Every finding on record at Luther Manor Retirement & Nursing Center

Based on observation, interview and record review, the facility failed to provide oversight and prevent injury for two residents (Resident #1 and Resident #44) in a sample of 23 residents. Resident #1 was dependent on staff for transfers. When his/her electronic bed did not function properly, staff manually transferred the resident and caused a laceration to the resident's leg, which required emergency medical care, including sutures, antibiotic use to prevent infection, pain management medication, wound care and wound clinic appointments. Resident #44 had a history of falls and wandering and staff failed to provide oversight, resulting in an elopement that resulted in a fall with injury. The facility census was 55. The administrator was notified of a past noncompliance on 11/06/25, for Resident #44 which occurred on 08/28/25. The facility inserviced staff on wander guards and door alarms. This noncompliance was corrected on 08/29/25. Additionally, past noncompliance occurred for Resident #1 on 09/22/25. The facility inserviced staff on proper transfers, including the removal of wheelchair pedals prior to transfers and that a mechanical hand crank was available in resident closets should one be needed. The deficiency was corrected on 09/22/25. 1.Review of Resident #1's undated face sheet showed the resident's diagnoses included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering and reasoning, to the point that it interferes with daily life), muscle weakness, difficulty in walking, reduced mobility, need for assistance with personal care, and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high).Review of the resident's care plan, revised 07/18/25, showed the following:-Potential for alteration in skin integrity related to incontinence, decreased mobility, and multiple disease processes;-Avoid shearing resident's skin during positioning, transferring and turning;-Monitor skin during routine care and notify nurse of any abnormalities;-Provide assist of two staff using a mechanical lift for all transfers;-At risk for bleeding due to daily use of antiplatelet medication;-Avoid hitting/bumping extremities during activities of daily living (ADL's) to prevent injury;-Maintain a safe environment to decrease risk of injury;-Observe for signs of active bleeding: sudden changes in mental status, lethargy.Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/04/25, showed the following:-Intact cognition;-The resident was dependent on staff for toileting, bathing, dressing, transfers and mobility;-The resident required a wheelchair for mobility and was dependent on staff for wheeling about. Review of the resident's progress note, dated 09/22/25 at 10:00 A.M., showed the following:-At 6:50 A.M., staff call Licensed Practical Nurse (LPN) P to the resident's room. The certified nurse assistant (CNA) was holding the resident's left lower extremity. A moderate amount of blood was seen on the towel. The resident had a large open laceration through several layers of skin and muscle. Staff applied pressure and called 911;-At 7:00 A.M., the resident's bleeding had stopped. The staff reported that the injury occurred with a transfer from the bed to the wheelchair. Staff do not know what could have caused the injury;-At 7:10 A.M., emergency medical services (EMS) arrived, report given and paperwork provided. Staff assisted the resident to the gurney via a mechanical lift. EMS bandaged the resident's left lower extremity;-At 7:15 A.M., EMS left the building. Staff placed a call to the resident's durable power of attorney (DPOA) to notify and to the physician on call for the medical director. Agreeable to send the resident to the hospital emergency room for evaluation and treatment;-At 7:20 A.M., called director of nursing (DON) to update and notify. Review of the facility incident reported, dated 09/22/25, showed the following:-Staff were in the resident's room to get him/her up out of bed for breakfast;-Staff noticed that the bed was not functioning appropriately and were unable to move the bed up and down;-The resident was a mechanical lift;-Staff were unable to get the mechanical lift underneath the bed for proper alignment to safely get the resident out of bed;-Staff provided a two person transfer to his/her wheelchair. During the transfer, the resident received a large open laceration to the left lower extremity;-Physician was notified and received an order to transfer the resident to the hospital for further treatment;-EMS notified and transferred to hospital emergency room (ER);-The resident received a laceration measuring 15 centimeters (cm) long with a depth of 10 millimeters (mm);-The resident will follow up with the wound clinic. Review of the resident's progress note, dated 09/22/25 at 10:06 A.M., showed the following:-Assessment of surroundings from LPN P with assistant director of nursing (ADON), CNA C and CNA S, revealed that injury possibly occurred while transferring the resident from the bed to the wheelchair;-Left lower extremity could have caught onto the wheelchair pedal while pedal was extended outward, and the lock piece was pointed outward. Review of the resident's progress note, dated 09/22/25 at 1:04 P.M. showed the following:-At 12:30 P.M., report received from hospital nurse that the resident will be returning with new orders for the resident to be seen at the wound clinic and to start antibiotic for 10 days, nursing facility to transport;-At 12:45 P.M., the resident returned to the facility via nursing facility transport, call placed to physician for pain management, new orders received for Tylenol (pain medication) 500 milligram (mg) two tablets every six hours as needed (PRN). Review of the resident's hospital record, dated 09/22/25, showed the following:-Patient presented to the emergency department via EMS with a laceration, onset prior to arrival;-Reportedly, staff was helping the resident out of the bed and got his/her leg tangled up with the railing/bar, causing a laceration to the left leg;-Patient had wound repaired;-Patient was given Cefdinir (antibiotic) 300 milligrams (mg) PO (by mouth) to initiate treatment of skin defect;-The wound had a three centimeter (cm) x two cm skin defect with subcutaneous (under the skin) tissue exposed;-Xeroflo packing (a type of dressing that keeps a wound moist) was placed and this will need to be changed twice daily;-Resident will be referred to the wound center for follow up;-Resident will need to have suture removal in 10 days approximately;-The resident will be transported back and is stable for discharge. Review of the resident's progress note, dated 09/23/25 at 12:11 P.M. showed the following:-Continues antibiotic therapy for left leg laceration;-Leg remains bandaged at this time, left leg elevated to decrease swelling;-Received call from resident's daughter this morning with questions regarding left leg laceration and explained incident occurred with transfer and that possibly occurred from leg pushing against the wheelchair pedal lock as the wheelchair pedal was extroverted at the time of the incident, explained orders from the hospital, informed we are treating any possible infection with oral antibiotics, explained interventions put in place to prevent reoccurrence. Review of the resident's progress note, dated 09/29/25 at 10:12 A.M., showed the following:-A call was placed to the wound clinic to receive and update on his/her appointment;-Education was provided to all nursing staff that if a bed malfunctions, there is a manual crank arm in all closets within the rooms;-Education will be provided to staff that when transferring a resident, the pedals of the wheelchair need to be removed for transfer then placed back on for transport. Review of the resident's care plan, revised 09/29/25, showed the following:-The resident was on antibiotic therapy related to a laceration of the left lower extremity;-The resident had alterations to his/her skin integrity related to a laceration to his/her left lower extremity;-The resident had potential for alteration in skin integrity related to incontinence, decreased mobility and multiple disease processes;-Avoid shearing resident's skin during positioning, transferring and turning;-Use lifting device when moving him/her in bed;-Provide assist with two staff using a mechanical lift (mechanical lift device) for all transfers;-Use wheelchair for mobility;-The resident is at risk for falls related to history of falls and multiple disease processes;-At risk for bleeding due to daily use of antiplatelet medication (medications used to help prevent blood clots from forming in the arteries);-Avoid hitting/bumping extremities during activities of daily living (ADL's) to prevent injury;-Maintain a safe environment to decrease risk of injury;-No documentation of a manual crank being in the resident's closet if the bed would not raise or lower;-No documentation regarding pedals needing to be removed when transferring the resident into the wheelchair or pedals being put on prior to transport. Observation on 10/01/25 at 11:15 A.M. showed there was a manual crank in the resident's closet. Observation on 10/01/25 at 11:15 A.M. showed the following:-LPN P completed the resident's wound treatment to his/her left leg with the assistance of CNA O;-LPN P removed the resident's old dressing (dated 09/30/25) from the resident's LLE that was saturated with serosanguineous dressing (a type of fluid that contains both serum (clear, watery fluid) and blood) and placed it in the trash;-The wound had several sutures and an area at the end of the sutures that had some serosanguineous drainage, measuring 13.5 centimeters (cm.) long. Review of CNA C's written statement, dated 09/22/25, showed the following:-He/She and CNA S transferred the resident from the bed to the wheelchair due to the bed not raising;-Once the resident was in the wheelchair, he/she noticed the resident's leg bleeding. Review of CNA S's written statement, dated 09/22/25, showed the following:-He/She was working with CNA C and when getting the resident up, his/her bed wouldn't move, he/she then tried to unplug and replug the bed in and the bed still wouldn't move;-He/She and CNA C decided to two man the resident and somehow the resident's leg got cut open;-He/She and CNA C instantly started to apply pressure to the area and yelled for the nurse. Review of a written statement by LPN P, dated 09/22/25, showed the following:-He/She was called to the resident's room by staff at 6:50 A.M.;-He/She observed CNA holding the resident's left lower leg, a moderate amount of bleeding seen;-Staff reported that while transferring the resident from the bed to the wheelchair that the resident obtained a large, separated laceration, multiple skin layers seen;-Staff were unable to identify what caused the laceration;-Pressure applied and call placed to 911;-The resident denied pain until pressure was applied;-Bleeding stopped;-At 7:10 A.M., EMS arrived, report and paperwork given;-Staff assisted to gurney and resident left facility;-Assessment of surroundings with ADON and CNA C and CNA S revealed that injury possible occurred while transferring the resident from his/her bed to the wheelchair;-Left lower extremity could have caught onto the wheelchair pedal while pedal was extroverted outward and lock piece of foot pedal was sticking out near where laceration is located;-Orders received to send to ER for evaluation and treatment. During an interview on 10/02/25 at 6:56 P.M., the Director of Nursing (DON) said the following:-She would not expect staff to manually transfer a resident that should be a mechanical lift transfer;-She would expect staff to use the manual crank in the resident's closet if the bed would not raise or lower;-Wheelchair pedals should be removed prior to transferring the resident into the wheelchair to avoid catching in the wheelchair pedals that could cause injury. 2. The facility did not have a policy for wander guards/alarms that addressed ensuring an alarm being loud enough to be heard throughout the building. 3. Review of Resident #44's undated face sheet showed the resident's diagnoses included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering and reasoning, to the point that it interferes with daily life), Alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory and thinking skills, eventually leading to the inability to carry out simple daily tasks).Review of the resident's significant change MDS, dated [DATE], showed the following:-The resident had intact cognition;-The resident used a walker mobility device;-The resident required supervision or touching assistance with walking;-Wander/Elopement alarm used daily. Review of the resident's care plan, revised 07/28/25, showed the following:-The resident requires wander guard secondary to increased instances of wandering and increased confusion related to dementia progression;-Check function of alarm every shift;-Personal alarm placed on resident. Review of the resident's nursing note, written by Licensed Practical Nurse (LPN) B, dated 08/28/25 at 5:00 P.M., showed the following:-While pharmacy delivery driver was at the facility making a delivery, the driver told this nurse that there was a resident with a walker sitting outside on the porch;-When the driver left, he/she came back into the facility and stated that the same resident was trying to get into his/her car and had fallen;-Upon going outside, this nurse found the resident with wander guard attached to his/her walker; had not heard alarm going off prior; checked and verified that wander guard was working. Review of the resident's nursing note, written by the ADON, dated 08/28/25 at 8:07 P.M., showed the following:-She was in her office working and overheard a conversation in the hallway that someone had fallen outside and then heard several staff members run by;-She followed the staff members outside and saw the resident sitting upright on his/her bottom in the parking lot;-The resident was just off of the sidewalk in the parking lot with his/her back leaned up against a vehicle;-The charge nurse (LPN B) and Certified Nurse Assistant (CNA) H and CNA Q were outside with the resident;-The resident was repeating that he/she fell off of the sidewalk and that his/her lower legs/feet hurt;-She assisted LPN B with assessing the resident; no injury noted in the parking lot;-Assisted the resident to stand with gait belt and assist of two; once standing, pivot transferred the resident to the wheelchair;-The pharmacy driver was standing outside of the vehicle; he/she had seen the resident outside when he/she entered the building and the resident had started walking down the sidewalk; when he/she returned to the parking lot after dropping off the medications, the resident was on the ground in front of the vehicle, so he/she went and informed the nursing team;-Took the resident inside for further assessment; the resident reported his/her wrist hurt; assessment found two injuries, an abrasion to the right hip measuring 5.0 centimeters (cm) x 5.0 cm and a second abrasion to the right elbow measuring 2.0 cm x 1.0 cm;-The resident requested to go to bed; once in bed, the resident began reporting severe pain to his/her lower legs and then reported pain to bilateral (both) hands;-The resident observed to have facial grimacing while informing this nurse about his/her pain;-Call made to resident's durable power of attorney (DPOA) regarding the unwitnessed fall outside and informed no injury noted besides two small abrasions, but that the resident was complaining of severe pain; this nurse would like to send resident out to the emergency room (ER) for evaluation to be safe;-The DPOA stated that the resident had hardware in his/her right hip and would like him/her sent to a specific hospital for evaluation since that is where his/her orthopedic surgeon was located;-ADON called 911, emergency medical services (EMS) arrived, report given, and resident taken to requested hospital ER. Review of the facility incident report, dated 08/28/25, showed the following:-The resident was outside sitting on the front porch when the pharmacy delivery driver came to deliver medications;-LPN B checked in the medications at that time and the delivery driver went back out to leave and found the resident on the ground by a vehicle;-The pharmacy driver came back into the facility to let LPN B know;-Staff then went outside to assess the resident and then placed the resident in a wheelchair to transport him/her back inside the facility;-The ADON reassessed the resident and noted complaints of pain to the resident's wrist and lower extremities;-Abrasions noted to the resident's right hip and right elbow;-The resident's DPOA was notified of the incident and requested the resident be send to the hospital for further evaluation;-The on-call physician was notified;-The resident's wander guard was assessed for proper functioning, and it was functioning appropriately;-Education will be provided to all staff on wander guard policy;-When the resident returns to the facility, staff will do hourly visual checks to monitor for safety. Review of a written interview statement dated 08/28/25 at 5:52 P.M., the resident told the ADON the following:-He/She fell off the sidewalk and he/she hurt so bad;-He/She was just trying to do everything; just walking down the sidewalk and fell off;-He/She was outside enjoying the weather just on a walk. During an interview on 10/02/25 at 12:36 P.M., the resident's family representative said the resident was not supposed to go outside without someone with him/her. Review of the pharmacy deliver driver's written statement, dated 08/28/25, showed the following:-On Thursday, August 28, 2025 at 4:55 P.M., he/she pulled up to the facility to deliver medication;-When he/she pulled up, there was a resident sitting on the porch;-When he/she was getting the medication out of the car, the resident got up with his/her walker and started walking towards his/her vehicle;-He/She went inside and delivered the medication;-He/She let LPN B know there was a resident outside with their walker going towards his/her vehicle;-When LPN B was done signing for the medication, LPN B gave him/her the medication returns, and he/she walked out the door to leave;-As soon as he/she walked out the door, he/she saw the resident on the ground and immediately went back into the facility to let LPN B know that he/she needed to get someone because the resident was on the ground;-LPN B got other workers and they all came outside and checked out the resident before getting him/her off of the ground and taking him/her back inside. Review of Dietary Aide W's written statement, dated 08/28/25 at 6:36 P.M. showed the following:-He/She saw the resident in the hallway around 4:45 P.M. coming up the 200 hall;-He/She did not see the resident go outside;-He/She did not hear the door alarm going off;-He/She did notice earlier that day that the resident seemed a little off; the resident seemed to be wandering and was combing his/her hair with a fork at breakfast and he/she reported it to the charge nurses RN D and LPN A. Review of Dietary Aide X's written statement, dated 08/28/25 at 6:29 P.M. showed the following:-He/She did not see the resident outside;-He/She did hear the door alarm go off, but saw a person walking into the building, the person was not the resident;-While looking at the door, while the alarm was going off, he/she did not see the resident anywhere. Review of CNA T's written statement, dated 08/28/25 at 7:03 P.M., showed the following: -He/She saw the resident at 4:45 P.M. when he/she went to get the resident up for supper; The resident was in his/her room, stood up on his/her own, and walked down the 200 hall on his/her own;-When he/she came out of another room, he/she found the resident going down the 300 hall and he/she redirected the resident towards the dining room; he/she did not follow the resident to the dining room because he/she was going to get another resident;-He/She did not hear the door alarm going off at any point. During an interview on 10/27/25 at 3:05 P.M., CNA T said the following:-The resident resided on the 200 hall and was walking down the 300 hall when he/she noticed him/her going the wrong direction;-He/She was halfway down the 300 hall, heading into another resident's room to get another resident up for dinner and redirected the resident into the correct direction of the dining room to go to dinner;-He/She did not walk with, or assist the resident, to the dining room;-He/She never heard the alarm go off down the hallway and didn't realize that the alarm couldn't be heard from down the hallway until after the incident. Review of CNA H's written statement, dated 08/28/25 at 6:57 P.M. showed the following:-He/She did not see the resident outside until he/she was asked to come help the resident up after the fall;-He/She was in the dining room around 4:45 P.M. to assist residents with meal service;-He/She did not hear the door alarm go off at any point. Review of CNA U's written statement, dated 08/28/25 at 6:54 P.M. showed the following:-He/She was in the dining room around 4:30 - 4:45 P.M. to assist residents with meal service;-He/She did not hear the door alarm go off at any point. Review of CNA I's written statement, dated 08/28/25 at 6:51 P.M., showed the following:-He/She went to the dining room around 4:50 P.M. to start assisting residents;-He/She did not hear the door alarm go off at any point. Review of CNA Q's written statement, dated 08/28/25 at 6:48 P.M., showed the following:-He/She did not see the resident outside until he/she was called to help because the resident fell;-He/She went to the dining room at 4:45 P.M. to help assist residents;-He/She did not hear the door alarm go off at any point. Review of LPN B's written statement, dated 08/28/25 at 7:10 P.M., showed the following:-The last time he/she had seen the resident was when he/she had sent CNA T to get the resident, and he/she saw the resident going down the hall toward the dining room; the resident was ambulating by himself/herself with his/her walker;-He/She was at the dining room around 4:30 P.M. to finish passing medications;-He/She did not hear the door alarm go off at any point. During an interview on 10/27/25 at 4:11 P.M., LPN B said the following:-All of nursing staff was responsible for keeping an eye on the resident and watching all the residents;-He/She had CNA T redirect the resident toward the dining room for supper when the resident was walking down the wrong hallway and that was the last he/she saw of the resident until he/she found the resident outside;-CNA T pointed the resident in the direction of the dining room;-The resident was up ad lib (as desired) and did not require stand by or contact guard assistance;-When the pharmacy delivery driver told him/her that there was a resident out on the front porch, he/she did not go out to check on the resident because there are a lot of residents that can go out on the porch;-The pharmacy delivery driver did not tell him/her that the resident was walking toward the vehicle; he/she had just told him/her that the resident was sitting on the porch;-From the time the pharmacy delivery driver entered and alerted him/her that the resident was on the porch, about 15-20 minutes elapsed between checking in the medications and the delivery driver finding the resident on the ground when he/she left;-He/She did not hear the alarm. Review of the ADON's written statement, dated 08/28/25 at 7:45 P.M., showed it included the following:-Administrator present in facility and made aware of incident;-Called and updated DON;-Conducted interviews with all in house staff at time of incident;-No staff members report having seen the resident go outside or being outside before being made aware of the fall;-Only dietary staff member reports having heard the door alarm going off this evening but stated when he/she looked at the door, a younger aged person he/she did not know was entering the building; he/she did not see the resident at that time. During an interview on 10/27/25 at 2:32 P.M., the ADON said the following:-She could not recall who the dietary staff member was that did hear the alarm; the dietary aide was a new employee and didn't know what the alarm meant, so he/she did not report the alarm to anyone when he/she heard it go off;-She provided immediate in-servicing and education to the dietary aide and followed up with more in-servicing for all staff regarding the wander guard policy;-They began doing hourly checks on the resident after the incident;-She believes it was CNA T that was the last person that had seen the resident walking down the wrong hall and pointed the resident in the direction of the dining room to go to dinner, but did not walk with the resident as he/she was going to get other resident's up for dinner;-The pharmacy driver had seen a resident outside when he/she walked in; they have resident that often sit outside, so when the driver reported it to the nurse, they signed in the medications, then the nurse headed to check on the resident, the pharmacy driver had walked out right before him/her and saw the resident on the ground; -It was probably only 5 - 10 minutes from the time the driver came in to drop off the medication until the time they went back outside to find the resident on the ground;-The business and main offices are near the front door, but at the time that the incident occurred, all the main office staff were already gone for the day, so the only staff that were around the front were dietary workers and aides that were coming and going, bringing residents into the dining room;-The facility is not a locked facility, so they do not have staff always monitoring the doors. During an interview on 10/02/25 at 6:56 P.M., the Director of Nursing (DON) said they began hourly monitoring of the resident after this incident. MO 2603355MO 2603421MO 2624115

