 24-48 hours after. -The Employee TB tests were not completed correctly. During an interview on 5/4/22 at 10:12 A.M., the Minimum Data Set (MDS) Coordinator said: -He/she was not aware of who was responsible for completing TB testing for the residents. -The first step was administered to a resident and read 48-72 hours later. -The second step was administered to a resident seven days later and read 48-72 hours later. During an interview on 5/5/22 at 10:59 A.M., the Administrator said: -When TB testing were completed for employees, the first TB test was given and read 48 hours later. -The second TB test was administered 14 days later and read within 48 hours. -The employee TB testing should start prior to hire. -The Director of Nursing (DON) was completing these prior to leaving the facility. -He/she was completing the TB testing for employees now. 6. Record review of the facility Glucometer Disinfection Policy, revised on 5/1/22, showed: -Glucometers will be cleaned and disinfected after each use and according to manufacturers recommendations. -The glucometer should be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that is effective against Human Immunodeficiency Virus ([CONDITION(S)]), [CONDITION(S)] and [CONDITION(S)] B virus. -Staff were directed to gather supplies, wash hands, put on gloves, obtain the blood sample, remove gloves and wash hands prior to exiting the resident's room. Staff were then to reapply gloves, remove two disinfectant wipes from the container, using the first wipe to remove any blood or contamination, then the second wipe to thoroughly disinfect the glucometer, then allow the glucometer to air dry, then perform hand hygiene (remove gloves and wash/sanitize hands). --The policy did not instruct staff to place the glucometer on a barrier after it has been disinfected. Record review of the facility Hand Hygiene Policy, revised on 5/1/22, showed: -The use of gloves does not replace hand hygiene. -If your task requires gloves, perform hand hygiene prior to donning (applying) gloves and immediately after removing gloves. 7. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 5/2/22 at 5:55 A.M., showed: -RN A donned gloves without washing or sanitizing his/her hands. -Without sanitizing or disinfecting the glucometer, he/she entered Resident #8's room and obtained the resident's blood sugar sample. -After obtaining the resident's blood sample, RN A exited the resident's room with his/her gloves on and placed the glucometer on top of the medication cart without a barrier and without disinfecting the glucometer. -He/she removed his/her gloves and without washing or sanitizing his/her hands, removed a denture cup from the top of the medication cart and delivered it to the resident in his/her room. -Without washing or sanitizing his/her hands, he/she exited the resident's room and started typing on the tablet on the medication cart then pushed the medication cart down the hall. -He/she left the medication cart, walked to the nurse's desk, removed a bottle of hand sanitizer, brought it to the cart and sanitized his/her hands. 8. Record review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 5/2/22 at 5:59 A.M., showed: -RN A donned gloves and removed the glucometer which had not been disinfected from the previous resident off the top of the medication cart without a barrier, applied hand sanitizer to his/her hands and sanitized the glucometer with the hand sanitizer, then placed the glucometer on top of the contaminated medication cart without a barrier. -He/she removed the glucometer from the top of the medication cart and entered the resident's room. -He/she obtained the resident's blood sample, exited the resident's room, removed his/her gloves, and placed the glucometer on top of the medication cart without a barrier. -He/she then placed the glucometer in the medication cart drawer without sanitizing or disinfecting the glucometer. During an interview on 5/4/22 at 7:36 A.M., RN A said: -Staff should disinfect the glucometer with a bleach wipe or alcohol before and after use. -The glucometer should be placed on a barrier and not on top of the medication cart when not in use. -The glucometer should be disinfected prior to returning to the medication cart drawer after use. -Staff should wash or sanitize their hands before putting on gloves and after removing gloves. 9. Record review of the facility Nebulizer Therapy policy, dated 5/1/22, showed staff were directed to store the nebulizer cup and mouthpiece in a bag. Record review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's May 2022 POS showed: -Check oxygen saturation every shift. If below 90 percent (%), may use oxygen as ordered as needed. -[MEDICATION(S)]-[MEDICATION(S)] 0.5-2.5 milligrams (mg) per milliliter (ml) (a breathing treatment used to help increase the movement of air into the lungs) 1 vial, inhale orally every six hours as needed for shortness of air or wheezing four times a day as needed. Observation on 5/2/22 at 5:31 A.M., showed the resident was lying in bed asleep. The resident was wearing supplemental oxygen. Observation on 5/2/22 at 8:46 A.M. and at 12:08 P.M., on 5/3/22 at 9:49 A.M. and 2:13 P.M., on 5/4/22 at 7:34 A.M., and on 5/5/22 at 8:51 A.M., showed -A nebulizer machine (a machine used to deliver breathing treatment medication) was on the resident's night stand. The nebulizer mask was on top of the machine not stored in a bag and a bag was not on or near the nebulizer. -Oxygen tubing curled up on top of the oxygen concentrator with some of the tubing on the floor. The tubing was not stored in a bag and a bag was not on or near the oxygen concentrator. During an interview on 5/5/22 at 8:51 A.M., the resident said he/she wears the oxygen at night and received breathing treatments. During an interview on 5/5/22 at 8:54 A.M., Certified Medication Technician (CMT) A said: -The resident used his/her oxygen as needed. -Oxygen tubing and nebulizer masks should be stored in a plastic bag when not in use and should not be on the floor. During an interview on 5/5/22 at 8:56 A.M., Agency LPN A said: -The resident used his/her oxygen mostly at night. -He/she gave the resident breathing treatments through the nebulizer during the day. -Oxygen tubing and nebulizer masks should be stored in a plastic bag when not in use. -Oxygen tubing should not be on the floor. During an interview on 5/5/22 at 10:54 A.M., the Administrator said: -Oxygen tubing and nebulizer masks should be stored in a bag when not in use. -Oxygen tubing should not be on the floor. 10. Record review of the facility Resident Screening for [CONDITION(S)] Policy revised on 5/1/22 showed: -New resident screening: --Prior to or at the time of admission, all new residents will receive TB testing and/or chest radiograph (X-Ray) in accordance with state requirements. --The facility shall follow the CDC recommendations for targeted testing for TB infections. --A two-step TB test will be given two weeks apart unless the resident has previously been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] -Current resident screening: --All residents previously TB test-negative will be retested according to state requirements. --In the absence of state requirements, the residents will be retested annually. 11. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's May 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] --May have TB screening yearly. Record review of the resident's electronic medical record on 5/2/22 showed the resident's last TB screening was completed on 3/5/21. 12. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -His/her first step TB test was administered on 2/15/22 and read on 2/17/22. -His/her second step TB test was administered on 2/22/22 and read on 2/24/22. --His/her second step TB test was administered seven days after the first step was administered. 13. Record review of Resident #117's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This was two days after the resident was admitted to the facility. 14. Record review of Resident #265's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This was eight days after the resident was admitted to the facility. During an interview on 5/5/22 at 10:54 A.M., the Administrator said: -The charge nurse was responsible to ensure a resident received his/her first step TB test upon admission to the facility. -The TB test would be documented on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -The second step TB test should be administered two to three weeks after the first TB test. -Residents should then be screened yearly for signs and symptoms of TB if their two step test was negative upon admission to the facility.