Based on observation, interview, and record review, staff failed to store, prepare, and serve food in a safe and sanitary manner. Staff failed to ensure the temperature of a refrigerator used to store resident food was maintained at or below 45 degrees Fahrenheit (F) and the freezer was maintained at or below 0 degrees F. Staff failed to ensure food was discarded when it showed signs of deterioration. Staff did not practice proper handwashing, glove hygiene or hair restraint usage when preparing and serving food in the kitchen. Staff failed to ensure the facility's ice machine was clean and sanitary. The facility census was 55. The facility did not provide policies for food storage, dietary handwashing/gloving, hair restraints, ice machine cleaning, or storing resident food items. 1. Record review of the September 2025 Refrigerator/Freezer Temperature Log for the Family Room refrigerator located on the 300 hall, showed the following: -9/1/25: 49 degrees F (refrigerator) /23 degrees F (freezer); -9/2/25: 50 degrees F / 32 degrees F; -9/3/25: 49 degrees F / 26 degrees F; -9/4/25: 48 degrees F / 22 degrees F; -9/5/25: 48 degrees F / 24 degrees F; -9/6/25: 42 degrees F / 20 degrees F; -9/7/25: 42 degrees F / 20 degrees F; -9/8/25: 44 degrees F / 20 degrees F; -9/9/25: 44 degrees F / 22 degrees F; -9/10/25: 49 degrees F / 28 degrees F; -9/11/25: 48 degrees F / 27 degrees F; -9/12/25: 49 degrees F / 29 degrees F; -9/13/25: 50 degrees F / 29 degrees F; -9/14/25: 49 degrees F / 28 degrees F; -9/15/25: 49 degrees F / 27 degrees F; -9/16/25: 48 degrees F / 27 degrees F; -9/17/25: 48 degrees F / 27 degrees F; -9/18/25: 49 degrees F / 28 degrees F; -9/19/25: 46 degrees F / 21 degrees F; -9/20/25: 45 degrees F / 20 degrees F; -9/21/25: 45 degrees F / 20 degrees F; -9/22/25: 48 degrees F / 24 degrees F; -9/23/25: 49 degrees F / 26 degrees F; -9/24/25: 48 degrees F / 26 degrees F; -9/25/25: 49 degrees F / 28 degrees F; -9/26/25: 48 degrees F / 21 degrees F; -9/27/25: 48 degrees F / 21 degrees F; -9/28/25: 49 degrees F / 21 degrees F; -9/29/25: 49 degrees F / 22 degrees F; -9/30/25: 50 degrees F / 30 degrees F. -On 24 of 30 days, the refrigerator temperature was above 45 degrees F; -On 30 of 30 days, the freezer temperature was above 0 degrees F. Observation on 9/29/25 at 3:10 P.M., of the Family Room refrigerator, showed the following: -Slices of pizza in an unlabeled pizza box;-An unknown food item, with fuzzy gray mold-like substance on the surface of the food item, in a black container with a clear lid labeled with a resident's name;-The thermometer in the refrigerator read 50 degrees F.;-No items were stored in the freezer. During an interview on 9/29/25 at 3:10 P.M., the Maintenance Supervisor said the Family Room refrigerator was used to store residents' food items. The refrigerator was starting to get warm, and the facility was looking into replacing it. During an interview on 9/29/25 at 4:28 P.M., the Administrator said he was unaware the Family Room refrigerator was not cooling properly. Observation on 9/30/25 at 6:26 P.M., in the Family Room refrigerator, showed the following: -Slices of pizza in an unlabeled pizza box;-An unknown food item, with fuzzy gray mold-like substance on the surface of the food item, in a black container with clear lid labeled with a resident's name;-A sandwich (labeled with a resident's name) wrapped in a fast food wrapper;-The thermometer in the refrigerator read 50 degrees F; -In the freezer compartment, there was a partially melted ice pack, and the thermometer read 30 degrees F. 2. Observation on 9/29/25, from 11:37 A.M. to 12:18 P.M., in the kitchen, showed the following: -Cook BB served residents' food at the steam table for the lunch meal service; -He/She used his/her gloved hands to touch serving utensil handles and grasp breadsticks and placed them on residents' plates;-He/She adjusted his/her clothes with gloved hands and continued serving food to residents and touching breadsticks with his/her gloved hands; -He/She removed his/her gloves, discarded one glove in the trash can by the handwashing sink, and dropped the other glove on the floor by the trash can by the handwashing sink; -He/She picked up the glove from the floor and put it in the trash can by the handwashing sink; -Without washing his/her hands, he/she put on new gloves and continued serving food to residents, including picking up breadsticks with his/her gloved hands and placing them on residents' plates. Observation on 9/30/25 from 4:45 P.M. to 5:07 P.M., in the kitchen, showed the following: -Cook Y served residents' food at the steam table for the dinner meal service; -He/She did not wear a hairnet and had 3-inch long sections of hair that hung down by his/her face. During an interview on 10/1/24 at 2:45 P.M., [NAME] Y said staff should wear hair restraints when preparing or serving food and should wash their hands in between glove changes, after picking up items from the floor, and after taking breaks. During an interview on 10/1/25 at 2:15 P.M., the Dietary Manager said he expected staff to wear hair restraints and wash their hands frequently while working in the kitchen, such as prior to conducting clean tasks, after conducting dirty tasks, and when changing gloves. 3. Observation on 9/30/25 on 6:22 P.M., of the ice machine located in the facility's dining room, showed the following:-Moist, black speckled debris on the ice dispensing spout;-Various splatters and drips across the surface of the ice dispensing area;-Brown crusty debris above the metal grate located directly below the ice dispensing area. During an interview on 10/1/25 at 12:02 P.M., Maintenance Staff R said maintenance staff cleaned the interior of the ice machine monthly. Dietary staff were responsible for cleaning the exterior of the ice machine. During an interview on 10/1/25 at 2:15 P.M., the Dietary Manager said dietary staff cleaned the exterior of the ice machine weekly.

Based on observation, interview and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) buy using gowns and gloves during high-contact resident care activities) and properly handle dirty linens for two residents (Resident #1 and #6) in a review of 23 sampled residents. Additionally, the facility failed to complete a required Legionella (a type of bacteria found in [NAME] that cased Legionnaires' disease, a severe form of pneumonia, when inhaled in water droplets or mist) program. The facility census was 55. Review of the facility policy, EBP Policy and Procedure, revised 08/05/25, showed the following: -Purpose: To reduce the risk of transmission of MDROs in the facility;-EBP refers to an infection control intervention designed to reduce transmission of targeted MDROs that employs targeted gown and glove use during high contact resident care activities. EBPs are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high contact resident care activities;-High contact activity: activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel and occur in the resident's room, shower/bathroom, or therapy room and include: c. Transferring;d. Providing hygiene;e. Changing linens;f. Changing briefs or assisting with toileting;h. Wound care: any skin opening requiring a dressing;-Wounds that require EBP: include, but are not limited to, chronic/open wounds that typically require dressing changes such as pressure injuries (PIs), venous/arterial/diabetic/neuropathic ulcers, open or blistered burns;-Policy statement: The facility will identify, report, investigate and control the transmission of MDROs to other staff and residents;-Procedure: b. Residents with a history of, or who are known to be colonized with, a targeted MDRO will be placed in EBP for the duration of their stay;c. Residents with an indwelling medical device, or an open wound and no history of MDROs will be placed in EBP until their wound heals or the device is removed;f. The need for EBP will be included in each resident's care plan;g. The Infection Preventionist (IP) will communicate the need for EBP and maintain a list of residents on EBP. 1.Review of Resident #1's undated face sheet showed the resident had diagnoses that included laceration (a tear or ragged cut in skin or flesh), of the left lower leg. Review of the resident's physician orders, dated 09/24/25, showed the following:-Clean left lower leg laceration with normal saline; apply Xeroform (fine-mesh gauze dressing) and non-stick dressing; twice a day, morning and bedtime;-No order for EBP. Review of the resident's care plan, updated 09/29/25, showed the following:-Antibiotic therapy related to laceration of left lower extremity (LLE);-The resident's laceration will heal without complications through the next review date;-Alteration in skin integrity related to laceration to LLE;-No update/revision regarding EPB. Observation on 10/01/25 at 11:15 A.M. showed the following:-No EBP signage or supplies outside or inside of the resident's room;-Licensed Practical Nurse (LPN) P washed hands, donned gloves, wiped down the bedside table with purple top Sani-wipes, applied a barrier towel to the top of the bedside table, and placed all supplies on top of barrier;-LPN P doffed gloves, washed hands, donned new gloves;LPN P did not don a gown;-Certified Nurse Assistant (CNA) O washed hands, donned gloves but did not don a gown; -CNA O removed the resident's blankets and lifted the resident's left leg off the bed;-LPN P removed the resident's old dressing from the resident's LLE that was saturated with serosanguineous drainage (a type of fluid that contains both serum (clear, watery fluid) and blood) and placed it in the trash;-LPN P doffed gloves, hand sanitized, and donned gloves;-LPN P used non-woven sponges sprayed with wound cleanser to cleanse the wound, doffed gloves, hand sanitized and donned gloves;-The wound had several sutures and an area at the end of the sutures that had some serosanguineous drainage;-LPN P covered the wound with Xeroform dressing on the end of the wound that was open without sutures, wrapped the LLE with gauze, applied tape to the gauze to secure the dressing, dated and initialed the dressing, doffed gloves and washed hands;-CNA O placed the resident's leg back on the bed, doffed gloves, washed hands, and covered the resident back up with a blanket. During an interview on 10/01/25 at 11:38 A.M., CNA O said the following:-Staff should wear PPE (gown and gloves) if there was a sign to do so on the resident's door;- The Assistant Director of Nursing (ADON) puts the signs and supplies on the doors; that was how he/she knew who required EBP;-PPE should be worn if the resident has an infection, urinary tract infection (UTI) or if they commonly get infections;-The facility had not educated him/her on all of the reasons to wear PPE. During an interview on 10/01/25 at 11:20, LPN P said the following:-He/She would wear full PPE with a gown if the resident was on precautions or if it were a sterile treatment;-The ADON usually completed wound treatments and placed the EBP signage and supplies on the resident's doors;-All residents that required EBP have the supplies and signage on their doors and that was how he/she knew which residents required EBP. 2. Review of Resident #6's undated Continuity of Care Document (CCD) showed the resident had a diagnoses that included extended spectrum beta lactamase/ESBL (a type of enzyme made by some bacteria that break down and destroy antibiotics making it hard to treat infections caused by ESBL and is considered an MDRO). Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Dependent on staff for transfers, personal hygiene, toileting hygiene and bathing;-Always incontinent of bowel and urine;-Diagnoses of MDRO infection and urinary tract infection;-Special treatment of isolation or quarantine for active infectious disease. Review of the resident's care plan, updated 07/16/25, showed the following: -Requires EBP for high contact activities related to history of ESBL UTI;-PPE per facility protocol. Observation on 09/30/25 at 9:07 A.M., showed the following: -EBP signage and supplies located hanging on the outside of the resident's door indicated use for bed A & B. Also indicated uses of gown and gloves for high-contact resident care activities; -EBP supplies of gown and gloves available in the hanging supplies container on the outside of the resident's door; -CNA F and CNA G completed hand hygiene with alcohol-based hand sanitizer and applied gloves prior to entering the resident's room and initiating care; -CNA F and CNA G attached a mechanical lift pad to the lift and transferred the resident from the wheelchair to his/her bed;-The resident was incontinent of urine;-CNA G assisted the resident to turn to his/her left side with the resident leaning against CNA G, touching his/her uniform top;-CNA F provided pericare to the resident's buttocks, removed gloves, completed hand hygiene with hand sanitizer and applied a clean pair of gloves;-CNA F assisted the resident to turn to his/her back and completed peri care to the resident's genitalia;-CNA F assisted the resident to turn to his/her right side to place an incontinent product on the resident and the resident was touching CNA F's uniform top;-CNA G and CNA F attached the incontinent product, remove his/her gloves and completed hand hygiene with hand sanitizer;-CNA G and CNA F provided all resident cares without wearing a gown. During an interview on 09/30/2025 at 7:05 P.M., the resident said the following:-Staff do not always wear a gown when providing cares but always wore gloves;-He/She was unsure why staff use the gown and gloves when care is provided but thought it was due to something in his/her urine. During an interview on 10/02/25 at 1:37 P.M., CNA G said the following:-If a resident had an EBP sign, staff should wear a gown, gloves and mask;-Staff know who was on EBP by the signs on the door, charts and care plans;-Wounds and catheters need EBP;-He/She did not use a gown when caring for the resident because the EBP was for the resident's roommate;-He/She was unaware that the EBP sign was for both residents in the room and just thought bed B was the one that needed EBP;-After looking at the signage posted for the resident's room, a gown and gloves should have been used to provide care. During an interview on 10/02/25 at 1:38 P.M., CNA F said the following: -If a resident had an EBP sign on the door, staff should wear a gown and gloves to provide resident care;-Staff know who was on EBP by the sign on the door and by the chart;-EBP was worn for wounds, catheters and infections like C-Diff (an infection in the bowel);-He/She did not use a gown to provide cares for the resident because he/she thought the EBP was for the resident's roommate;-After seeing that the sign on the resident's door said bed A and B, a gown should have been used to protect his/her clothing from germs. During an interview on 10/02/25 at 1:26 P.M., the Assistant Director of Nursing/Infection Preventionist, said the following:-Any resident with a wound or who had ever been diagnosed with an MDRO would be placed on EBP; -EBP signage and supplies were located the resident's door; the IP puts this signage and supplies on the resident's door;-If two residents were in a room and only one was on EBP, there would an A or B marked on the corner of the EBP signage so staff would know which resident had been placed on EBP;-All staff should wear gown and gloves when providing personal cares or wound cares for a resident who had been placed on EBP:-All staff had been trained on EBP protocol. During an interview on 10/02/25 at 6:56 P.M., the Director of Nursing (DON) said the following:-EBP would depend on the situation;-EBP should be worn if there is a sign on the door indicating to use and the IP has determined it necessary;-If an EBP sign was posted on the outside of a resident's door, she would expect staff to wear a gown and mask if necessary;-The sign on the door indicates which resident bed needed the EBP. 4. Review of the facility's policy, Handling Contaminated Linen by nursing staff, reviewed 12/29/16, showed the following: -Nursing staff will collect all contaminated linens out of the resident room and transport to housekeeping with minimum agitation to avoid contamination of air, surfaces and persons;-Place all soiled linen in a plastic bag in laundry barrels at the point of use. 5. Observation on 09/30/25 at 6:30 P.M., showed the following:-LPN B walked down the 200-hallway with dirty linens in his/her gloved hands;-The dirty lines were not contained in a plastic bag;-He/She put the dirty linens in a dirty linen cart in the 300-hallway bathroom. During an interview on 10/02/25 at 2:33 P.M., LPN B said the following:-All dirty linens should be put in a plastic bag before leaving the residents' room;-He/She had carried loose dirty linens to the soiled laundry cart and put them in the cart without them being in a plastic bag;-There were no plastic bags in the resident's room to use. 6. Observation on 09/30/25 at 6:55 P.M., showed the following:-CNA J walked down the 300 hallway with dirty clothing items in his/her gloved hands; -The dirty linens were not contained in a plastic bag;-He/She put the dirty linens in a dirty linen cart in the 300-hallway bathroom. During an interview on 09/30/25 at 7:05 P.M., CNA J said the following:-He/She had carried the dirty linens down the hall without a trash bag;-The dirty linens did not need to be placed in a trash bag because they were not soiled; -The clothes had been worn by a resident;-If a clothing item was slightly wet, staff could still carry it down the hall without placing the items in a trash bag;-Dirty clothes could be placed in the soiled linen cart without being in a trash bag;-He/She was not aware the facility policy required all soiled linen was to be placed in a plastic bag in laundry barrels at the point of use. 7. Observation on 09/30/25 at 7:15 P.M. of the soiled linen cart in the 300 hall bathroom, showed the cart had loose clothes laying in the cart. Observation on 09/30/25 at 7:22 P.M., showed the following:-Housekeeper M had a blue laundry cart;-He/She emptied the soiled linen cart from the 300 hall bathroom;-Several loose items were emptied from the soiled linen cart in the bathroom to the blue laundry cart;-The loose items included clothes and bed linens;-The loose bed linens had a strong smell of urine. During an interview on 09/30/25 at 7:22 P.M., Housekeeper M said the following:-There were loose clothing items and bed linen in the soiled linen cart he/she had just emptied;-There was normally a mixture of loose clothing items and in plastic bags;-Dirty linens were supposed to be placed in a plastic bag before going in the soiled linen cart. During an interview on 10/02/25 at 2:20 P.M., the housekeeping supervisor said the following:-A blue cart was used to empty the laundry carts on the hallways;-Usually, dirty linens were put into plastic bags, but there had been loose clothing items placed into the soiled linen carts;-There have been loose clothing items in the blue laundry cart when it arrived back in the laundry room;-There should be no loose linens in the hallway soiled linen carts;-All soiled linens needed to be placed in a plastic bag. During an interview on 10/02/25 at 1:26 P.M., the Assistant Director of Nursing/Infection Preventionist, said the following:-All linens should be placed in plastic bag before leaving the resident's room;-No dirty loose linens should be carried down the hall to the soiled linen carts. During an interview on 10/02/25 at 6:56 P.M., the DON said contaminated linens should not be carried down the hall without being in a trash bag. 8. Review of the undated facility policy, Legionella Water Management Policy, showed the following: -Purpose: a. Identify where Legionella and other opportunistic waterborne pathogens could grow and spread;b. Specifies testing protocols;c. Maintains compliance with federal, state and local requirements;-Scope: The maintenance and housekeeping departments are to carry out all actions outlined by this plan throughout the facility;-Guideline: A. Conduct a facility risk assessment;1. Plan for cleaning water sources: water heaters, pipes/valves/fittings, expansion and cooling tanks, water dispensers, ice machines, faucets, shower heads, whirlpool, hoses, any decorative fountains, humidifiers, medical equipment (concentrators, CPAP machines, hydrocollator), eyewash stations and cooling towers;B. Address items labeled at risk for the facility risk assessment;C. Possible infection: send samples out to be tested to the local board of public works. 9. Review of the undated facility water management plan showed the following: -A copy of the Center for Disease Control (CDC) tool kit for development of a water management Legionella plan;-No evidence of a water management team;-No evidence of a plan that follows the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidelines for development of a legionella water management plan;-No evidence of a water flow diagram;-No evidence of any water testing;-No evidence of flushing of areas with stagnant water, whirlpool in the therapy room and bathtub/shower on the 300 hall (both of which have not been used for quite some time and are acting as a storage room);-No evidence of testing cold water temperatures;(the plan was the CDC toolkit and there was no specific facility plan with expectations available for review). During an interview on 10/02/25 at 1:07 P.M., the maintenance director said the following: -He had been with the facility for 14 years and the maintenance director for the last three years;-He was not part of the water management team;-He was currently taking hot water temperatures weekly but not taking any cold-water temperatures; -He did not know a lot about legionella;-There were two bathtubs and one whirlpool at the facility;-The bathtub on 300 hall and the whirlpool in the therapy room has not been used for years and he has not flushed those lines for quite some time. During an interview with the administrator on 10/02/25 at 1:15 P.M. and 7:07 P.M., showed the following: -He has been at the facility since December 2024;-Since he had been the administrator they have not had an active water management team or had any meetings;-He would expect the water management team to consist of himself, the DON, maintenance director and the housekeeping/laundry supervisor;-He was unaware of ASHRAE guidelines regarding a water management team or legionella.

Based on interview and record review, the facility failed to ensure nurse aides received the required 12 hours of in-service education annually. The facility census was 55. The facility was not able to provide a policy regarding required in-service training for Nursing Assistants upon request. Review of the facility assessment, dated 05/01/23, showed the following: -Staff competencies and annual training requirements per regulatory authority and/or facility policy: 1. Abuse, neglect, exploitation and misappropriation;2. Advanced directives;3. Behavioral health;4. Communication;5. Compliance and ethics;6. Cardiopulmonary resuscitation;7. Dementia care management;8. Equipment and assistive device training;9. Infection Control;10. -Other areas identified as areas of weakness during annual performance review/competency evaluation;11. Promoting resident's independence;12. Quality assurance and performance improvement;13. Resident rights including confidentiality of resident information, right to dignity, privacy and property;14. -Safety and emergency procedures;15. Job responsibilities and lines of authority;16. Emergency preparedness;17. Facility policies and procedures;18. Change in condition. During an interview on 10/02/25 at 4:05 P.M., the Director of Nursing (DON) said the following: -She and the nurse educator do in-services and education for the Certified Nursing Assistants (CNAs);-The nurse educator provides education during CNA classes;-She does not have documentation of inservices;-She does not track the CNA in-services to ensure they have 12 hours of annual education;-She was aware of the required 12 hours of mandatory training for CNA's, but was not aware of what specific education needed to occur within those twelve hours;-She had not seen a facility assessment indicating what in-service education was identified within that document.

Based on interview and record review, the facility failed to maintain individual resident ledgers for two residents (Resident #3 and #34) of two residents the facility held funds for, failed to send quarterly statements to the resident or the resident's representative and failed to distribute the accrued interest in the resident trust fund between the residents' accounts. The facility census was 55. Review of the facility policy, Personal Funds Policy and Procedures, updated 11/11/24, showed the following:-Upon written authorization of a resident, a resident may deposit personal funds for safekeeping with the facility if they so desire. Each resident will have their own personal ledger accounting of all transactions; -Deposit of funds:- Bank interest shall be accrued and credited to each individual account at least quarterly;-A written account shall be provided to each resident, showing receipts in and will be signed by the resident or their representative; -Withdrawal of funds:-A written account shall be provided to each resident, showing disbursements out and will be signed by the resident or their representative;-Facility responsibility: -All residents' funds will be brought current monthly, and a statement shall be given to the resident or representative noting all transactions at least quarterly. Additional statements may be requested at any time. Review of the facility policy, Nursing Home Resident Rights, updated 11/12/24, showed the following:-Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law; -Rights Regarding Financial Affairs: Personal funds of more than $100 ($50 for residents whose care is funded by Medicaid) deposited by the facility in a separate interest-bearing account and financial statements quarterly or upon request. 1. Review of a facility provided document, showing accounting transactions for the resident fund account, showed the facility held funds for two residents, Resident #3 and #34. 2. Review showed there was no documentation of each resident's, (Resident #3 or #34), own ledger accounting for all transactions as directed by facility policy. 3. Review showed there was no documentation to show the residents, or the resident's responsible party, received quarterly resident fund statements or documentation of a written account provided to each resident, showing receipts in or out, signed by the resident or their representative as directed by facility policy. 4. Review of the facility's monthly resident fund bank statements and resident trust fund records, for September 2024 through August 2025 showed the following:-Resident fund bank statement dated 09/30/24 showed interest added $3.86;-Resident fund bank statement dated 10/31/24 showed interest added $2.41;-Resident fund bank statement dated 11/29/24 showed interest added $1.00;-Resident fund bank statement dated 12/31/24 showed interest added $1.04;-Resident fund bank statement dated 01/31/25 showed interest added $0.99;-Resident fund bank statement dated 02/28/25 showed interest added $1.01;-Resident fund bank statement dated 03/31/25 showed interest added $1.00;-Resident fund bank statement dated 04/30/25 showed interest added $1.04;-Resident fund bank statement dated 05/30/25 showed interest added $1.30;-Resident fund bank statement dated 06/30/25 showed interest added $1.67;-Resident fund bank statement dated 07/31/25 showed interest added $1.42;-Resident fund bank statement dated 08/29/25 showed interest added $1.47;-There was no documentation to show the facility disbursed the interest occurred to the two residents the facility held funds for. 5. Review of Resident #34's face sheet showed the resident's family member listed as his/her durable power of attorney. During an interview on 09/30/25 at 10:22 A.M. and 10/02/25 at 11:49 A.M., the resident's representative said the following:-He/She had not received any statements from the facility showing how much money was going in or out of the resident's fund;-He/She received no quarterly statement from the facility for money in the resident's trust fund;-He/She had verbally requested a resident trust fund statement, and it had not been provided;-The resident had been putting money into the resident trust fund account for about two years;-The resident had money direct deposited into the resident trust fund account. 6. During an interview on 10/02/25 at 9:19 A.M., the Accounts Receivable (in training) staff said the following:-There were no quarterly statements for the resident funds that were held by the facility sent to the resident and/or their representatives;-No resident with money in the resident funds account had been given a statement showing a breakdown of their account. During an interview on 10/02/25 at 9:12 A.M., the Accounts Payable/Accountant said the following:-There were no quarterly statements for the resident funds that were held by the facility sent to the resident and/or their representatives;-Since there were no resident fund statements, she had not been distributing the accrued interest into each resident's account;-The residents did not have individual ledgers. During an interview on 10/02/25 at 7:07 P.M., the administrator said the following:-He would expect residents to know how much money was in their account with a breakdown of credits and debits to their account;-He would expect quarterly statements to be sent to the resident or representative.