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, well graded driving surface to prevent the pooling of water, in the event of an evacuation of residents, and/or for emergency and transport vehicles. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility. The resident census was 14 residents with a licensed capacity for 60 residents. 1. Record review of the facility's disaster manual entitled Master Emergency Book, last reviewed and updated on 12/12/18 and obtained from the nurse's station, showed the following: -On the page entitled Evacuation Considerations, under point #4, which was a list of evacuation terms, at part c, it stated, Complete/Outside Evacuation: Moving residents, staff, and visitors to a pre-designated area outside of the building. -An accompanying map of the facility had the main parking lot outside the front entrance marked as the Final Meeting Place. -On the page entitled Plan of Action for Evacuation Procedures for Removal of Residents & Medical Records/Necessities, it stated, During an evacuation of the facility, a designated vehicle will park at the back door located outside the kitchen area. Observations during the Life Safety Code (LSC) outer perimeter inspection with the Maintenance Director on 5/3/22 between 1:05 P.M. and 1:39 P.M. showed the following: -There was a large pothole in the middle of the driving surface outside the kitchen that was approximately 3 feet (ft.) by 4 ft. and 3 inches (in.) deep that was pooled with water from a recent rain. -A the southwest section of the main parking lot outside the entrance there were numerous uneven patches, signs of erosion, and potholes, in an area approximately 20 ft. long and 7 ft. wide, all of various depths and pooled with water from a recent rain. During an interview on 5/5/22 at 10:18 A.M., the Maintenance Director said that if the parking lot areas were listed as evacuation meeting areas the surface should be smooth enough for wheelchairs, walkers, and emergency and evacuation vehicles. During an interview on 5/5/22 at 11:44 A.M., the Administrator said they would expect any areas listed as evacuation meeting areas to be smooth enough for wheelchairs and walkers.

Based on observation, interview, and record review the facility failed to ensure one sampled resident (Resident #8) was transferred with a two person staff assist and a hoyer lift which resulted in a displaced segmental fracture of the humerus shaft of the left arm (a spiral fracture (occurs due to a rotational, or twisting, force) of the upper arm), failed to complete a thorough investigation and put in interventions in place to ensure an incident would not recur out of eighteen sampled residents. The facility census was eight residents. Record review of the facility's Accident and Incident-Investigating and Reporting policy, revised 12/07, showed: -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the incident or accident. -The following shall be included on the report/incident accident form: --The date and time. --The nature of the injury. --The circumstances surrounding the injury. --Where the accident took place. --The names of the witnesses and their accounts of the accident/incident. --The injured person's account of the accident/incident. --The physician's notification and response. --The notification of the resident's family. --The condition of the resident including vital signs (heart rate, blood pressure). --The disposition of the injured (hospital, put to bed, sent home). --Any corrective action taken. --Follow-up information. --Other pertinent data required. -The facility was in compliance with the rules and regulations governing the accident/incident. -The Director of Nursing (DON) shall ensure the Administrator received a copy of the report. -The accident/incident report would be reviewed by the safety committee for trends related to the accident or the safety hazard and to analyze any individual resident vulnerabilities. Facility policy review of Investigation of Bruises, Skin Tears, Scratches, undated, showed: -A licensed nurse will complete an investigation and fill out the investigation form, by the end of the shift. -Resident care plan will be revised with interventions to prevent future injury. -Nursing Administration will review the investigation to determine if the injury is of unknown origin, or, suspicious in nature. -Injury must be investigated and referred to the quality assurance process for problem identification and to put in place needed corrective action. 1. Record review of Resident #8's Admission Record showed the resident was readmitted to the facility on [DATE] and had the following diagnoses: -Stroke (a condition when the blood supply to the brain is interrupted or reduced). -Flaccid [CONDITION(S)] (paralyzed on one side of the body). -Lack of coordination. -[CONDITION(S)] of the left shoulder (cartilage that cushions the ends of your bones wears down over time). Record review of the resident's Physician's Orders Sheet (POS) showed the following physician's order dated 9/11/20: the resident required a two staff person assisted transfer with a hoyer lift. Record review of the resident's Nurses Notes, dated 9/12/20, showed: -The resident was on 72 hour monitoring for readmission to the facility. -The resident was thrilled to be back at the facility. -The resident had a flaccid left side and his/her paralysis (the loss of the ability to move) persists. Record review of the resident's Nurses Notes, dated 9/14/20 at 3:38 P.M., written by Licensed Practical Nurse (LPN) A showed: -At approximately 8:00 A.M., this nurse was called to the resident's room by a Certified Nurses Aide (CNA). -The CNA stated he/she and another CNA transferred the resident into a shower chair without the use of a hoyer lift (a mechanical lift that lifts the entire body from place to place) and they heard a pop during the transfer. -The resident did complain of left arm pain after the incident and was given a pain medication. -The resident's left side was flaccid and he/she used a tray on the left side for arm rest and immobilization of left arm. -The CNA's were educated to never transfer the resident without a hoyer lift. -The physician was immediately notified. -The physician ordered stat (immediate) x-rays (imaging pictures of the inside of your body) of the resident's left shoulder. -The x-ray technician arrived around 12:00 P.M. -After the x-ray technician completed the left shoulder x-ray he/she stated something was seen on the resident's left arm. -The resident's physician was called and gave physician's orders for an x-ray of the resident's left arm. -The x-ray technician stated it would be a few hours to process the results of the x-ray. -At around 2:00 P.M., he/she called the x-ray company to check on the results of the x-ray. -The results were received and the resident's physician was notified the resident had a left arm humerus fracture. -The DON and Administrator were notified and a message was left for the resident's family member. -The resident was transported by ambulance to the hospital. -There was no staff documentation that showed when the resident returned from the hospital. Record review of the undated resident's Transfer Form showed the resident was sent to the hospital for a fractured left humerus. Record review of the resident's hospital medical records, dated 9/14/20, showed: -The resident presented to the emergency room stating he/she was at the nursing home this morning and some staff members picked him/her up by his/her arm and there was a pop in his/her left arm. -He/She had a pain level of five out of ten on a pain scale (moderate pain). -His/Her left arm had been hurting ever since. -The resident had a history of a stroke. -The resident was awake, alert, and there was no acute distress. -The resident had an x-ray and he/she had a left middle arm humerus fracture. -The left humerus fracture was discussed with the orthopedic physician. -The orthopedic physician recommended an immobilizer (on the resident's left arm). -The orthopedic physician would see the resident in a week in his/her office. -An orthopedic appointment was scheduled for 9/21/20. -The resident was stable and was discharged from the emergency department. Record review of the resident's hospital Radiology report dated 9/14/20 at 4:42 P.M. showed the resident had a acute mildly displaced left mid humerous fracture. Record review of the facility's Risk Management Report, dated 9/14/20, completed by LPN A showed: -At approximately 8:00 A.M., this nurse was called to the resident's room by a CNA. -The CNA stated he/she and another CNA transferred the resident into a shower chair without the use of a hoyer lift (a mechanical lift that lifts the entire body from place to place) and they heard a pop during the transfer. -The resident did complain of left arm pain after the incident and was given a pain medication. -The resident's left side was flaccid and he/she used a tray on the left side for arm rest and immobilization of left arm. -The CNA's were educated to never transfer the resident without a hoyer lift. -The physician was immediately notified. -The physician ordered stat (immediate) x-rays (imaging pictures of the inside of your body) of the resident's left shoulder. -The x-ray