Based on observation, interview and record review, the facility failed to ensure staff indicated in the resident's medical record their wishes for Cardiopulmonary Resuscitation (CPR - an emergency life-saving procedure for someone whose breathing or heartbeat has stopped) and documented the residents' choice of code status in such a way to be readily accessible to staff in the event of an emergency. This affected five residents (Resident #1, #18, #19, #60 and #61) in a sample of 23 residents. The facility census was 55. Review of the undated facility policy, Full Code vs. Do Not Resuscitate (DNR) Protocol, showed the following:-Upon finding a resident with an absence of pulse and respirations, the first actions should be to notify a nurse and determine the resident's code status;-The code status was in the Electronic Medical Record (EMR); the policy did not specify where;-If a resident was listed as a Full Code, or no code status or DNR form was on file, a full code would be initiated by direct care staff. 1. Review of Resident #1's undated face sheet showed the following:-The resident admitted to the facility on [DATE];-The resident's family member was his/her durable power of attorney (DPOA)/personal representative. Review of the resident's care plan, revised [DATE], showed the resident's advance directive as full code status. Review of the resident's physician order sheet (POS) for [DATE], did not show an active order for code status. Review of the full code list posted at the nurse's station on [DATE] at 9:05 A.M. showed the resident as a full code. During an interview on [DATE] at 9:51 A.M., the resident's representative/DPOA said he/she thought the resident was a DNR but wasn't sure and advised to contact the resident's second DPOA. During an interview on [DATE] at 10:08 A.M., the resident's second listed representative/DPOA said he/she was told the resident was a DNR. 2. Review of Resident #18's face sheet showed the following:-The resident admitted to the facility on [DATE];-No code status was documented on the face sheet;-No advanced directives were selected for this resident;-The resident's family member was listed as his/her responsible party. Review of the resident's baseline care plan, dated [DATE], showed the code status was left blank. Review of the physician's orders, dated [DATE], showed no order for code status. Review of the resident's care plan, revised/reviewed on [DATE] at 11:37 A.M., showed the following:-No code status was listed at the top of the document by the residents' name;-Documentation showed no code status. Review of the residents' undated Continuity of Care Document (CCD) showed there was no advance directives on file for the resident. Observation on [DATE] at 9:05 A.M. and 11:05 A.M., at the nurses' station showed the following:-A piece of paper listing residents who were full codes was affixed to the nurses' station countertop;-There was no date on the paper;-The resident was not listed on the full code sheet, indicating the resident was a DNR. During interview on [DATE] at 4:17 P.M., the resident's responsible party said the facility asked him/her when the resident admitted about code status. He/She told the facility he/she would have to get back with them. 3. Resident #19's face sheet showed the following: -The resident admitted to the facility on [DATE];-No code status was documented on the face sheet;-No advanced directives were selected for this resident;-The resident's family member was listed as his/her responsible party. Review of the resident's base line care plan, dated [DATE], showed the code status was left blank. Review of the physician's orders, dated [DATE], showed no order for code status. Review of the resident's care plan, revised/reviewed on [DATE] at 1:44 P.M., showed the following:-No code status was listed at the top of the document by the residents' name;-Documentation showed no code status. Review of the residents' undated CCD showed there was no advance directives on file for the resident. Observation on [DATE] at 9:05 A.M. and 11:05 A.M., at the nurses' station showed the following:-A piece of paper listing residents who had elected a full code status was affixed to the nurses' station countertop;-There was no date on the paper;-The resident was not listed on the full code sheet, indicating the resident was a DNR. During interview on [DATE] at 4:17 P.M., the resident's responsible party said the facility asked him/her when the resident was admitted about code status. He/She told the facility he/she would have to get back with them 4. Review of Resident #60's undated face sheet showed the following:-The resident admitted to the facility on [DATE];-The resident was his/her own person. Review of the resident's undated base line care plan showed the code status was left blank. Review of the resident's physician order sheet (POS) for [DATE], showed no order for code status. Review of the resident's comprehensive care plan, dated [DATE], showed the advance directive as full code status. Review of the full code list at the nurse's station on [DATE] at 9:05 A.M. did not have the resident listed as a full code. During an interview on [DATE] at 12:22 P.M., the resident said he/she would not want CPR performed and wished to be a DNR code status. 6. Resident #61's face sheet showed the following: -The resident admitted to the facility on [DATE];-The resident was his/her own responsible party;-No code status was documented on the face sheet;-No advanced directives were selected for this resident. Review of the resident's base line care plan, dated [DATE], showed the code status was left blank. Review of the physician's orders, dated [DATE], showed no order for code status. Review of the resident's care plan, revised/reviewed on [DATE] at 9:50 A.M., showed the following:-No code status listed at the top of the document by the residents' name;-The resident had been admitted to hospices services on [DATE] due to decline in status. Review of the residents' undated CCD showed there was no advance directives on file for the resident. Review of the resident's hospice records showed no documentation of an elected code status. Review of the full code list at the nurse's station showed it did not have the resident listed as a full code, indicating the resident was a DNR. During an interview on [DATE] at 9:37 A.M. the resident said he/she would not want to have CPR if his/her heart stopped beating. 7. During an interview on [DATE] at 6:15 P.M., the care plan coordinator said the following:-She would expect a resident's code status to be listed on their face sheet upon admission; -She would expect the resident to have a physician order signed showing their code status upon admission; -She would expect the residents' code status to be listed on his/her baseline care plan upon admission; -She would expect the residents' code status to be updated on his/her care plan; -Social services was responsible for obtaining code status orders on all newly admitted residents. During an interview on [DATE] at 10:43 A.M., Licensed Practical Nurse (LPN) A said in the event of an emergency, he/she would check the resident's face sheet and the full code sheet at the nurse's station to verify their code status. During an interview on [DATE] at 10:41 A.M., Registered Nurse (RN) D said the following:-There were no hard charts in the building. All documentation was completed in residents' EMRs;-Code status should be listed on each resident's face sheet; -All full code residents were listed on a sheet at the nurse's station-The resident's face sheets were always accurate;-In the event of an emergency, he/she would check the resident's face sheet and the full code sheet at the nurse's station to verify code status. During an interview on [DATE] at 10:46 A.M., the Assistant Director of Nursing (ADON) said the following:-The full code sheet at the nurse's station was updated upon a resident's admission;-The full code sheet at the nurse's station was updated when there were any changes and the resident's code status was reviewed at all care plan meetings; -Nurses could check the code status sheet or face sheet in the event of an emergency. During an interview on [DATE] at 6:59 P.M. the Director of Nursing (DON) said the following:-She would expect to have a signed physician's order showing a residents' code status; -She would expect a residents' code status to be listed on their face sheet; -She would expect a residents' code status to be listed on their baseline care plan; -She would expect the resident's code status be listed on their care plan and for the care plan to be up to date;-Code status should be entered on the resident's face sheet, baseline care plan and have a physician's order within twenty-four hours after a resident has been admitted .

Based on interview and record review, the facility failed to complete required background screenings including the criminal background check (CBC) and employee disqualification list (EDL) checks, prior to employment for four of ten newly hired employees (Administrator, Housekeeper M, Registered Nurse (RN) JJ and Activity Assistant KK) who were hired since the last annual survey. The facility policy failed to address the Nurse Aide (NA) registry check as part of employment screening. The facility failed to complete the NA Registry check for five of ten employees (Administrator, Maintenance/Driver DD, Dietary [NAME] EE, Certified Nursing Assistant (CNA) GG and Caregiver II). The facility census was 55. Review of the undated facility policy, Employment Procedures, showed the following: -Prior to employment, the facility is required by state regulation to check the state EDL, run a criminal record check, and file application to the Family Care Safety Registry (FCSR). An applicant will not be placed on the schedule until the criminal record check is returned and approved by the administrator;-The policy did not address NA registry checks. Review of SentryLink National Criminal Background Check website, sentrylink.com, showed the criminal background check was comprehensive but not guaranteed to include the Missouri State Highway Patrol (MSHP) checks unless it was a specialized, state-mandated check or involved MSHP fingerprinting. SentryLink's standard national checks access state and county records, but for specific MSHP checks, typically need to initiate a state-level request through the MSHP directly. 1. During an interview on 10/06/25 at 1:47 P.M., the administrator said he checked with SentryLink to see if they included the MSHP in the CBC and they do not. 2. Review of the Administrator's employee file showed the following: -Date of hire 12/02/24;-FCSR letter date 12/10/24 (eight days after hire, requested on 12/05/24, three days after hire);-EDL check 12/05/24 (three days after hire);-NA registry check 12/05/24 (three days after hire). 3. Review of Dietary Aide FF's employee file showed the following: -Date of hire 01/23/25;-SentryLink CBC check 01/20/25;-No documentation of CBC that would include MSHP CBC prior to hire;-No documentation of a FCSR letter. 4. Review of Housekeeper M's employee file showed the following:-Date of hire 09/22/25;-SentryLink CBC check 09/12/25; -No documentation of CBC that would include MSHP CBC prior to hire;-NO documentation of a FCSR letter. 5. Review of Caregiver II's employee file showed the following: -Date of hire 03/12/25;-NA registry check 09/30/25 (203 days after hire). 6. Review of RN JJ's employee file showed the following: -Date of hire 07/11/25;-SentryLink CBC check 07/07/25;-No documentation of CBC that would include MSHP CBC prior to hire;-No documentation of a FCSR letter. 7. Review of Activity Assistant KK's employee file showed the following:-Date of hire 08/15/25;-SentryLink CBC check 08/08/25;-No documentation of CBC that would include MSHP CBC prior to hire;-No documentation of a FCSR letter. 8. Review of Maintenance/Driver DD's employee file showed the following:-Date of hire 05/20/25;-NA registry check 09/30/25 (134 days after hire). 9. Review of Dietary [NAME] EE's employee file showed the following:-Date of hire 05/14/25;-NA registry check 09/30/25 (140 days after hire). 10. Review of CNA GG's employee file, on 10/01/25, showed the following:-Date of hire 05/21/25;-No date of NA registry check (134 days after hire). 10. During an interview on 10/01/25 at 5:36 P.M., the unit secretary said the following:-She was responsible for completing the required checks for employment;-Required checks included the criminal background check, EDL and NA registry and should be completed prior to hire;-She was told by the previous administration that the SentryLink included everything required for the CBC;-She noticed on a review, after the state agency asked for the employee files, that some of the NA registry checks had not been completed, so she completed those after the state agency asked for the employee files. During an interview on 10/01/25 at 6:00 P.M., the Administrator said the following: -He was not aware SentryLink did not include the MSHP to complete the CBC;-He expected staff to complete the CBC check, EDL check and NA Registry check prior to the employee's hire date.

Based on observation, interview, and record review, the facility failed to provide each resident with a palatable meal served at appetizing temperatures. The facility census was 55. 1. During an interview on 09/29/25 at 2:35 P.M., Resident #34 said the following:-He/She normally ate his/her dinner in his/her room;-The meal was cold by the time staff served him/her in his/her room. During an interview on 09/29/25, at 2:09 P.M., Resident #52 said the following:-Some evenings he/she ate in his/her room;-The food was warm, but did not taste good at all. During the resident council meeting on 09/30/25 at 1:10 P.M., several residents in attendance said their food was cold at dinner when served as a room tray. 2. Review of the facility's Resident Diet Orders, printed 9/30/25, showed the following: -Forty-seven residents with a physician-ordered regular diet; -Four residents with a physician-ordered mechanical soft diet. Review of the facility's temperature logs, taken prior to serving the dinner meal on 9/30/25, showed the following: -Regular entree (sloppy joe on a bun): 168 degrees F; -Mechanical soft entree (ground meat): 160 degrees F; -Starch (steak fries): 170 degrees F; -No recorded temperature for mechanical soft starch (mashed potatoes) or mechanical soft vegetable (carrots). Observation on 9/30/25, in the kitchen at the steam table, showed the following: -From 4:45 P.M. to 5:07 P.M., [NAME] Y served food from the steam table to residents in the dining room; -From 5:08 P.M. to 5:17 P.M., [NAME] Y plated hall meal trays, added a plate cover to each plate of food, and staff placed the trays of food on a cart; -At 5:18 P.M., [NAME] Y plated a test tray of regular and mechanical soft food. Dietary Aide Z placed the test tray on the cart with the resident hall meal trays and wheeled the cart to each of the resident halls. Observation on 9/30/25 from 5:22 P.M. to 5:38 P.M., showed Dietary Aide Z and Dietary Aide AA served trays from the cart to residents' rooms on the 100-300 halls. Observation on 9/30/25, at 5:39 P.M., of the test tray, after all residents had been served on the halls, showed the following: -The temperature of the mechanical soft ground meat was 96.1 degrees Fahrenheit (F). The meat tasted bland and was cool; -The temperature of the mechanical soft mashed potatoes was 100.7 degrees F. The mashed potatoes tasted bland and were cool; -The temperature of the mechanical soft carrots was 107.4 degrees F. The carrots were cool to taste; -The temperature of the regular sloppy joe was 114.1 degrees F. The meat tasted like chili powder and was cool; -The temperature of the steak fries was 104.7 degrees F. The fries tasted bland and were cool. During an interview on 10/1/25 at 2:15 P.M., the Dietary Manager said he expected hot foods to be served hot and cold foods to be served cold. He expected staff to take temperatures of food items before serving food and to log the temperatures on the food temperature log sheets. During an interview on 10/1/24 at 2:45 P.M., [NAME] Y said hot foods should be at 160 degrees F on the steam table and served to residents at a temperature of least 140 degrees F.

Based on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. The facility census was 55. Review of the undated facility policy, Quality Assurance Performance Improvement (QAPI) Plan, showed the following: -Purpose statement: The purpose of QAPI is the organization is to take a proactive approach in improving the way the facility cares for and engages with residents, caregivers and other partners. To do this, employees will participate in ongoing QAPI efforts which support the mission of caring and sharing in the resident's home away from home;-The QAPI program encompasses all segments of the facility, including resident/family feedback, individualized resident care plans, information technology, facility assessment and QAPI;-Aspects of service and care are measured against established performance goals;-Key monitors are measured and trended on a regular basis;-The QAPI committee monthly prioritized activities, endorses or re-endorses policies and procedures, and continually monitors for improvement using a QAPI self-assessment;-In addition, the QAPI committee will implement Performance Improvement Plan (PIP) topics indicated by data analysis;-The facility will use data at QAPI meetings to ensure performance measures are meeting QAPI goals. 1. Review of the last three QAA notes, provided by the administrator on 10/01/25 at 3:30 P.M., showed the last meeting minute notes were dated 09/30/25. No identification of any identified or addressed quality assurance deficiencies in the meeting minutes noted. During an interview on 10/01/25 at 3:30 P.M., the administrator said the following: -He started in December 2024;-He had a QAA committee meeting monthly and had sign in sheets and minutes documented;-QAA members present during QAA meetings included himself, the Director of Nursing at times, the Medical Director, dietary manager, maintenance director, social services director, sand sometimes the Minimum Data Set nurse;-During QAA, the department heads discussed issues that needed to be addressed or taken care of, but that discussion was only verbal, with no written performance improvement plans (PIP) documented;-He had not identified any areas of widespread deficient practice in any area related to quality of care or quality of life.