technician arrived around 12:00 P.M. -After the x-ray technician completed the left shoulder x-ray he/she stated something was seen on the resident's left arm. -The resident's physician was called and gave physician's orders for an x-ray of the resident's left arm. -The x-ray technician stated it would be a few hours to process the results of the x-ray. -At around 2:00 P.M., he/she called the x-ray company to check on the results of the x-ray. -The results were received and the resident's physician was notified the resident had a left arm humerus fracture. -The DON and Administrator were notified and a message was left for the resident's family member. -The resident was transported by ambulance to the hospital. -The resident was alert and oriented. -The resident had been admitted to the facility within the last 72 hours. -This was an injury related to a transfer. -The resident had a history of [CONDITION(S)] and had suffered a previous fracture to his/her left upper arm in 2019. Record review of the facility's investigation, dated 9/14/20, showed: -Untitled investigation summary signed by the past DON and the current Administrator: --It was reported that two CNAs were completing a two person transfer on the resident when they heard a pop in his/her shoulder. --It was reported to the nurse on duty immediately then reported to the DON and Administrator. --After x-rays were completed it was identified the resident's shoulder was fractured. --Statements were gathered from CNA A and CNA B. --The DON interviewed the resident who stated he/she did not feel he/she was in harm or danger and the two CNAs were just doing their job. --The resident did acknowledge he/she was in pain. --The resident's family was contacted related to the incident. --Other residents were interviewed regarding ADL care and if there were any issues with CNA A and CNA B and none were reported. --Educational write ups were completed for CNA A and CNA B on 9/17/20. --CNA A was interviewed by the DON and CNA A stated: --He/She was in the process of getting the resident up to have a shower. --He/She was aware the resident was a two-person assist with transfers so he/she went to get CNA A to assist. --CNA A stated he/she was unaware the resident now required a Hoyer lift transfer. --CNA A and CNA B completed a normal two-person assisted transfer and while raising the resident up a pop was heard in the resident's shoulder. --The resident was re-positioned on the bed. --CNA A stayed with the resident while CNA B went to inform the nurse what happened. -CNA B was interviewed by the DON and CNA B stated: --He/She was completing resident showers and CNA A asked him/her to assist with the resident's transfer. --He/She was unaware the resident was now a hoyer lift transfer since he/she returned to the facility. --In the process of getting the resident up, a pop was heard and the resident winced in pain. --At that moment, they sat the resident back down on the bed and he/she went down the hall to inform the nurse of what happened. -LPN A was interviewed by the DON and LPN A said: --CNA B came to get him/her when they heard a pop in the resident's shoulder during a transfer to the shower chair. --The resident was assessed and x-rays were ordered. --The CNAs were both educated the resident was not a two person transfer anymore and needed a hoyer lift for transfers. --Both CNAs stated they were not aware the resident was no longer a two person assist with transfers (from previous stay at the facility). -CNA B's written witness statement: --He/She assisted CNA A with a two-person transfer to take the resident for a shower. --He/she was on the right side of the resident and CNA A was on the left side of the resident. --They both heard a pop. --The resident stated his/her shoulder was out of place. --He/She went to get the charge nurse and inform him/her about the resident's shoulder. --He/She was then informed by the charge nurse (LPN A) the resident required a hoyer lift transfer. --He/She had never worked with the resident before and if he/she had known the resident required a hoyer lift transfer, he/she would have used the hoyer lift. --CNA A seemed to know what type of transfer was used for the resident. -CNA A's written witness statement: --He/She and CNA B were transferring the resident to the shower chair. --In the process of transferring the resident they heard a pop and the nurse was notified immediately. -There was no documentation that showed if a gait belt was used during the transfer, if an audit was completed related to resident transfer methods, if education and competencies were provided to all staff related to transfers, and if a system was put into place to prevent another transfer incident. Record review of the resident's Activity of Daily Living (ADL-the things we normally do in daily living including any daily activity we perform for self-care such as feeding ourselves, bathing, dressing, grooming, transferring) Care Plan, dated 9/15/20, showed the resident: -Had an ADL self-care performance deficit related to left sided flaccid [CONDITION(S)] following a stroke. -Needed the extensive assistance of two staff members for transfers with the use of a hoyer lift. -Review showed no other interventions were put in place after the incident. Record review of the resident's physician's History and Physical Progress Note, dated 9/15/20, showed: -The resident was a recently transferred from another facility to this facility. -Staff had reported a pop during a transfer and the resident had been found to have a displaced left humerus fracture. -The resident had a history of a stroke and was unable to use his/her left side of his/her body. -The staff were to continue with the plan of care, continue to use the immobilizer (a device designed to hold your arm against your body) and follow up with an orthopedic surgeon. Record review of the Nurses Notes, dated 9/15/20, showed: -The resident's family member called asking about the treatment plan. -The resident's family member wanted to go with the resident to his/her orthopedic appointment. -The resident had an appointment with the orthopedic physician on 9/21/20 at 2:00 P.M. -A transport van would be used to take the resident to the appointment. Record review of the resident's Nurses Notes, 9/16/20, showed the resident: -Was on incident charting related to his/her left humerus injury. -Had no complaints of pain at this time. -Had an immobilizer in place (on his/her left arm). Record review of the resident's Nurses Notes, dated 9/17/20, showed the resident: -Was on incident charting related to his/her left humerus injury. -Had no complaints of pain at this time. -Was resting in bed with his/her eyes closed. Record review of the CNA A's Corrective Action Form, dated 9/17/20, showed: -On 9/14/20, the staff member injured a resident while transferring the resident. -CNA A was educated on appropriate transferring and use of a gait belt. -CNA A was educated on speaking to the nurse on a new residents to find out the resident's method of transfer. -CNA A did not have any comments and refused to sign the form. Record review of the CNA B's Corrective Action Form, dated 9/17/20, showed: -On 9/14/20, the staff member injured a resident while transferring the resident. -It was reported to the nurse a pop was heard in the resident's shoulder. -CNA B was educated on transferring and using a gait belt. -CNA B refused to sign and felt they had not done anything wrong and understood the importance of a gait belt. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning purposes), dated 9/18/20, showed the resident: -Was cognitively intact. -Needed the extensive assistance of two staff members for transfers. -Could not ambulate. -Had a functional limitation of his/her range of motion on one side of his/her upper and lower extremities. -Had the following diagnoses: stroke, [CONDITION(S)], and a fracture. Record review of the resident's Nurses Notes, dated 9/21/20 through 10/5/20, showed there was no staff documentation related to the orthopedic appointment or the resident's left humerus fracture. Record review of the resident's orthopedic physician's notes, dated 9/21/20, showed: -The resident had a displaced segmental fracture of the humerus to his/her left arm. -[NAME] brace (used to stabilize a fracture in your upper arm while leaving your elbow free, allowing motion in your forearm and hand. Promoting the recovery of long-bone humerus fractures) to the left upper extremity. Cover for showers (brace can be removed for shower if re-applied correctly). -New x-rays needed to be obtained on 11/3/20. -A follow up appointment was scheduled for 11/4/20. Record review of the resident's POS showed the following physician's orders dated 9/21/20: -[NAME] brace to the left upper extremity. Cover for showers (brace can be removed for shower if re-applied correctly). Record review of the resident's Nurses Notes, dated 10/6/20, showed the resident went to a doctor appointment in the facility van and all paperwork was sent with the resident. Record review of the resident's Nurses Notes, dated 10/6/20, showed: -The orthopedic physician needed an x-ray of the resident's left shoulder on 11/3/20 related to a follow up appointment on 11/4/20. -The appointment card for the orthopedic appointment was given to social services. Record review of the resident's Physician's Progress Notes, dated 10/20/20, showed: -The resident had no new issues. -His/Her left arm remained in an immobilizer. -The resident had no complaints of pain. Record review of the resident's Nurses Notes, dated 10/28/20, showed the resident was transferred to another facility. During an interview on 1/6/20 at 10:55 A.M., Registered Nurse (RN) A said: -He/She was not here the day the incident occurred. -He/She heard the resident had been transferred with a hoyer lift and suffered fracture to his/her arm. -He/She was unsure if a gait belt was used by the CNAs that transferred the resident but had heard a gait belt was not used. -One side of the resident's body was flaccid. -He/She was responsible for completing an incident report. -The incident report would flag to the DON in the electronic medical record. -The investigation would be completed by the DON. During a telephone interview on 1/6/21 at 11:25 A.M., CNA B said: -He/She no longer worked at the facility but remembered the incident. -He/She was called to the resident's room by CNA A to complete a transfer on the resident from his/her bed to the shower chair. -He/She had not worked with this resident before. -CNA A did not instruct him/her to use a gait belt or a hoyer lift for the transfer. -CNA A worked with the resident the previous day and stated he/she knew the resident's method of transfer. -The facility was moving resident's in and out related to COVID 19 (an infectious disease caused by severe acute respiratory syndrome) and it was hard to keep up to know the resident's ADL needs. -He/She along with CNA A were transferring the resident underneath the arms from the bed when they heard a pop. -The resident was lifted by his/her arms and a gait belt was not used. -He/She had been a CNA for eight years. -A gait belt should have been used during the transfer but he/she had trusted what CNA A had said about the resident's method of transfer. -After we attempted the transfer on the resident, the resident said they should have used a lift for the transfer. -After the resident said this, he/she went to go get the LPN A. -LPN A later told him/her the resident needed a hoyer lift for all transfers. -The resident's left arm was broken. -He/She was unsure if the residents' method of transfer was on the care plans. -He/She had never been trained when he/she started at the facility in 6/2020. -After the incident occurred, he/she had been given a list of all the residents' method of transfer. .During an interview on 1/6/21 at 1:55 A.M., RN A said: -If a resident fell , the nurses were responsible for assessing the resident. -He/She would create a Risk Management report. -He/She did not put interventions in place after the fall. -He/She thought the MDS Coordinator put in interventions after a fall. -At this time, there was no MDS Coordinator in the building. During an interview on 1/7/21 at 9:28 A.M., the Assistant Director of Nursing (ADON) said: -He/She had just got to the facility and was told an incident had occurred. -CNA A and CNA B had transferred the resident to take the resident to the shower when they felt the resident's arm pop. -He/She was told the staff members used a gait belt transfer for the resident instead of a sit to stand lift (a devices designed to help patients who lack the specific strength or muscle control to rise to a standing position). -He/She thought the resident used a sit to stand lift and not a hoyer lift. -The DON had been notified. -The nurses were responsible for completing the Risk Management report (incident report). -He/She had not been involved in the investigation. -The DON, who was no longer working at the facility, was responsible for completing the investigation. -When an incident occurred, the Interdisciplinary Team (IDT) would meet and go over the incident. -There had not been IDT team meetings completed at the facility and had fallen through the cracks by the previous DON. -When this incident had occurred, he/she expected the staff to be suspended pending an investigation. -The IDT team should have met and went over the incident. -All staff should have been in-serviced related to transfers and all resident care plans should have been updated to have the correct method of transfer. -The CNAs have access to the residents' care plans in the electronic record to know the resident's method of transfer. During an interview on 1/7/21 at 11:39 A.M., the DON said: -He/She had been the facility wound nurse at the time of the incident. -He/She had asked both CNAs if a gait belt had been used when they transferred the resident and was told a gait bent had not been used. -The nurses were responsible for completing the Risk Management report and the DON was responsible to complete the investigation along with the Administrator. -If a wrong transfer was completed and the resident was injured, he/she would suspend the employees immediately pending the investigation. -He/She would notify the residents' family and physician. -Witness statements should be obtained from the staff. -The IDT should have met to put individualized interventions in place after each fall. -This would be documented on the Risk Management report after a meeting was held and the resident's care plan should be updated. -IDT meetings had not been held at the facility since 3/2020 and he/she was going to put these meetings back in place. During an interview on 1/7/20 at 1:04 P.M., the Administrator said: -He/She did not complete investigations related to incidents and these were handled by nursing. -The DON was responsible for completing the investigations. Phone call attempts were made to CNA A on: -1/6/21 at 11:23 A.M.: CNA A stated he/she remembered the incident, was busy, and needed to call back due to being busy at the moment. -1/7/21 at 9:09 A.M.: voice mail box was full and no message could be left. -1/11/21 at 9:27 A.M.: voice mail box was full and no message could be left. -1/11/21 at 9:44 A.M., a call was received from CNA A wanting to know who surveyor was. Surveyor explained an interview regarding the incident was needed. CNA A stated he/she just woke up, needed time to wake up, and would call back later. Phone call attempts were made to LPN A on 1/6/21 at 11:12 A.M., 1/7/21 at 9:11 A.M., and 1/11/21 at 2:51 P.M. and a message said the wireless customer you were trying to reach was not available. Messages could not be left. Phone call attempts were made to the resident's physician (also the Medical Director) and messages were left on his/her cellular phone on 1/8/21 at 9:31 A.M., 1/11/21 at 9:29 A.M., on 1/13/21 at 9:48 A.M., 1/14/21 at 4:30 P.M. and 6:30 P.M. and 1/15/21 2:30 P.M. and 5:30 P.M., a return call was not received. A certified letter was sent to the resident's physician on 1/12/21 to contact the State Agency (SA). MO 025

Based on interview and record review, the facility staff failed to identify, monitor and promptly intervene for a change in condition for one sampled resident (Resident #1), resulting in delayed basic life support including cardiopulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heart beat or breathing has stopped), for the Full Code resident. The resident expired. The facility census was 45 residents. The Administrator was notified on [DATE] at 12:47 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the violation of the facility's Resident Change in Condition or Status and CPR policy. The staff member was suspended pending investigation. The facility in-serviced staff on the Change in a Resident's Condition or Status and CPR policy. The IJ was removed and corrected on [DATE]. Record review of the facility's Change in a Resident's Condition or Status policy, dated ,[DATE], showed the following: -The nurse will notify the resident's attending physician or physician on call when there has been a/an: --Accident or incident involving the resident. --Significant change in the resident's physical/emotional/mental condition. --Need to alter the resident's medical treatment significantly. --Need to transfer the resident to a hospital/treatment center. --Specific instruction to notify the physician of changes in the resident's condition. -A significant change of condition is a major decline or improvement in the resident's status that: --Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Record review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy, dated ,[DATE], showed: -Personnel have completed training on the initiation of CPR and basic life support, including defibrillation, for victims of sudden [MEDICAL CONDITION] (a loss of heart function due to abnormal heart rhythms). -If an individual is found unresponsive and not breathing normally, or if sudden [MEDICAL CONDITION] is likely, a licensed staff member who is certified in CPR shall initiate CPR unless: --It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or --There are obvious signs of irreversible death (rigor mortis - stiffening of the joints and muscles of a body a few hours after death). 