Based on observation, interview and record review, the facility failed to provide incontinent care consistent with acceptable standards of practice to prevent urinary tract infections (UTI) and failed to follow proper infection control procedures for one sampled resident (Resident #46). The facility census was 55. Review of the undated facility policy, Policy for Performing Catheter Care with Peri Care, showed the following: -Check catheter (flexible tube inserted into the bladder to drain urine) and drainage bag for leaks, kinks, level of bag, color and character of the urine, and make sure bedside drainage bag is attached to the frame of the bed;-Make sure catheter is secure, coiled and draining properly. 1. Review of Resident #46's undated Continuity of Care Document diagnoses included chronic kidney disease (longstanding disease of the kidneys leading to renal (kidney) failure) and benign prostatic hyperplasia without lower urinary tract symptoms/BPH (a condition in which the prostate gland enlarges but does not cause any noticeable problems with urination). Review of the resident's care plan, revised 09/29/25, showed the following: -Alteration in elimination related to indwelling catheter;-Keep catheter bag below the level of the bladder to prevent reflux (back flow of urine into the bladder);-Minimize contamination. Keep collection bag in a dignity bag when outside the room;-Use leg bag as appropriate. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/30/25, showed the following:-Cognitively intact;-Partial to moderate staff assistance needed for toileting hygiene;-Dependent on staff for toileting transfer;-Indwelling catheter present;-Diagnosis of BPH and neurogenic bladder (nerve damage that keeps the bladder from working properly). Observation on 09/30/25 at 5:30 P.M., showed the resident self-propelled himself/herself in a wheelchair from the dining room. The resident's urinary drainage bag was in a dignity bag fastened under the seat of the resident's wheelchair, with the catheter tubing dragging the floor. The urine in the tubing was cloudy yellow with a moderate amount of white sediment (normal urine is clear yellow without sediment). Observation on 09/30/25 at 6:30 P.M., showed the following: -Certified Nurse Assistant (CNA) H and CNA I attached a mechanical lift pad to the mechanical lift;-CNA H retrieved the urinary drainage bag from the dignity cover on the resident's wheelchair and raised it above the level of the resident's bladder to attach it to the lift pad for transfer;-CNA H and CNA I transferred the resident to bed;-CNA H removed the resident's sweatpants and threaded the urinary drainage bag through his/her pant leg and raised the drainage bag higher than the bladder, causing urine to back flow toward the bladder;-CNA H and CNA I assisted the resident to turn to his/her left side;-CNA I raised the drainage bag above the level of the bladder, causing urine to back flow up the tubing and toward the bladder;-The urine was cloudy yellow with moderate white sediment. Observation on 10/01/25 at 10:05 A.M., showed the resident sat in his/her wheelchair in the solarium. The resident's urinary drainage bag was in a dignity bag under the resident's wheelchair. The catheter tubing touched the floor. The resident's urine was cloudy yellow with a small amount of white sediment. During an interview on 10/22/25 at 10:58 A.M., Certified Nurse Aide (CAN) H said the following:-He/She helped transfer and care for the resident on 9/30/25;-He/She was not aware he/she raised the resident's catheter bag above the level of the resident's bladder during care. During an interview on 10/02/25 at 6:56 P.M., the Director of Nursing (DON) said the following:-Catheter tubing should be stored in the dignity bag and never drag the floor;-A catheter bag should never be raised above the level of the bladder to decrease the risk of back flow that could potentially cause a UTI.

Based on interview and record review, the facility failed to provide a written notice of transfer/discharge to three residents (#1, #2 and #3) or the representatives, in a sample of 23 residents reviewed that include the required information: reason for discharge/transfer, location being discharged /transferred to, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. The facility also failed to communicate transfer and discharges to the Ombudsman (a trained advocate, often a volunteer, who works to protect the rights and improve the quality of life for residents in long-term care facilities, such as nursing homes and assisted living facilities). The facility census was 55. Review of the undated facility policy, Policy and Procedure for Resident Discharge, showed the following: -Policy statement: The resident who resides at the facility will be discharged from the home in a safe and organized fashion with adequate follow-up arrangements per physician order;-Resident discharge to hospital:-Consult with the physician to obtain discharge to hospital of resident choice. Address and transcribe any following orders that the physician has ordered;-Notify the family to inform of resident change in status and physicians orders;-Obtain the following paperwork to transport resident to the hospital: fill out transfer sheet with physicians' orders to transport, print out or send the last history and physical, progress note, physician order sheets, code status, Durable Power of Attorney (DPOA) papers, medication administration sheets, and last two days of nursing notes;-Obtain vital signs and notify the ambulance department giving information required;-Call the emergency department to give report on resident condition;-Notify the Director of Nursing (DON) and administrator regarding resident's trip to the emergency department;-If emergency discharge from the facility is needed or likely the charge nurse will populate the discharge form letter and deliver to the resident or resident representative as soon as practicable. 1.Review of Resident #1's undated face sheet showed the resident had a family representative/DPOA.Review of the resident's progress notes, dated 09/01/25 at 12:02 A.M., showed staff documented the resident was not acting himself/herself, has very spacey look, resident cannot blink or close eyes, speech very slurred, right sided weakness and a droop to the right side of his/her mouth; call made to DPOA; in agreement to sending to the emergency department for evaluation. Review of the resident's progress notes, dated 09/01/25 at 12:28 A.M., showed the following:-Call placed to 911 at 12:10 A.M.;-Emergency Medical Services (EMS) arrived at 12:15 A.M., face sheet, Continuity of Care Document (CCD), and most recent vital signs sent with EMS;-EMS took resident out of the facility at 12:21 A.M.;-Fax sent to physician notifying him/her of change in condition. Review of the resident's Notice of Transfer/Discharge, dated 09/01/25, and authored by the Social Services Director (SSD), showed the following:-Notice was given verbally to the resident's DPOA; -The document did not include the reason for discharge/transfer, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities of the contact information for the agency that is an advocate for residents with mental illness. 2. Review of Resident #2's face sheet showed he/she had a DPOA listed. Review of the resident's census report, dated 05/06/25 at 12:07 A.M., showed the resident was transferred to the hospital. Review of the resident's progress notes, dated 05/06/25 at 12:07 A.M., showed the following:-The resident was not acting like his/herself, he/she very confused and very lethargic and he/she had pain in his/her back and flank area;-During the shower, the resident had another bout of liquid diarrhea with blood;-911 was contacted;-12:02 A.M. resident left with EMS to local hospital;-The family and the DON were notified. Review of the resident's progress notes, dated 05/06/25 at 11:04 A.M., showed the following:-Progress note discipline: Social services;-This writer notified early this morning that the resident went out to the hospital. Copy of the transfer/bed hold policy was emailed to the resident's DPOA. Informed the resident will return to the facility when medically ready and no bed hold charge. Review of the resident's Notice of Transfer/Discharge, dated 05/06/25, showed the following:-Notice was provided to the resident's DPOA;-The document did not include the reason for discharge/transfer, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. Review of the resident's census report, dated 05/08/25 at 10:14 A.M., showed the resident returned from the hospital. Review of the resident's progress notes, dated 05/08/25 at 6:02 P.M., showed the resident was readmitted to the facility (from the hospital). Review of the resident's progress notes, dated 07/01/25 at 5:46 P.M., showed the following:-At 5:00 P.M., the resident became lethargic while sitting on the toilet;-He/She was placed on bed with the help of staff;-His/Her blood pressure was 82/38; -He/She reported his/her stomach hurt and pointed to his/her lower abdomen;-An order was obtained to send the resident to the hospital emergency room for evaluation and treatment;-The Assistant Director of Nurses (ADON) and the resident's family member were notified;-EMS arrived and transported the resident to the hospital. Review of the resident's progress notes, dated 07/01/25 at 8:30 P.M., showed the following:-Staff spoke with the emergency room and the resident was going to be transferred to another hospital; Review of the resident's census report, dated 07/01/25 at 11:03 P.M., showed the resident transferred to the hospital. Review of the resident's Notice of Transfer/Discharge, dated 07/01/25, authored by the SSD, showed the following:-Notice was provided to the resident's DPOA (documentation did not specify if the notice was verbal or written); -The document did not include the reason for discharge/transfer, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. Review of the resident's progress notes, dated 07/07/25 at 1:10 P.M., showed the resident readmitted to the facility (from the hospital). 3. Review of Resident #3's undated face sheet showed he/she had a family representative/DPOA. Review of the resident's progress notes, dated 03/25/25 at 6:06 A.M., showed the following:-The resident put his/her call light on and said he/she wasn't feeling well;-Staff took vital signs as temperature 102.6 (normal 98.6 F. orally), heart rate 113, respirations 22, oxygen saturation 90% and blood pressure 115/73;-At approximately 5:30 A.M., vital signs were re-taken, and they were 101.4, 103, 20, 91% and 125/88;-Phone call made to provider on call who ordered to have resident transported by EMS due to hypoxia (low oxygen saturation);-Resident prepared for transport, paperwork completed and 911 called;-EMS arrived at approximately 5:35 A.M.;-DPOA notified. Review of the resident's Notice of Transfer/Discharge, dated 03/25/25, showed the following:-Written notice was provided to the resident's DPOA; -The document did not include the reason for discharge/transfer, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. 4. During email communication on 09/22/25 at 4:35 P.M., the Ombudsman said the facility has not been sending them the information on residents transferred or discharged from the facility. During an interview on 10/02/25 at 11:55 A.M., the Social Services Director (SSD) said the following: -She was not aware that transfer/discharge notices needed to be sent to the ombudsman monthly and had not been sending them;-She was not aware of some of the specific information that needed to be on the transfer/discharge notice and bed holds; -She gives the bed holds personally if she is available on the transfers, and if not, she will follow up the next day to make sure it has been given, but nursing can also give a bed hold.

Based on interview and record review, the facility failed to update and document a facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The facility census was 55. Review of the facility's Daily Census Report, dated 09/29/25, showed the facility census was 55. Review of the facility provided, facility assessment, showed the following:-The updated facility assessment of 10/01/25 only included page one that had the facility contact information and facility licensing information;-The remaining facility assessment for review was from 05/01/23 that listed information relating to residents for that date. During an interview on 10/01/25 at 3:30 P.M., the administrator said the following:-He had not updated the facility assessment since he had been at the facility as he was taking care of other things that needed attended to first;-Page one was updated on 10/01/25, after the annual survey began, and nothing else had been addressed on the facility assessment.

Based on observation, interview, and record review, the facility failed to document and implement fall interventions to prevent falls for one resident (Resident #1), in a review of five sampled residents. On 07/06/25, staff failed to implement all interventions to prevent falls, including wedge cushions, while the resident was in bed. The resident rolled out of bed which resulted in a fracture of the tibia (a break of the larger of the two bones in the lower leg). The facility census was 55.Review of the facility's Fall Policy, dated 11/14/18, showed the following:-Purpose was to prevent a fall from occurring by identifying conditions and risk factors that typically lead to a fall. Protect the resident from injury in the event a fall does occur, and to provide care to a resident who has fallen by performing assessments, documentation, and early intervention;-Complete comprehensive care plan by day 20 (following admission) using information from Care Area Assessments along with resident and family discussion of interventions if necessary. More individualized risk mitigation techniques based on more comprehensive fall assessment. Update care plan quarterly with resident and family discussion;-Post fall without injury, staff are to utilize the fall investigation form and chart the circumstances of the fall in the electronic medical record;-Fall and injury prevention included keeping call lights and personal items within resident's reach;-Fall interventions include low beds, fall mats, cradle mattress, toileting program, physical therapy screening, increase in assistance, directed activities, and increased monitoring. 1. Review of Resident #1's Care Plan for falls, dated 1/21/25, showed the following:-The resident was at high risk for falls related to a history of falls and multiple disease processes;-An update, dated 4/18/25, for a bolster mattress on the resident's bed;-An update, dated 4/22/25, to make sure the resident's wheelchair cushion was tied to his/her chair or he/she had anti-slip material between cushion and wheelchair; Review of the facility's fall event report, dated 04/26/25, showed the following:-On 04/26/25 at 9:20 P.M., the resident was found on the floor at his/her bedside;-The resident said he/she rolled out of bed;-Staff transferred the resident to the bed and positioned him/her with wedge cushions. Review of the resident's care plan interventions, dated 04/26/25, showed for staff to assure the resident was positioned in the center of his/her bed. (Staff did not document to use wedge cushions to position the resident in bed.) During an interview on 07/24/25 at 11:50 A.M., the Care Plan Coordinator said the following:-The charge nurses documented immediate interventions after a resident fell;-When the interdisciplinary team (IDT) met, they reviewed the interventions that the charge nurse put into place and determined the appropriateness and/or made changes as needed;-Once the IDT determined interventions, they were added to the resident's care plan and verbally communicated to care staff;-After the resident's fall on 04/26/25, the charge nurse documented in the event report to use wedge cushions, but she did not document the use of them in the resident's care plan;-There was no IDT meeting documented to discuss the resident's fall on 04/26/25 or interventions added following the fall;-She was not aware the resident used wedge cushions while in bed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/28/25, showed the following:-His/Her diagnoses included non-traumatic brain dysfunction, aphasia (loss of ability to understand or express speech caused by brain injury), dementia, and Parkinson's disease (a progressive disease of the nervous system marked by tremor muscular rigidity and slow imprecise movements);-He/She was usually understood;-His/Her cognition was moderately impaired;-He/She was dependent on staff for all transfers;-He/She had two non-injury falls since prior assessment (01/28/25);-He/She had one fall resulted in injury since prior assessment (01/28/25). Review of the resident's Fall Risk Assessment, dated 04/28/25, showed the following:-History of one or more falls within the previous six months;-Was on one or more high fall risk drugs;-Required assistance or supervision for mobility, transfer, or ambulation;-High risk for falls. Review of the resident's care plan intervention added on 05/01/25 showed to always keep the call light within the resident's reach in his/her room and to answer all calls for assistance promptly. Review of the facility's fall event report, dated 05/02/25, showed the following:-On 05/02/25 at 2:22 P.M., staff found the resident on his/her hands and knees beside the bed with his/her head resting on the chair cushion next to the bed;-The resident said he/she was trying to reach his/her water;-The resident's water was out of his/her reach;-The resident's call light was pinned to the top of the bed and out of reach. Review of the facility's fall event report, dated 07/06/25, completed by Registered Nurse (RN) F, showed the following:-On 07/06/25 at 9:45 A.M., staff found the resident on his/her right side on the fall mat next to his/her bed;-The resident had been in bed prior to the fall;-Staff noted the interventions were effective, but there was no documentation what interventions were used;-Staff did not review or update the care plan. Review of the resident's nurse's note, dated 07/12/25 at 7:17 P.M., showed the following:-The resident's spouse reported the resident complained of left knee pain;-Assessment showed swelling of the left knee;-Staff notified the physician and sent the resident to the hospital for evaluation and treatment. Review of the resident's nurse's note, dated 07/13/25 at 2:31 A.M., showed the hospital reported the resident had a posterior proximal fracture of the tibia and a fiberglass splint was placed on the resident's foot to the knee. During an interview on 07/23/25 at 12:45 P.M., Certified Nurse's Assistant (CNA) said the following:-He/She had only worked at the facility for a couple of months and had cared for the resident much;-He/She and CNA B assisted the resident to bed on 07/06/25, but did not place wedge cushions next to the resident because he/she did not know to use them and did not see the wedge cushions in the resident's room; -Staff conducted walking rounds, but communication was poor. Staff did not communicate to him/her to use wedge cushions to position the resident in bed;-He/She had not reviewed the care plan for care interventions and relied on what staff reported to him/her when caring for the residents. During an interview on 07/23/25 at 1:04 P.M., CNA B said the following:-He/She was new to the facility and 07/06/25 was the first time he/she assisted with the resident's care;-He/She and CNA A assisted the resident to bed on 07/06/25, but did not place wedge cushions next to the resident because he/she did not know to use them, and he/she did not see the wedge cushions in the resident's room;-He/She received one day of orientation on each hall working with other staff to get to know the residents and the care they required;-He/She could look at the resident's care plan to review specific care interventions, but he/she had not. During an interview on 07/23/25 at 3:00 P.M., Licensed Practical Nurse (LPN) C said the following:-The resident's fall interventions included wedge cushions in place when the resident was in bed to prevent the resident from falling out of bed;-The wedge cushions were implemented as an intervention to prevent falls prior to the resident rolling out of bed on 07/06/25;-Staff should know to put the wedge cushions in place when the resident was in bed;-He/She was unsure if the wedge cushions were documented on the resident's care plan since he/she was not responsible for documenting interventions on the care plans. During an interview on 07/24/25 at 2:20 P.M., RN F said the following:-The resident was supposed to have wedge cushions on both sides while he/she was in bed to prevent the resident from rolling out of bed;-CNA A and CNA B, who provided care for the resident on 07/06/25, were new and were not aware to use the wedge cushions;-Failure to use the wedge cushions was partly his/her fault for not providing proper education to the new CNAs;-He/She was unsure if the wedge cushions were documented on the resident's care plan; he/she did not have much to do with the care plans;-The resident could be left unattended in his/her room if all interventions, including low bed, fall mat, and wedge cushions were utilized properly. During an interview on 07/23/25 at 4:00 P.M., the Director of Nursing (DON) said the following:-Staff were to use the wedge cushions to assure the resident was positioned in the center of the bed;-The wedge cushions should be documented in the resident's care plan and should have been utilized on 07/06/25 to prevent the resident from rolling out of bed;-Staff verbally communicated interventions;-All staff had access to the resident's care plan, and he/she expected staff, especially new staff, to review the care plan to understand the interventions the resident required;-Call lights were supposed to always be in reach;-The Care Plan Coordinator was responsible for updating the care plans with new fall interventions after the fall;-After investigation of the resident's fall on 07/06/25, it was determined the fracture occurred because of the resident falling out of the bed on 07/06/25. During an interview on 07/23/25 at 4:18 P.M., the Administrator said he expected staff to follow all interventions identified to prevent the resident from falling.