1. Record review of Resident #1's face sheet showed he/she admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -End stage [MEDICAL CONDITION] (the last stage of [MEDICAL CONDITION]). -Severe protein-calorie malnutrition. -[MEDICAL CONDITION] (a chronic condition in which the heart does not pump blood as well as it should). -Liver disease (any condition that damages the liver and prevents it from functioning well). -Dependence on [MEDICAL TREATMENT] (a substitute for the natural work of the kidneys). Record review of the resident's care plan, dated [DATE], showed: -Resident has a Full Code status (a person will allow all interventions needed to get their heart started. This may include chest compressions and defibrillation). -Resident will be informed of the right to complete advance directives to direct medical care and make treatment goals known. -Advance directives and resident wishes will be honored. -Resident has completed advanced directive for a Full Code. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated [DATE], showed: -A Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. -Required extensive assistance for bed mobility. -Required total dependence upon staff for transfer and bathing. -Required assistance of two staff for dressing and moving to different locations in the facility. -Supervision only for eating. -Assistant of one staff for toileting and hygiene needs. Record review of the Resident physician order [REDACTED]. -Had an order for [REDACTED].>Record review of the resident's Nursing Progress Notes, dated [DATE], showed: -At 6:25 A.M., Registered Nurse (RN) A, witnessed Licensed Practical Nurse (LPN) C exiting Resident #1's room headed towards the crash cart (a wheeled container carrying medicine and/or equipment for use in emergency situations). -RN A joined LPN C in getting the crash cart to the resident's room. -LPN B was at the nurses' desk and followed RN A and LPN C to the resident's room. -CPR was started at approximately 6:28 A.M. -Emergency Medical System (EMS) was called at 6:31 A.M. -At 6:35 A.M., RN B arrived and offered assistance. -RN B gathered necessary paperwork and placed call to the physician. -RN B called resident's mother, Administrator and the Director of Nursing (DON). -EMS arrived at approximately 6:37 A.M. and took over chest compressions. -Time of death per EMS was 7:09 A.M. Record review of the facility's investigation, dated [DATE], showed: -A change in the resident's condition was noted at 5:15 A.M., per Certified Nursing Assistant (CNA) D. -LPN B assessed the resident. -LPN B assessed pulse oximetry (a test used to measure the oxygen level of the blood). -LPN B stated to CNA D that the resident's pulse was shallow and he/she did not know how much longer the resident had. -LPN B instructed CNA D to make the resident look decent and he/she would tell the oncoming nurse. -CNA D and CNA E provided cares for approximately fifteen minutes. -CNA D left the room to find the on-call number unsuccessfully. -CNA D then contacted LPN C and RN A. -The nurses arrived on-site and CPR was initiated at approximately 6:29 A.M. -EMS was notified at 6:30 A.M. -A message was left with the family at 7:10 A.M. -The Physician was notified at 7:11 A.M. -Local police department notified of death (untimed). -Nursing management contacted LPN B who was placed on suspension pending the results of the investigation. Record review of the facility's typed statement from CNA E, dated [DATE], showed: -CNA E responded to the resident's call light about 4:30 A.M. -The resident was sleeping and hanging out of the bed, so he/she pulled him/her back in the bed. -About 5:30 A.M., CNA E was asked by CNA D to assist with putting the resident back in bed, as he/she was hanging out again and looked abnormal and unresponsive. -CNA E and CNA D rushed to the nurse to report. -Upon returning to the resident's room a puddle of green liquid was on the floor. Record review of the facility's typed statement from LPN B, dated [DATE], showed: -LPN B was called to the resident's room by CNA D shortly after 5:00 A.M. -The resident was minimally responsive. -Palpated (examine a part of the body by touch) a weak, thready (weak pulse, difficult to feel or obliterated easily with slight pressure) apical pulse (placing a stethoscope at the apex of the heart and counting for one minute). -Oxygen saturation per the pulse oximetry tool was eighty-one to eighty-two percent. (Normal is ,[DATE]%). -The resident had dark, liquid emesis (the action or process of vomiting). -LPN B instructed CNA D to cleanse resident and to reposition the resident in bed. -LPN B then resumed the morning blood sugar checks and medication pass. -LPN B was called to the resident's room forty-five to fifty minutes later by an off duty nurse who stated the resident had coded (cardiopulmonary arrest). -CPR and EMS were activated and on their arrival he/she resumed his/her assigned responsibilities. Record review of the facility's typed statement from CNA D, dated [DATE], showed: -At about 5:15 A.M., CNA D entered the resident's room, as the roommate had accidentally turned on the call light. -Resident #1 was slumped over, which was common after the resident had received [MEDICAL TREATMENT], so that seemed normal. -CNA D tried to speak with the resident, but the resident was unresponsive to his/her words. -CNA D touched the resident lightly to try and arouse the resident, but that did not work either. -CNA D reported to LPN B that he/she felt something was wrong with the resident and told him/her the resident needed to be checked. -LPN B checked the resident and said he/she had no respirations. -LPN B checked the pulse oximetry and said that the reading was zero. -CNA D asked LPN B what is the foamy stuff coming out of the resident's mouth. -LPN B checked the resident's pulse and said he/she has a shallow pulse. -LPN B said to make the resident look presentable and that he/she would let the day shift nurse know when he/she came in. -CNA D then provided cares to the resident with CNA E, for about fifteen minutes. -CNA D said that during this time, the resident was not breathing or responding, he/she thought that the resident passed away. -CNA D went to the nurses' station to find the on call nurses' numbers, but was unsuccessful. -At 5:52 A.M., he/she called LPN C. -At 6:15 A.M., he/she sent RN A a text that said he/she thought the resident was gone and that the night nurse was waiting for day shift to come in. -At 6:30 A.M., he/she saw RN A, LPN C and LPN B going toward the resident's room. -RN A and LPN C began compressions on the resident. -EMS arrived within a few minutes and took over CPR. Record review of Resident #5's (Resident #1's roommate) quarterly MDS, dated [DATE], showed he/she was cognitively intact with a BIMS score of 14. Record review of Resident #5's, typed statement, dated [DATE], showed: -At 8:40 P.M., Resident #5 was attempting conversation with Resident #1, but Resident #1 was incoherent. -At 9:00 P.M., Resident #5 told CNA D to tell the nurse to call the hospital. -Resident #5 woke at 4:00 A.M., and heard his/her roommate moaning in his/her bed and had a conversation with him/her. -Resident #5 woke again at 5:15 A.M., when CNA D was in the room providing cares for Resident #1. -CNA D said he/she thought something was wrong with Resident #1 and left to notify the nurse. -CNA D returned to the room with LPN B who checked Resident #1 for pulse and oxygen saturation. -Resident #5 asked LPN B if he/she had called anyone about Resident #1 and LPN B stated that he/she was going to wait for RN B. Record review of RN A's typed statement, dated [DATE], showed: -On [DATE] at 6:16 A.M., he/she received a text from CNA D stating that he/she thought Resident #1 was gone and that LPN B was going to wait until the day shift nurse arrived. -Upon arrival at the facility, he/she saw LPN C coming out of Resident #1's room stating he/she was not able to palpate or auscultate a pulse and was headed in the direction of the crash cart. -He/She assisted LPN C and returned to the resident's room and began compressions and used the ambu bag (a bag valve mask used as a manual resuscitator). -LPN B arrived to the room and switched positions with LPN C, LPN B did the compressions, LPN C used the ambu bag and RN A called 911. Record review of LPN C's typed statement, dated [DATE], showed: -On [DATE] at 5:52 A.M., he/she received two calls from CNA D, but he/she did not hear the calls. -At 6:00 A.M., he/she received two text messages stating: --Need you down here right away thinks resident is gone. --There was no on call number he/she could call. -Just before 6:30 A.M., he/she arrived to the resident's room. -CNA D said that the nurse was just not doing anything and was going to leave the issue for day shift. -He/She was unable to find a pulse or respirations and the resident did not respond to sternal rub (application of painful stimulus with the knuckles of a closed fist to the center of the chest of a patient who is not alert and does not respond to verbal stimuli). -He/She got the crash cart stethoscope and didn't hear an apical pulse. -LPN B joined him/her in the room and both started the chest compressions on the resident and used the ambu bag. -LPN B shared with LPN C that he/she had been in the room and the resident had an irregular pulse previously and low oxygen. -EMS arrived and took over CPR. Record review of local fire department's