Based on interview and record review, the facility failed to notify one resident's (Resident #2) physician timely of hip pain following a fall on 05/21/25. The resident complained of hip pain and received pain medication twice on 05/21/25, however, staff did not notify the physician of the resident's pain at the time of the fall until 05/23/25. An x-ray on 05/24/25 showed the resident fractured his/her hip. The facility census was 54. Review of the facility's protocol and procedure regarding nursing assessments, dated July 2012 showed the following: -It was the responsibility of every licensed and registered nurse to perform thorough nursing assessments on residents; -The nurse would notify the physician with any abnormal findings and/or complaints making sure the total assessment was performed and communicated with the physician. 1. Review of Resident #2's undated Continuity of Care Document (CCD) showed his/her diagnoses included hemiplegia (paralysis or inability to move one side of the body) affecting left nondominant side, muscle weakness, need for assistance with personal care, and lack of coordination. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/18/25, showed the following: -His/Her cognition was moderately impaired; -He/She required substantial/maximum assistance with bathing; -He/She was dependent on staff for transfers; -His/Her range of motion was limited on both upper and lower extremity on one side. Review of the facility's event report, dated 5/21/25 at 2:18 P.M., showed the following: -Licensed Practical Nurse (LPN) A documented the resident slid out of the shower chair and landed on the floor on 05/21/25 at 1:00 P.M.; -The resident complained of right hip soreness but was able to move appropriately without increased pain. Review of facility's communication to physician fax, dated 05/21/25, showed LPN A communicated to the resident's physician that the resident slid out of the shower chair and there were no injuries. (Review showed no documentation LPN A communicated the resident's complaint of right hip soreness to the resident's physician.) During an interview on 06/11/25 at 7:50 A.M., Certified Nurse Assistant (CNA) D said he/she was present with the resident when the resident fell out of the shower chair on 05/21/25. The resident initially complained of right leg pain after the fall. During an interview on 06/11/25 at 9:25 A.M., LPN A said the following: -Staff called him/her to the shower room after the resident fell out of the shower chair (on 05/21/25); -Initially, the resident complained of right hip pain, however, the resident did not complain of pain with range of motion; -He/She reassessed the resident approximately one hour after the fall, and the resident did not have any further complaints of pain; -He/She faxed the resident's physician to notify him/her of the resident's fall; -He/She did not notify the physician of the resident's initial complaint of hip pain because the resident did not have pain when he/she reassessed the resident (approximately one hour) after the fall. Review of the resident's progress notes, dated 05/21/25 at 5:38 P.M., showed LPN B documented the resident complained of hip pain and received Tylenol (pain medication). (Review showed no documentation staff notified the resident's physician of the resident's hip pain which required pain medication to treat.) Review of the resident's Medication Administration Record (MAR), dated 05/21/25, showed the resident received two tablets of Tylenol 500 milligrams (mg) at 3:37 P.M. During an interview on 06/11/25 at 12:15 P.M., LPN B said the following: -He/She medicated the resident with Tylenol for complaints of hip pain which he/she believed was following a fall; -He/She did not recall notifying the resident's physician of the resident's complaints of hip pain. Review of the resident's MAR, dated 05/21/25, showed LPN E administered Tylenol 500 mg two tablets at 11:45 P.M. for complaints of pain. Review of the resident's progress notes, dated 05/21/25, showed no documentation related to staff administering Tylenol to the resident at 11:45 P.M. (Review showed no documentation staff notified the resident's PCP of the resident's complaints of pain.) During an interview on 06/12/25 at 11:10 A.M., LPN E said the following: -He/She received report (on 05/21/25) that the resident fell in the shower room; -The resident complained of pain later the evening following the fall; -He/She did not notify the resident's physician of the resident's pain. Review of the resident's progress notes, dated 05/23/25 at 10:12 A.M., showed Registered Nurse (RN) C documented the following was communicated via fax to the resident's physician: -The resident fell in the shower on 05/21/25; -The resident complained of pain in his/her right hip after the fall, but did not have pain in the hip at this time; -The resident now complained of left shoulder pain which he/she thought was due to the fall. Review of the resident's progress notes, dated 05/23/25 at 10:41 A.M., showed RN C documented the following: -Staff contacted the resident's spouse about the resident's complaint of left shoulder pain and the request for an x-ray of the shoulder; -The resident's spouse questioned if an x-ray of the resident's right hip was requested due to complaints of pain in the right hip on the day of the fall; -Staff contacted the resident's physician's office to request an x-ray order of the right hip. During an interview on 06/11/25 at 9:25 A.M., LPN A said the following: -On 05/23/25, RN C noted the resident complained of pain and requested x-rays of the left shoulder and right hip; -When x-rays were being obtained on 05/24/25, the resident said it was his/her left hip that hurt, not his/her right hip; -The x-ray of the left hip revealed a fracture. Review of the resident's progress notes, dated 05/24/25 at 12:15 P.M., showed LPN A documented the following: -Mobile x-ray results of the left hip showed a mildly displaced fracture (broken bone) of the femoral neck (hip fracture); -Physician notified the resident said it was his/her left hip that hurt not the right hip. Review of the resident's left hip x-ray report, dated 05/24/25, showed a mildly displaced left subcapital femoral neck fracture (left hip fracture). During an interview on 06/16/25 at 12:10 P.M., the resident's nurse practitioner (NP) said the following: -He expected staff to notify him of the resident's initial complaint of hip pain following the fall (on 5/21/25); -He would have ordered an x-ray on 05/21/25 if staff had notified him the resident complained of hip pain. During an interview on 06/16/25 at 1:07 P.M., the Director of Nursing said she expected staff to notify the resident's physician of any complaints of pain, including the resident's initial hip pain following the fall. During an interview on 06/16/25 at 1:07 P.M., the Administrator said he expected staff to notify the resident's physician of any complaints of pain, including the resident's initial hip pain following the fall. MO254765 MO254949

Based on interview and record review, the facility failed to report an injury of unknown origin to the state survey agency for one resident (Resident #1), who suffered a fractured humeral shaft (new fracture), in a review of five sampled residents. The facility census was 56. Review of the facility's undated policy, Abuse Prevention Program, showed the following: -Facility management shall promptly and thoroughly investigate all reports of resident abuse, neglect and injuries of unknown source; -Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator or his/her designee, will immediately send validated report to the Department of Health and Senior Services, local police or licensing agencies; -If the events that cause the allegation involve abuse or result in serious bodily injury, the allegation must be reported within two hours. 1. Review of Resident #1's nurses note, dated 5/6/25, showed he/she was admitted to the facility from the hospital with a diagnosis of left humerus fracture with open reduction internal fixation (ORIF) from a fall at home. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/13/25, showed the following: -Moderately impaired cognition; -Required moderate assistance of staff for bed mobility, transfers and ambulation; -Required maximum assistance of staff for bathing and dressing; -He/She had physical impairment on one side of his/her upper extremity; -He/She had a fall and fracture prior to admission; -No falls since admission. Review of the resident's nurses' notes, dated 5/15/25, showed Licensed Practical Nurse (LPN) A documented the resident had a follow up appointment today to have his/her left arm assessed. He/She had a fracture of the left arm and was to be NWB to left upper extremity (LUE), use ice and elevate the LUE throughout the day. Use the sling for comfort when out the bed/chair. The resident will have surgery on Friday. During interview on 5/22/25 at 8:26 P.M., LPN A said he/she found out the resident had a fracture in his/her arm from the physician's office after the resident's follow-up appointment on 5/15/25. He/She thought it was the initial fracture and they scheduled the resident for surgery. The resident had not had any recent falls or trauma while at the facility and had not complained of any additional pain. Staff transferred the resident with two assist, a gait belt (an safety device used to assist in moving and walking) and a hemi walker (type of mobility device for people who have use of only one hand or arm). He/She reported the fracture to the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on 5/15/25. Review of the resident's care plan, dated 5/19/25, showed the following: -Impaired activities of daily living (ADLs) related to recent hospitalization for left humerus fracture/repair; -Non-weight bearing (NWB) to left upper extremity; -Provide assist of one for bathing and dressing; -Provide assist of two for all transfers. Apply arm sling during transfers. Review of the resident's hospital discharge note, dated 5/22/25, showed the discharge diagnosis of fracture of humerus shaft, left. The resident had an initial ORIF (open reduction internal fixation) of the left supracondylar (located in the upper arm near the elbow) humerus on 5/2/25. He/She had further ORIF of the left humeral shaft fracture on 5/16/25. During interview on 5/22/25 at 6:38 P.M., the ADON said the resident was readmitted to the facility today after having surgery on his/her left arm. The resident had had a follow-up appointment on 5/15/25 for his/her fractured arm. The hospital notified the facility on 5/15/25 that there was a fracture that would require surgery. She thought the fracture had not set correctly so that is why the resident had to have surgery (on 5/16/25). The resident had not fallen since he/she was admitted to the facility. The new fracture should have been considered an injury of unknown origin and should have been reported to the state agency. During interview on 5/23/25 at 8:23 A.M., the DON said the following: -She was aware the resident had surgery for a fractured arm prior to his/her original admission to the facility; -She was notified about the second fracture when the physician's office called and told staff the resident had a fracture. She didn't know if it was new because the resident had not had any falls. The physician's office did not give the facility much detail regarding the fracture; -She didn't consider the fracture an injury of unknown origin because she knew the resident had not had any incidents while at the facility; -She wouldn't necessarily have reported the fracture as an injury of unknown origin because she didn't have much information about what happened and why it happened. During interview on 6/3/25 at 1:05 P.M., the Administrator said he found out about the resident's fracture after the resident's follow-up appointment with his/her physician (on 5/15/25), but was not aware it was a new fracture or he would have reported it as an injury of unknown origin. He learned of the new fracture upon the state agency's investigation. MO254546 MO254640

Based on observation and interview, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust and debris. Staff failed to ensure the facility's ice machine was clean, ice scoops were stored in a clean container, and the ice machine drain contained an air gap. The facility census was 52. (The facility was unable to provide a kitchen/dietary policy, food safety requirement policy, or food preparation guidelines policy). 1. Observations on 10/17/23 from 9:35 A.M. to 5:30 P.M., in the kitchen, showed the following: -A moderate buildup of dust and debris on the walk-in cooler fan cover; -A moderate buildup of grease, dust and debris on the top, front, and sides of the oven, with buildup of grease and liquid runs on the inside front glass, doors, and sides of the oven; -A moderate buildup of grease, dust, and debris on the outside and inside surfaces of the kitchen range hood system; -A moderate buildup of grease, dust, and debris on the 10 baffle filters in the range hood; -A buildup of grease and debris on all surfaces of the deep fryer; -A buildup of grease, debris, and dark stains on the left and right sides of the gas stove top and griddle unit; -A buildup of dust and debris on the coiled power cord to the serving window fire curtain drop. Observation on 10/17/23 at 10:36 A.M., of the ice machine located in the staff break room, showed the following: -A light buildup of dust on the top surface of the ice machine; -A white plastic scoop and a metal scoop lay on the top surface of the ice machine and were not stored in a scoop holder or container; -A white scaly substance on the front of the ice machine, along the approximately 36 inch vinyl door hinge; -A white scaly substance on the right side of an approximately 2 inch flat vinyl edge, where the ice machine door sealed when closed; -Two, approximately 1 inch plastic ice machine drain pipes inside of and touching an approximately 4 inch plastic bell flange drain. There was no air gap between the ice machine drain pipe and the drain. During an interview on 10/17/23 at 1:26 P.M., the dietary manager said the following: -Dietary staff should keep the the walk-in cooler fan cover clean and free of dust and debris; -She expected dietary evening staff to clean the outside surfaces of the oven each night, and inside the oven weekly; -She expected evening dish washing staff to run the range hood filters through the dishwasher and to clean the surfaces inside and outside the range hood each Friday; -She expected dietary evening staff to clean the surfaces of the deep fryer each night; -She expected dietary evening staff to clean the stove top unit each night; -She expected dietary staff to clean the coiled power cord to the serving window fire curtain drop weekly or as needed; -She did not know who was responsible for the ice machine or the scoops in the staff break room; -Dietary staff were responsible for the ice machine in the dining room. During an interview on 10/18/23 at 12:05 P.M., the maintenance director said the following: -He did not know who was responsible for the daily/weekly cleaning of ice machine in the staff break room; -The outside of ice machine should be cleaned weekly or as needed to prevent the white powdery substance on the machine; -He was aware there was to be an air gap between the ice machine drain pipes and the drain; -He was not aware the drain pipes to the ice machine in the break room were inside of and touching the bell flange drain; -He expected the ice machine drain pipes not to touch the drain pipe and be above it, creating an air gap. During an interview on 10/20/23 at 10:26 A.M., the registered dietician said she expected staff to keep the kitchen and dietary equipment and the kitchen area to be kept clean and sanitized. During an interview on 10/18/23 at 11:00 A.M., the administrator said he expected dietary staff to clean and sanitize the kitchen and dietary equipment daily, weekly, and as needed.

Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed when staff failed to wash their hands when they removed contaminated gloves while performing post-incontinence care for two resident (Resident #9 and Resident #25), who had been incontinent of bowel, in a review of 17 sampled residents. The facility failed to post signs to alert staff and visitors to use precautions and appropriate personal protective equipment (PPE) for four residents (Resident #34, #35, #39 and #302) who were on isolation precautions and failed to close the door of one resident's room (Resident #39) who was on isolation precautions. The facility failed to maintain the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) when the facility failed to ensure Tuberculin Skin Tests (TST) for four new employees (Dietary Aide C, Certified Nursing Assistant (CNA) G, CNA I and Caregiver J), of ten new employee files reviewed, were completed in accordance with the general requirements for TB testing for long-term care employees. The facility census was 52. Review of the undated facility policy, Employment Procedures, showed each employee is required by state regulation to take a TB screening upon hire and on an annual basis thereafter. Review of the facility's policy and procedure for droplet isolation, dated February 2007, showed the following: -In addition to standard precautions, droplet precautions for a resident documented or suspected to be infected with microorganisms transmitted by droplet that could be generated by the resident coughing, sneezing, talking, or by the performance of procedures such as suctioning; -A yellow sign on the door would be hung to alert visitors to go to the nurses's station for instructions; -Staff would inform visitors about wearing masks before entering room and hand hygiene before leaving room, and have hand gel sanitizer available and in sight for visitors and staff to use. Review of the facility policy and procedure for Contact Isolation, dated September 2011, showed the following: -Contract isolation is a procedure that is done in order to keep different infections localized and to prevent the spread of infection to other residents and staff; -Contact isolation procedure involves hand washing, sanitizing and gloving procedure or universal precautions when performing direct care needs; -Procedure: When an infection has been identified by the physician that requires contact isolation, the following procedure will be executed: Place an orange contact isolation sign on the outside of the resident's door. Review of the Centers for Disease Control website for the Implementation of PPE, updated 7/12/22, showed when implementing Contact Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this, post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves) are to be used. Review of the CDC guidance for COVID-19 (a contagious viral illness caused by the SARS-CoV-2 virus), dated 5/8/23, showed facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. Review of the facility's hand washing policy, dated March 2010, showed staff were to wash their hands as follows: -Before and after contact with a resident; -Always after glove use; -When hands come in contact with blood and/or body fluids and mucous membranes; -Whenever hands were visible soiled; -When moving from a contaminated body site to a clean site during care activity; -After contact with objects including equipment in the resident's room. 1. Review of Resident #35's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/18/23 showed the following: -Alert and oriented and able to answer questions; -Able to make self understood and able to understand others; -Requires limited assistance of one staff member for Activities of Daily Living (ADL's); -Diagnoses of stroke, hypertension, diabetes and urinary tract infection. Review of the resident's nurses notes dated 10/15/23 at 6:30 P.M. showed staff documented the resident continues with cold symptoms. COVID-19 test administered and was positive. Review of the nurses notes, dated 10/16/23 at 5:14 A.M., showed staff documented the resident was in isolation due to a positive COVID test. Observation on 10/17/23 and 10/18/23, at various times of the day, showed the following: -The resident's room door was closed; -A black and white sign posted on the door that said to see the nurse before entering. Observation on 10/18/23 at 6:47 A.M. showed the following: -The Director of Nursing (DON) came out of the resident's room wearing goggles and an N95 (a type of filtering face mask) mask; -She took off the N95 mask and placed it in the front left pocket of her shirt; -She took off her goggles and wiped them down with a sanitizer wipe. 2. Review of Resident #39's quarterly MDS, dated [DATE], showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decision; -Independent with ADL's; -Diagnoses of asthma and low blood pressure. Review of the resident's nurses notes, dated 10/16/23 at 10:00 A.M., showed staff documented the resident tested positive for COVID-19 during house wide testing. He/She was placed on isolation. Observations on 10/16/23 at 10:59 A.M., 11:33 A.M. and 12:19 P.M. showed the following: -The door to the resident's room was open; -There was no sign posted to alert staff and visitors of the isolation or of what PPE should be worn in the resident's room. Observation on 10/17/23 at 12:18 P.M. showed the following: -The door to the resident's room was open; -A black and white sign was posted on the door that read to see nurse before entering; -The resident was at the open door and would place his/her head outside of the door; -Several staff members walked past the resident's room and did not instruct the resident to stay in his/her room or attempt to close the door. Observation on 10/17/23 at 6:10 P.M., showed the following: -The door to the resident's room was open; -A black and white sign was posted on the door that read to see the nurse before entering; -A red PPE bag sat open on the resident's floor and was approximately 1/3 full. Observation on 10/18/23 at 8:22 A.M. showed the following: -The door to the resident's room was open. The resident stood at the door with a plastic cup in his/her hand. A staff member took the plastic cup and placed it on a cart that contained clean plastic cups. The staff member handed the resident a clean plastic cup through the door and did not instruct the resident to close the door; -Another resident came to the door and handed Resident #39 an item while the Assistant Director of Nursing (ADON) and two other staff members stood at the door; -No staff member attempted to stop the other resident from touching Resident #39. During an interview on 10/18/23 at 11:00 A.M., the ADON said the following: -He/She was at Resident #39's door when another resident came and handed Resident #39 a piece of candy; -He/She should have stopped the resident from touching Resident #39; -He/She should have instructed the other resident to wash his/her hands. 3. Review of Resident #302's quarterly MDS, dated [DATE], showed the following: -Alert and oriented and able to make decisions; -Able to make self understood and able to understand others; -Supervision with ADL's; -Diagnoses of coronary artery disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypertension, Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's nurses notes dated 10/16/2023 at 10:21 A.M. showed staff documented the resident has tested positive for COVID. Observations on 10/16/23, 10/17/23 and 10/18/23, at various time of the day, showed no sign posted on the resident's door to alert staff and visitors of the isolation or of what PPE to wear when entering the resident's room. During an interview on 10/18/23 at 6:33 A.M., Registered Nurse (RN) A said the following: -The resident was diagnosed on [DATE] as COVID positive; -There was no sign on the resident's door; -There should be a sign on the resident's door saying to stop and see a nurse. 4. Review of Resident #34's quarterly MDS, dated [DATE], showed the following: -Alert and oriented and able to answer questions; -Able to make self understood and able to understand others; -Independent with ADL's; -Diagnoses of coronary artery disease, hypertension and diabetes. Review of the resident's nurses notes, dated 10/16/23 at 10:30 A.M., showed the resident tested positive for COVID-19 during house wide testing this morning. He/She does have cold symptoms including cough, runny nose and sneezing. He/She has been placed on isolation. Observations on 10/16/23, 10/17/23 and 10/18/23, at various times of the day, showed no sign posted on the resident's door to alert staff and visitors of the isolation or of what PPE to wear when entering the resident's room. 5. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -He/She was dependent on staff for toilet hygiene, lower body dressing, and rolling from left to right; -He/She was frequently incontinent of bowel and bladder. Review of the resident's care plan, last revised on 9/20/23, showed the following: -He/She was frequently incontinent of bowel and bladder; -Provide assistance of one to two staff with lower/upper body dressing; -Following pericare, apply antifungal cream to buttocks as ordered by his/her physician. Review of the resident's undated continuity of care document (CCD) showed on 10/16/23, his/her physician ordered miconazole nitrate 2% cream (antifungal cream) to be applied as needed to resident's buttocks and thighs for a rash and/or skin breakdown. Observation on 10/18/23 at 7:40 A.M. showed the following: -The DON and ADON entered the resident's room to assist him/her with ADL cares and transfer him/her from bed to the wheelchair; -The resident was incontinent of bowel; -The DON cleaned feces from the resident's buttock area with gloved hands, removed his/her gloves, and without washing and/or sanitizing hands, put on new gloves; -The DON obtained a clean brief and fungal cream from the resident's bedside table, applied the cream to the resident's buttocks, removed his/her gloves, and without washing his/her hands, put on new gloves; -She assisted the resident to dress, transferred the resident to his/her wheelchair, and transported the resident to the dining room; -The DON did not wash her hands before putting on gloves and after removing gloves during resident care. 6. Review of Resident #25's face sheet showed the resident's diagnoses included history of urinary tract infections. Review of resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -He/She was totally dependent on one to two staff for all ADL's; -He/She was always incontinent of bowel and bladder. Review of the resident's care plan, last revised on 7/24/23, showed the following: -He/She wore incontinence briefs at all times to address incontinence; -Provide peri care after each incontinent episode. Observation on 10/18/23 at 8:07 A.M. showed the following: -Certified Nurse Assistant (CNA) Q and CNA K entered the resident's room to assist him/her with ADL cares and transfer from bed to the wheelchair; -The resident was incontinent of bowel; -CNA Q cleaned feces from the resident's buttocks with gloved hands, removed his/her gloves, and without washing and/or sanitizing hands, put on new gloves; -CNA Q then removed the soiled incontinence pad, cleaned the resident's front peri area, applied a clean brief, and removed his/her gloves; -Without washing or sanitizing their hands, CNA Q and CNA K put on new gloves and changed the resident's pants and shirt, and then transferred the resident with the hoyer lift to the wheelchair; -Both CNA Q and CNA F failed to wash hands before putting on gloves and after removing their gloves during resident care. 7. Review of Dietary Aide C's employee file showed the following: -Date of hire 07/21/21; -First step TB test administered on 07/15/21 and read on 07/17/21; -Second step TB test administered on 08/17/21 (33 days after first test); -No documentation staff read the results of the second step TB test. 8. Review of CNA G's employee file showed the following: -Date of hire 11/11/21; -Documentation of a first step TB test and a second step TB test that was administered at a prior place of employment on 10/14/21 and 10/24/21; -There was no documentation of the results of the first and second step TB test from his/her prior place of employment; -No documentation the facility administered the first or second step TB test after CNA G's date of hire. 9. Review of CNA I's employee file showed the following: -Date of hire 08/11/22; -No documentation staff administered the first or second step TB test. 10. Review of Caregiver J's employee file showed the following: -Date of hire 08/09/22; -First step TB test administered on 08/08/22 and read on 08/10/22 with a result of 0 mm of induration; -No record of a second step TB test was found. 11. Review of Dietary Aide H's employee file showed the following: -Date of hire 04/17/23; -First step TB test administered on 04/14/23 and read on 04/17/23 with a result of negative only (no indication of mm of induration assessed); -Second step TB test administered on 05/05/23 and read on 05/08/23 with a result of 0 mm of induration. 12. Review of CNA K's employee file showed the following: -Date of hire, 03/20/23; -First step TB test administered on 03/17/23 and read on 03/20/23 with a result of 0 mm of induration; -Second step TB test administered on 03/31/23 and read on 04/03/23 with a result of negative only (no indication of mm of induration assessed). During interview on 10/18/23, at 2:55 P.M., the infection preventionist/ADON said the following: -Any nurse can administer or read a TB test for a new employee; -She was responsible for making sure the TB tests were completed; -She was the nurse that read the results for Dietary Aide H and CNA K; -She was aware results of the TB test should be documented as millimeters of induration and not just negative. During interview on 10/18/23 at 5:05 P.M., the DON said the following: -New employees should have two step TB tests administered unless they had one in the last year; -TB tests should be read with mm of induration indication and not just as negative; -Staff should wash their hands before and after resident care or after touching anything dirty. Staff can use hand sanitizer or soap and water; -Staff should not place N95 masks in their pocket; staff should remove the mask before leaving the isolation room; -Staff should remove and dispose of gloves before leaving an isolation room; -Staff should monitor residents and attempt to prevent them from touching a resident who is on isolation; -The doors to an isolation room should remain closed. If the resident refused to have the door closed, then staff should educate the resident and care plan that the resident wished for the door to remain open; -When a resident was placed on isolation, a yellow or orange sign should be posted on the door to alert staff and visitors to check with the nurse; -She was unaware a sign with what PPE should be worn should have been posted on the doors.

44665 Based on observation and interview, the facility failed to ensure ceiling vents were maintained free of a buildup of dust and debris. The census was 52. Observations on 10/17/23 between 9:20 A.M. and 6:30 P.M., showed the following: -In the biohazard room on the 100 hall, the ceiling vent had a moderate buildup of fuzzy debris; -In the full cylinder oxygen storage room, the ceiling vent had a moderate buildup of fuzzy debris; -In the sitting room (geri center) near the nurse's station, the ceiling vent had a heavy buildup of fuzzy debris; -At the nurses' station, the ceiling vent had a moderate accumulation of dust and debris; -In the unlabeled room, located next to the nurses' station and clean utility room, the ceiling vent had a heavy accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a heavy accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In the Personal Care room, the ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a heavy accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a heavy accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In unoccupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of cobwebs; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a heavy accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; -In the employee restroom, located across from the main dining room, the ceiling vent had a moderate accumulation of dust. During an interview on 10/17/23 at 11:22 A.M., the Maintenance Supervisor said maintenance staff was responsible for cleaning the ceiling vents monthly.