Comprehensive Report, dated [DATE] and received [DATE], showed: -Call type [MEDICAL CONDITION]. -First responder arrived at 6:36 A.M. -ECG Monitor (heart monitor), applied at 6:41 A.M., with asystole (a [MEDICAL CONDITION] rhythm). -6:43 A.M., Oxygen applied with non-rebreather mask (oxygen facemask that allows oxygen to be delivered at higher concentrations) at 15 liters per minute. -Pulse 108 - Assisted - at 6:44 A.M. -Disposition: Dead at scene. -Patient not transported. -Provider impression, [MEDICAL CONDITION]. -Report summary: -Called to a nursing care facility for a possible non-breather. -Patient was found lying on bed with staff initiating CPR. -Patient was not breathing, pulse-less, and unresponsive. -Patient was still found to be warm at the core. -Patient had a large amount of vomitus found around the patient face and across the bed. -Vomitus was a dark green color. -Patient was placed on a back board immediately and moved to the floor to begin code status. -Another look at the bed showed a great amount of vomitus found across pillow and down patient back. -Patient was found to have vomitus in the airway causing airway obstruction. -Patient was not breathing. -Patient with absence of carotid pulse. -Pupils fixed and dilated at time of arrival. -Patient abdomen seems to be distended, but was not rigid to touch. -Attempt at intubation (a placement of a flexible plastic tube into the trachea to maintain an open airway) difficult by airway continually filling back up with vomitus when CPR in progress. During an interview on [DATE] at 9:30 A.M., Resident #5 said: -On [DATE] about 4:30 A.M., he/she woke up because his/her roommate knocked something off his/her table. -He/She started talking back and forth with his/her roommate. -About 5:30 A.M. or maybe 6:00 A.M., he/she woke up with a leg cramp. -CNA D came in to talk to him/her and on the way out of the room asked Resident #1 if he/she was okay. -CNA D went to get the nurse then. During an interview on [DATE] at 10:15 A.M., RN A said: -On [DATE] at 6:16 A.M., he/she received a text from CNA D on duty. -The text said, that he/she thought Resident #1 was gone and the nurse on duty was going to wait until the day shift nurse arrived. -He/She arrived at the facility and LPN C was coming out of the resident's room running to get the crash cart. -LPN C, LPN B, and him/her set up the ambu bag and LPN C and LPN B started the compressions. -RN A said that he/she did not have any conversation with LPN B. -RN A called EMS. -Resident #1 had no signs of life, no breathing, and did not know if he/she was hearing a pulse or not. -He/She thinks the compressions were started about 6:26 A.M. to 6:27 A.M., and EMS was called at 6:31 A.M. -The facility had multiple ways to determine what a resident's code status. -Outside of each resident's door was the name plate that had either: --A red paper for DNR status or a green paper for full code. -Behind the nurses' station the facility had binders that listed all of the residents and their code status. -The medical computer system for facility documentation listed code status of each of the residents. During an interview on [DATE] at 1:00 P.M., CNA D said: -The resident's roommate had put on his/her call light about 5:15 A.M. -He/She does not remember Resident #5 telling him/her to tell the nurse to call the hospital the night before. -Resident #1 was sluggish and recently had [MEDICAL TREATMENT], but this was more than just sluggish, so he/she went and got the charge nurse, LPN B. -LPN B checked the resident's oxygen saturation. -LPN B said he/she heard something shallow. -He/She asked LPN B if he/she wanted him/her to get the oxygen. -LPN B said to just sit the resident up and make the resident look presentable. -He/She called two nurses and they came in and got the crash cart. -The nurses started CPR right away and told LPN B that the resident was a Full Code. -The day shift nurse showed up and began getting the paperwork ready for EMS. -He/She said that he/she was just a CNA, but knew that the resident wasn't doing well. -He/She said that he/she would have called 911, but that he/she is instructed to notify the charge nurse. -LPN B should have known what to do. During an interview on [DATE] at 1:15 P.M., CNA E said: -He/She checked on the resident about 2:15 A.M., and he/she was repositioned at that time. -He/She did not really notice anything unusual about the resident then. During an interview on [DATE] at 2:20 P.M., LPN C, said he/she: -Received two text messages, and had slept through two calls. -Arrived in the resident's room at the facility just before 6:30 A.M., and he/she did not feel a pulse on the resident or see the resident breathing. -Had went to get the crash cart and told LPN B that the resident was a Full Code. -Started compressions. -The pulse oximetry did not register anything. -Had already been told that the resident was gone, by CNA D. -Had asked LPN B what had happened, LPN B told him/her the resident's pulse was slow and irregular. -Told LPN B that the resident was a Full Code. During an interview on [DATE] at 8:42 A.M., LPN B said: -The aides called him/her to the room about 5:00 A.M. -The resident had dried emesis on him/her. -The resident's prior level of responsiveness had been questionable the past five to seven days. -He/She said he/she did not use the best judgement in the world. -This wasn't an excuse, but he/she was not use to working nights. -He/She was overwhelmed and should have activated the 911 system, when he/she first saw the resident, instead of starting CPR 45 minutes later. During an interview on [DATE] at 10:05 A.M., the DON said: -The expectation was the nurse should have provided interventions and initiated CPR. -There were a number of ways to determine code status and the code status was right on the door. During an interview on [DATE] at 9:55 A.M., the Administrator said: -His/Her expectation was the nursing staff were to provide the care the resident required, including CPR. -Nursing staff were to verify code status by the binders behind the nurses' station, the resident's door or through the Point Click Care (PCC) computer program. -He/She didn't know what LPN B was thinking. -He/She drove to the facility and began education with the facility staff and started the facility internal investigation. During an interview on [DATE] at 2:10 P.M., Physician #1, said: -If a resident was found unresponsive, not breathing and without a pulse, he/she would expect: --The nurse would assess the resident for breathing and a pulse. --Obtain confirmation of the resident's code status. --Initiate CPR immediately if the resident was a Full Code. MO 647

Based on interview and record review, the facility staff failed to monitor a resident with a history of aspiration pneumonia and swallowing difficulties, resulting in the resident choking on a hot dog and subsequently died for one resident Resident #1) out of ten sampled residents. The facility census was 48 residents. 1. Record review of Resident #1's Resident Admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. -[DIAGNOSES REDACTED] (a birth defect involving the spinal cord and the bones of the spine). -[DIAGNOSES REDACTED] (the buildup of cerebrospinal fluid deep within the brain which can lead to damage of brain tissues and brain function impairment). -Pneumonia (inflammation of one or both lungs with consolidation). -Dysphagia (inability or difficulty swallowing). -Gastroesophageal reflux disease (GERD - back-up of stomach acid/heartburn). Record review of the resident's Nutritional Status Care Plan dated [DATE] and updated on [DATE] showed: -He/She received finger foods on a divided plate. -The facility staff will monitor the resident for difficulty chewing, swallowing and pocketing food. -Provide assistance for meals as needed. -Weighted utensils, divided plate at meals, spill proof cup with lid and straw. Record review of the resident's medical record showed the following Speech Therapy Caregiver Discharge Plans, dated [DATE], located on the front of the resident's chart: -His/Her positioning during meals should be slightly tilted back in wheelchair using a bedside table with non-slip placemat. -Finger food diet with divided plate and weighted utensils. -Thin liquids given in a spill-proof cup with handle and straw placed to right of plate for easy access. -Provide the resident verbal reminders to do the following; --Hold his/her head up and back. --Bring his/her arm up and out to his/her mouth. --Take small bites and go slow. --Take a drink after a few bites. -Staff were to sign the bottom of the form to acknowledge the staff had read and understand the therapy discharge instructions. -No staff signatures were documented on the therapy discharge instructions sheet. Record review of the resident's Swallow Precautions inservice dated [DATE] showed: -He/She required a regular diet with finger foods. -One-to-one feeding if needed due to fatigue. -Regular drinks in a spill proof cup with a straw. -Keep up in a chair for 30 minutes and provide oral care and suctioning after all meals. -Staff were instructed to sign the Staff In-Service Training record after reading the swallowing precautions and education related to the resident's diet restrictions, oral care, and suctioning instructions. -Three staff signed the in-service record on [DATE]. -One staff signed the in-service record on [DATE]. -One of the four staff members who signed the in-service training record was on duty on [DATE], the date of the resident's choking incident. There were two Certified Nursing Aides (CNA) on duty in the dining room during the lunch service on [DATE]; also on duty on [DATE], was a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN) and neither the CMT and/or the LPN had signed as having completed the in-service training. Record review of the resident's Speech Therapy Progress and Discharge Summary dated [DATE] showed: -He/She was placed on Speech Therapy on [DATE] after a hospital stay. -He/She was discharged from Speech Therapy on [DATE] due to admission to Hospice (end of life care). -He/She was at risk for aspiration, was on a regular diet with finger foods and thin liquids using a divided plate, built up utensils, and spill proof cup with straw. -He/She required cueing and intermittent supervision from trained staff. Record review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated [DATE], showed he/she: -Has moderate cognitive impairment. -Was able to understand others and was understood by others. -Required extensive assistance with eating. -Was on hospice services. -Did not have a swallowing disorder. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated [DATE] showed: -The Licensed Practical Nurse (LPN) was called to the assisted dining room by a Certified Nursing Aide (CNA) due the resident choking at 12:15 P.M.. -The LPN called out to the Registered Nurse (RN) for assistance. -When the LPN entered the dining room, the resident was sitting upright in his/her wheelchair with "obvious" difficulty breathing and purple lips. -The LPN and RN began a Heimlich maneuver while the resident was in his/her wheelchair in the dining room. He/she was noted to be unable to speak at that time. -He/She became unresponsive. The staff assisted him/her to the dining room floor and began abdominal thrusts. -The LPN advised staff to call [DATE] at that time. -The LPN went to get the crash cart. -Staff was unable to remove the obstruction to clear the resident's airway. -The resident became pulseless and ceased respirations. -Emergency medical services arrived at 12:20 P.M. and took over CPR. Record review of the resident's emergency medical services report dated [DATE] showed: -At 12:13 P.M., a [DATE] call was received for ambulance assistance due to the resident choking for five minutes. -The facility staff reported the resident was feeding himself/herself lunch at the table when he/she started choking; the staff brought the resident to the floor after he/she became unresponsive and started CPR. -Emergency medical services staff found the resident unresponsive, pulseless, apnic (no respirations), and cyanotic (blue) in appearance on his/her back on the floor. -Emergency medical services staff performed CPR on the resident and after a visual inspection of the resident's upper airway (mouth to the back of the throat), the emergency medical services staff removed three large pieces of food material out of his/her airway. -He/She was transported to the hospital and remained unresponsive and pulseless with CPR continued during transport. -Upon arrival to the hospital emergency room , the hospital physician called to stop CPR and pronounced the resident dead at 12:54 P.M. Record review of the resident's hospital emergency room report dated [DATE] showed: -He/she was witnessed to be in respiratory arrest secondary to choking on a hotdog. -A lodged hotdog was removed from his/her vocal cords by the paramedics. -Time of death was pronounced at 12:54 P.M. -Cause of death was respiratory arrest due to foreign-body airway obstruction. Record review of the facility's investigation, a written statement dated [DATE] by CNA A showed: -He/she was in the dining room feeding another resident when he/she heard CNA D yell, "He/she's choking." He/she turned around to see the resident turning blue. -He/she tried patting the resident on the back then doing the Heimlich maneuver. -LPN A and RN A arrived in the dining room and took over. -He/she assisted the resident from his/her wheelchair to the floor while another CNA called [DATE]. -He/she did not see what happened and was not watching the resident during the meal. Record review of the facility's investigation, a written statement dated [DATE] by RN A showed: -He/she was called to the assisted dining room by a staff member requesting assistance due to the resident choking. -The resident was not able to speak when he/she arrived to the dining room and was turning blue. -The RN attempted to do the Heimlich and after a few attempts, he/she put his/her gloved finger in the resident's mouth to attempt to remove a foreign object when the resident bit down on his/her finger. He/she was unable to retrieve anything at that time. -A CNA called [DATE] while he/she and the LPN started CPR. CPR was continued by the LPN and RN until the emergency services personal arrived to take over. -Emergency services personal was able to remove a chunk of hot dog from the resident's mouth with a suction device. Record review of the facility's investigation, a written statement dated [DATE] by LPN A showed: -He/she was called to the assisted dining room at around 12:15 P.M. by CNA D. -He/she then yelled for RN A to assist. -He/she noticed the resident was sitting upright in his/her wheelchair and appeared to be choking. -LPN A and RN A attempted the Heimlich maneuver to clear the resident's airway without success. -The resident was then removed from his/her wheelchair, placed on his/her back on the floor, and abdominal thrusts were performed on the resident. -Facility staff called [DATE] at approximately 12:17 P.M. -The crash cart was brought to the assisted dining room while RN A continued abdominal thrusts. -The resident became unresponsive. -A small piece of hot dogs were removed from his/her mouth and airway. -The resident was without pulse or respirations, CPR was initiated and continued until the fire department to arrive. Record review of the facility's investigation, a written statement dated [DATE] by CNA D showed: -He/she was in the dining room assisting another resident with feeding at the same table with the resident. -He/she was not watching the resident. He/she looked up from the other resident at the table to see the resident was blue. -He/she got up from the side of the table he/she was sitting with the other resident, asked the resident if he/she was "ok", could he/she breathe, and was he/she choking? The resident replied "yes." -He/she asked the resident if the resident was "ok". He/she shook his/her head "no". CNA D asked the resident if he/she were choking and the resident nodded "yes". -The other CNA started patting the resident on the back while he/she called the nurse. -The nurse arrived, tried to remove the food, called the other nurse as all the staff attempted to assist the resident. -He/she assisted the resident from his/her wheelchair to the floor on the resident's back as the nurse started CPR and another nurse called [DATE]. -The facility staff continued CPR until the police and paramedics arrived. Record review of the facility's investigation, a written statement dated [DATE] by Speech Therapist A showed:-Speech Therapist A was sitting in the corner of the back of the dining room assisting another resident with swallowing issues during the noon meal. -He/she heard someone coughing at another table followed by a CNA asking the resident if the resident was "ok". -The resident was coughing faintly. -The CNAs at the table decided the resident was choking. One CNA left to get the nurse while the other attempted to help the resident dislodge the food by patting him/her on the back. -When the nurse arrived, he/she began patting the resident more forcefully on the back. -Speech Therapist A removed the resident's tray to allow more room for the nursing staff. He/she noticed the resident had whole peas and carrots, pieces of peaches and pears with marshmallows and a thin drink. -The nurse and Speech Therapist A both verbalized the resident's lips were turning blue. The nurse attempted the Heimlich maneuver while the resident was still sitting in his/her wheelchair. -The nurse directed the CNA to call [DATE] and yelled to another nurse for help and to get the crash cart. -When the other nurse arrived with the crash cart, the nurses attempted to move the resident from the wheelchair to the ground. He/She was still conscious and visibly struggling to breath. -The nurse donned a glove, put his/her hand into the resident's mouth, attempted to manually dislodge the food item and was bit by the resident. -Another nurse attempted to manually dislodge the obstruction and called out, "I got it! I got it!", and could be seen pulling something out of the resident's mouth. -The nurse started CPR at that time. -The paramedics arrived and continued CPR. -The resident was not on speech therapy services at that time. He/she did not know if he/she had special dining, eating, swallowing precautions at that time. During an interview on [DATE] at 1:30 P.M., CNA B said: -He/she was not in the assisted dining room at the time of the incident. -He/she heard staff call out for an emergency. -When he/she got to the assisted dining room from the main dining room, he/she saw the resident on the floor and the nurse was doing CPR. He/she saw the nurse take some food out of the resident's mouth, but he/she could not tell what it was or how much was removed. -The crash cart was in the dining room and facility staff continued CPR until the ambulance arrived. During an interview on [DATE] at 1:35 P.M., CNA C said: -He/she was not in the assisted dining room at the time of the incident. -He/she heard staff call out for an emergency. -When he/she got to the assisted dining room from the main dining room, he/she saw the resident on the floor and the nurse was doing CPR. He/she saw the nurse take some food out of the resident's mouth, but he/she could not tell what it was or how much was removed. -The crash cart was in the dining room and facility staff continued CPR until the ambulance arrived. During an interview on [DATE] at 1:45 P.M., CMT A said: -He/she was in the kitchen when the resident was choking. He/she heard the alarm that signals an emergency in the facility so he/she went to assist. -Staff were already in the dining room with the resident attempting to get the resident in position for RN A to do the Heimlich. -RN A attempted to do a mouth sweep and the resident bit RN A's finger. -The resident was still sitting up in his/her wheelchair. -Another staff member had left the room to call [DATE]. -The resident was then positioned on his/her back on the floor. LPN A and RN A initiated CPR and continued CPR until the ambulance arrived. During an interview on [DATE] at 2:10 P.M., RN A said: -He she was at the medication cart near the nurse's station when a call from the assisted dining room for assistance was shouted out by staff. -He/she was told the resident was choking, so he/she started a finger sweep at which time the resident bit his/her finger. -He/she then attempted to do the Heimlich maneuver with no success. -The resident was then placed on the floor on his/her back. He/She had turned blue and became unconscious. -Another staff member called [DATE] and CPR was started and continued until emergency medical services arrived to take over CPR. The emergency medical services personal removed "a bunch" of hot dog out of the resident's airway using a suction machine. During an interview on [DATE] at 2:17 P.M., CNA D said: -The resident was able to feed himself/herself finger foods. -He/she was sitting at the same table feeding another resident. -He/she was not watching the resident eat his/her lunch. -He/she looked up from feeding another resident and noticed the resident did not look right, his/her lips were blue. He/she did not hear the resident cough. -He/she asked the resident if the resident was "ok". He/she shook his/her head "no". CNA D asked the resident if he/she were choking and the resident nodded "yes". -He/she got up from the table and went to the resident. He/she patted the resident on the back and called out for a nurse. The second CNA at the table left to call [DATE]. -The nurse arrived at the table, initiated CPR, and tried to get what was stuck in the resident's throat. During an interview on [DATE] at 2:30 P.M., LPN A said: -He/she was not in the assisted dining room at the time the resident choked, but was in the hallway near the nursing station finishing blood sugar testing. -He/she heard a CNA call out to come to the assisted dining room. -When he/she arrived in the assisted dining room, the resident appeared to be choking. He/she did the Heimlich maneuver on him/her then placed the resident on his/her back on the floor. -RN A started CPR while he/she left to get the crash cart and a CNA called [DATE]. -He/she was able to get a tiny amount of hot dog out of the resident's mouth after performing the Heimlich maneuver. During an interview on [DATE] at 7:30 A.M., Speech Therapist B said: -The resident required verbal cueing to improve positioning. He/She had improved, but still needed to be monitored for positioning and swallowing. -He/she had provided caregiver education related to the resident's swallowing and positioning precautions. -The resident required his/her food to be cut up, but that the resident was able to feed himself/herself and did not want to be fed by others if at all possible. -The resident required staff to monitor him/her to ensure the resident took small bites, ate slowly, was positioned correctly, and took sips of a beverage after a few bites and to make sure he/she did not choke on his/her food or drink. During an interview on [DATE] at 8:15 A.M., Physician A said: -He/she did not believe the resident had any dietary restrictions. -He/she did not believe the resident was able to feed himself/herself and dined in the assisted dining room. -He/she expected the staff to watch the resident during meals for safe eating. -He/she expected the staff to have followed the speech therapy recommendations regarding the resident's diet and level of assistance. During an interview on [DATE] at 9:30 A.M., CNA A said: -He/she was in the assist dining room feeding another resident with his/her back to Resident #1. -He/she did not know of any special dining or swallowing precautions for the resident. -He/she had not had an inservice regarding the resident's eating and swallowing precautions. -CNA D was feeding another resident at the same table and would occasionally look at the resident. -CNA D called out that the resident was choking and got up to do the Heimlich maneuver. -LPN A entered the assisted dining room and also attempted to do the Heimlich maneuver on the resident. -RN A entered the assisted dining room and helped lower the resident to the floor and started CPR. -The Heimlich maneuver was unsuccessful. -He/she then went to comfort the resident's mother while staff continued CPR until the emergency medical services personal arrived. During an interview on [DATE] at 9:35 A.M., CNA D said: -He/she did not know of any swallowing or special dining precautions for the resident. -He/she was feeding another resident and was not watching the resident while he/she was eating. -He/she had not had any education or inservice's regarding swallowing or dining precautions. During an interview on [DATE] at 10:05 A.M., Speech Therapist A said: -He/she had not worked with the resident before. The resident was no longer on the Speech Therapy schedule. -He/she was not aware of any special precautions for the resident since the resident was not on speech therapy services. -He/she was in the dining room at the time the resident choked at another table working with another resident. -The facility staff were sitting at the same table with the resident with their backs to the resident, not monitoring him/her, feeding other residents at the table. -He/she turned to the direction of the resident when he/she heard coughing noises coming from the resident's direction. -A CNA at the table turned to the resident and asked the resident if he/she was "ok". The resident then coughed and did not make a sound with the cough. The CNA continued to ask the resident if he/she was "ok". -The Speech Therapist told the CNA the resident was no longer making a sound which meant the resident was not "ok". The CNA then got up from the table where he/she was sitting, went to the resident and began patting him/her on the back while the other CNA went to get the nurse. -The nurse arrived to the dining room and began patting the resident on the back then did the Heimlich maneuver while a CNA left to call [DATE]. -The Speech Therapist told the staff the resident's lips were blue and his/her eyes were closing as the resident was losing consciousness. The staff then took the resident out of his/her wheelchair, laid him/her on the floor on his/her back and began pushing on the resident's chest. -The nurse donned gloves and put a finger in the resident's mouth to do a sweep while the other nurse left to get the crash cart and ask for the resident's chart. -The nurses began CPR with chest compressions and using a mask and ambu-bag for respirations. -The nurse performed another mouth sweep and pulled out some pieces of food. The resident's airway was still not cleared at this point. -He/she then left to open the door for the emergency medical services personal. By this time, the resident had been down for about four and one-half minutes. -He/she moved the resident's meal tray out of the way and noticed the tray was set up correctly on the resident's place mat. The resident had mashed potatoes, whole peas and carrots, whole pieces of peaches and pears. He/she did not recall seeing a hot dog on the resident's tray. Complaint #: MO 488, MO 538, and MO 655 NOTE: At the time of the 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. During the onsite visit, the facility began immediately training the staff on monitoring residents during meal times to prevent choking hazards, identifying and reporting residents with difficulty swallowing and at risk of choking, and were altering the dining arrangements in the assisted dining room to ensure staff were able to observe all residents during meals. 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).