Based on interview and record review, the facility failed to check the Nurse Aide Registry prior to hire for five of ten employees reviewed, to ensure they did not have a Federal Indicator (the individual with a Federal Indicator cannot work in a certified long-term care facility). The facility failed to develop a policy to direct staff to check the Nurse Aide Registry prior to hiring new employees. The facility census was 52. Review of the undated facility policy, Employment Procedures, showed prior to employment, the facility is required by state regulation to check the state employment disqualification list, run a criminal record check and file application to the family safety care registry. The facility policy did not address checking the Nurse Aide Registry prior to hiring new staff members. 1. Review of Dietary Aide C's employee file showed the following: -Date of hire 07/21/21; -No record staff checked the Nurse Aide Registry prior to hire. 2. Review of Caregiver D's employee file showed the following: -Date of hire 10/09/23; -No record staff checked the Nurse Aide Registry prior to hire. 3. Review of Licensed Practical Nurse (LPN) E's employee file showed the following: -Date of hire 08/28/23; -No record staff checked the Nurse Aide Registry prior to hire. 4. Review of Caregiver F's employee file showed the following: -Date of hire 02/28/22; -No record staff checked the Nurse Aide Registry prior to hire. 5. Review of Dietary Aide H's employee file showed the following: -Date of hire 04/17/23; -No record staff checked the Nurse Aide Registry prior to hire. 6. During interview on 10/18/23 at 2:34 P.M., the human resources (HR) manager said the following: -She had been in the position less than a year; -She only checked the Nurse Aide Registry for newly hired nursing assistants, and had not checked the Nurse Aide Registry for all newly hired employees; -She received training from the previous HR manager and was not sure she was told to check the Nurse Aide Registry for everyone. If she was told, she did not remember. During interview on 10/18/23, at 5:19 P.M., the administrator said the following: -He expected staff to check the Nurse Aide Registry for all new hires; -He was unaware staff was not checking the Nurse Aide Registry on all new hires.

Based on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination of respiratory equipment according to facility policy, when staff failed to protect continuous positive airway pressure (CPAP)/Bilevel positive airway pressure (BiPap) (devices that helps with breathing) equipment and nebulizer treatment equipment when not in use, and failed to change oxygen tubing and ensure proper infection control was utilized according to facility policy for five residents (Resident #47, #152, #33, #4 and #7) in a review of 17 sampled residents. The facility census was 52. Review of the facility's undated Oxygen Tubing Policy, showed the following: -Maintenance: 10:00 P.M. to 6:00 A.M. charge nurses are responsible for ensuring that all e-tanks (portable oxygen tanks) used by the residents are checked every night so the e-tanks are ready when the resident wants to rise in the morning; -Oxygen tubing is changed every month and as needed by the 10:00 P.M. to 6:00 A.M. nursing staff. Review of the facility's undated policy for cleaning and storage of nebulizer and oxygen equipment showed the following: -Purpose of the policy was to reduce the risk of respiratory infections; -All oxygen tubing, nasal canulas, and masks should be stored up off the floor when not in use. Mesh bags were available for easier storage of oxygen tubing if needed; -Nebulizer tubing should be changed monthly and as needed. Tubing should be dated with the date it was changed; (The policy did not direct staff on specific storage of Bi-Pap and C-Pap masks when not in use.) 1. Review of Resident #47's undated continuity of care document (CCD) showed his/her diagnoses included sleep apnea (intermittent cessation of breathing while sleeping). Review of the resident's care plan, dated 9/7/23, showed the resident had respiratory insufficiency and ineffective airway clearance secondary to sleep apnea and used a BiPap with oxygen every night. Review of the resident's physician's order, dated 10/3/23, showed the resident was to use a BiPap with 2 liters of oxygen at bedtime via a nasal pillow mask. Observation on 10/17/23 at 11:20 A.M., showed the resident's BiPap was located on his/her bedside table. The BiPap mask rested on the machine and the tubing was stretched across a gray basin that contained perineal wipes. Observation on 10/17/23 at 12:05 P.M. showed the resident's BiPap mask lay on the resident's bedside table and was uncovered. Observation on 10/18/23 at 5:00 A.M. showed the resident's BiPap mask lay on the resident's bedside table and was uncovered. During an interview on 10/18/23 at 5:20 A.M., Certified Medication Technician (CMT) L said the following: -The resident would start wearing his/her BiPap mask at the beginning of the night, but he/she would remove it and refuse to keep it on; -BiPap/CPap breathing masks should be covered and in plastic bag when not in use; -Oxygen tubing used to be changed weekly on night shift. Residents complained of staff coming in their room to much at night so it was changed to weekly on day shift, but she was not sure if it was. 2. Review of Resident #152's face sheet showed the following: -admitted on [DATE]; -Diagnoses included congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic cough, atrial fibrillation (and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). Review of the resident's October 2023 physician order sheet showed an order for ipratropium-albuterol (an inhaled medication used to treat respiratory issues) solution for nebulization (an aerosol breathing treatment), one vial every four hours as needed (original order dated 10/09/23). Observation on 10/16/23 at 10:32 A.M., showed a nebulizer machine (a device used to administer medication in the form of a mist inhaled into the lungs) sat on the resident's bedside table; the nebulizer set up (the mask, reservoir and tubing used with the nebulizer machine) sat on his/ her bedside table uncovered. The nebulizer set up was not stored in the holder of the nebulizer machine. Review of the resident's October 2023 medication administration sheet showed the last administration of the as needed ipratropium-albuterol breathing treatment was 10/16/23 at 3:05 P.M. Review of the resident's care plan, revised 10/17/23, showed the following: -Respiratory insufficiency and ineffective airway clearance secondary to pulmonary hypertension, wheezing and chronic cough; -Administer respiratory medications per physician order. Observation on 10/17/23 at 9:37 A.M., showed the resident's nebulizer set up sat on the resident's bedside table uncovered. The nebulizer set up was not connected to the nebulizer machine. Observation on 10/18/23, at 5:13 A.M., showed the resident's nebulizer set up sat on the resident's bedside table uncovered. The nebulizer set up was not connected to the nebulizer machine. The resident said he/she had not used the nebulizer in a few days. 3. Review of Resident #33's CCD showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD/a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's care plan, edited 08/24/2023, showed the following: -History of respiratory insufficiency related to COPD; -Administer oxygen per physician orders. Review of the resident's October 2023 physician order sheet showed an order for oxygen, apply continuously at 3 liters per minute per nasal cannula (NC) with a order start date of 02/14/23. Observation on 10/17/23 at 9:34 A.M. showed the resident sat in his/her recliner and received oxygen from an oxygen concentrator. The oxygen tubing was not dated. During an interview on 10/18/23 at 5:24 A.M., Licensed Practical Nurse (LPN) B said the following: -When oxygen is not in use, the tubing should be wrapped and stored in a clear bag; -When nebulizer equipment was not in use, staff should place the equipment on the nebulizer machine and cover it with a bag; -Resident #152's nebulizer should be covered. 4. Review of Resident #4's CCD, dated 10/18/23, showed his/her diagnoses included COPD, unspecified asthma, obstructive sleep apnea, dependence on supplemental oxygen and upper respiratory tract hypersensitivity reaction. Review of resident's quarterly MDS, dated [DATE], showed the resident required oxygen therapy and the use of a non-invasive mechanical ventilator (CPAP). Review of the resident's care plan, dated 10/16/23, showed the following: -Respiratory insufficiency secondary to COPD/Asthma; -Use of oxygen (O2) via NC; -CPAP when in bed, diagnoses: dependence on supplemental oxygen, obstructive sleep apnea, congestive heart failure; -Administer O2 per physician order; -Administer respiratory medications per physician orders. Review of the resident's October 2023 physician orders showed the following: -CPAP at bedtime (HS) and as needed (PRN); -Oxygen at 3LPM (liters per minute) via nasal cannula; -Ipratropium-albuterol solution (inhaled lung medication) for nebulization; 0.5 milligrams (mg) - 3 mg/3 milliliters (ml;) Use 1 vial (3 ml) via nebulizer every 4 hours. Observation on 10/16/23 at 10:15 A.M. in the resident's room showed the following: -The oxygen nasal cannula was on top of the resident's bedding, not stored in a storage bag; -The resident's CPAP mask was on the resident's nightstand and not stored in a storage bag; -The nebulizer mask hung from a nebulizer machine on the resident's bedside table, and was not stored in a storage bag. 5. Review of Resident #7's CCD showed his/her diagnoses included dementia, COPD, dyspnea (difficult or labored breathing), cough and acute upper respiratory infection. Review of the resident's quarterly MDS, dated [DATE], showed the resident had an active pulmonary diagnosis of asthma, COPD or chronic lung disease. Review of the resident's care plan, updated 8/25/23, showed the following: -Respiratory insufficiency and ineffective airway clearance secondary to COPD and diagnoses that included malignant neoplasm of bronchus and lung (lung cancer), left upper lobe lung resection for lung cancer (the process of cutting out tissue or part of an organ), dyspnea. Wears oxygen. BiPap started at bedtime on 6/1/23; -Administer respiratory medications per physician order. Review of the resident's October 2023 physician orders showed the following: -BiPap at bedtime; -Ipratropium-albuterol solution for nebulization; 0/5 mg-3mg/3ml; 1 vial; inhalation. Special instructions: Inhale one vial four times daily as needed for shortness of breath; -No specific order as to when to change the nebulizer tubing. Observation in the resident's room on 10/16/23 at 10:40 A.M. showed the following: -Nebulizer tubing dated 8/30/23; (the tubing had not been changed monthly as the facility policy instructed); - The BiPap mask was on top of the resident's bed, uncovered and not in a storage bag; -The BiPap tubing was on the floor and not in a storage bag. Observation on 10/18/23 at 5:23 A.M. showed the following: -The resident's BiPap mask was on top of the bed and uncovered; -The resident's BiPap tubing was on the floor and not in a storage bag. During an interview on 10/18/23 at 5:40 A.M., LPN B said the following: -Some residents have bags on the back of their wheelchairs or on their concentrators to store tubing when not in use, but not everyone has a storage bag; -Nebulizer masks just hang from the machine and are not kept in a storage bag when not in use. During an interview on 10/18/23 at 5:05 P.M., the Director of Nursing said the following: -She expected staff to change oxygen tubing weekly and to date the tubing when changed; -Masks and tubing should be appropriately stored, including up off of the floor; -Nebulizers masks should be attached to the machine. Masks should also be covered with a bag; -CPAP/BiPaps should be stored per the way the durable medical equipment (DME) manufacturer suggests (the facility did not provide manufacturers suggestions for CPAP/BiPap devices). 42592 45563

Based on observation, interview and record review the facility failed to ensure one resident (Resident #1) of six sampled residents, received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection of pressure ulcers (a 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) who the facility identified at risk for pressure ulcers. The resident initially presented with a superficial nickel size Stage II pressure ulcer to the coccyx. The pressure ulcer increased to quarter size and presented with slough (Stage III), with an additional ulcer, previously not identified, in the same area. The facility census was 52. Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, showed the definitions of the different stages of pressure ulcers (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) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister. Review of the facility's policy titled Skin and Wound Care Program, revised 1/26/16, showed the following: -Stage III: 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 and tunneling. -The purpose of the program is to identify residents who may be at risk for the development of pressure ulcers and to provide interventions for preventing and treating pressure ulcers; -Residents identified as moderate or high risk will be assessed head to toe by the skin and wound care nurse according to the assigned time frames and documented on the skin condition report sheet; -The resident's skin status will be monitored by the nurse aides every shift. The skin and wound care nurse or charge nurse will be notified immediately of any reddened or open areas on skin; -Upon identification of a facility acquired pressure ulcer, and with a change of status of a pressure ulcer the skin and wound care nurse or charge nurse will: 1.) Initiate the pressure ulcer healing chart; 2.) Obtain treatment orders; 3.) Document in the nurse's notes the location, size, color, drainage, odor, and any pain related to the wound or treatment; 4.) The skin and wound nurse will assess and measure the wound weekly; 5.) The wound nurse will measure the wound length by width and depth; 6.) Notify the Director of Nursing (DON); 7.) If the Assistant Director of Nurses (ADON) or Director of Nurses (DON) are unavailable, a wound communication sheet will be addressed by the charge nurse and placed in the ADON or DON box so the area can be examined by the in house wound nurse or DON the next day. If it is a weekend, the charge nurse is to obtain treatment order. All shift nurses are to document on the area and monitor for pain, drainage, redness, inflammation. May also call the Registered Nurse (RN) on call for further instructions. Review of the facility's policy Wound Protocol, When to Call the Physician, dated April 2005, showed the following: -The physician will be notified by the nurse in charge of weekly wound measurements when 1.) There is an increase in drainage or becoming necrotic in odor; 2.) Visual signs of no improvement within seven to 10 days; 3.) Visual signs of [CONDITION(S)], redness, and warmth to the area. 1. Review of Resident #1's Care Plan, dated 3/30/22, showed the following: -The resident was at risk for skin breakdown related to limited mobility and need for assistance with activities of daily living, urinary incontinence, and [CONDITION(S)] of both lower extremities; -The resident was on hospice; -Monitor skin during routine care and notify the nurse of any abnormalities; -Provide assistance of one to two staff using a gait belt and walker/wheelchair for all transfers, being careful during care and transfers to avoid injury; -Place the resident in bed between meals to off-load pressure and aide with preventing skin breakdown; -Bath aide to monitor skin condition weekly with bathing and notify nurse of any abnormal findings; -Provide incontinence care after each incontinent episode. Toilet and change the resident's brief at least every two hours during waking hours; -Turn and reposition every two hours and as needed to aide with pressure relief measures; -Keep the resident as clean and dry as possible with routine toileting and check/change. Minimize skin exposure to moisture. Review of the resident's Braden Scale (assessment tool to identify a resident's risk of developing pressure ulcers), dated 7/6/22, showed the resident was at moderate risk for pressure ulcer development. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff), dated 7/6/22 showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was moderately impaired; -Rejection of care did not occur; -Required extensive assistance of two or more staff for bed mobility, transfers, toilet use, and hygiene; -Occasionally incontinent of bowel and bladder; -Weight of 95 pounds; -At risk for pressure ulcer development; -No unhealed pressure ulcers; -Pressure reducing device for the bed and chair; -Turning and repositioning program; -Applications of ointments/medications (to areas other than feet). Review of the resident's nurse's note, dated 7/12/22 at 1:52 P.M. showed a superficial, nickel sized, open area was noted to the resident's coccyx (a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum). The hospice nurse was notified and barrier cream was applied. Review of the resident's care plan, updated 7/12/22, showed a superficial, nickel size, open area was noted to the resident's coccyx. The hospice nurse was notified. Barrier cream was applied. New orders received for treatment. Lay the resident in bed between meals, as he/she would allow, to aide with pressure relief measures. The resident frequently refused to lay down or allow staff to toilet him/her due to confusion. Review of the resident's Treatment Administration Record (TAR), Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review showed no documentation of skin assessments or wound measurements for the resident's Stage II pressure ulcer from 7/13/22 to 7/18/22. Review of the resident's nurse's note, dated 7/18/22 at 1:48 P.M. showed a new order was received to treat the resident's coccyx with [MEDICATION(S)] ( a topical preparation used to protect skin from wetness, urine, or stool. It is used to treat minor cuts, scrapes, or [CONDITION(S)]. Do not use on open or deep wounds) and foam dressing, change daily and as needed. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Calmospetine ointment apply topically as needed to rash (order date 3/30/22); -Treat Stage II pressure ulcer to coccyx with calmospetine with foam dressing. Change daily and as needed for soiled, loose dressing (order date 7/18/22). Record review showed no documentation of skin assessments or wound measurements for the resident's pressure ulcer on the coccyx from 7/18/22 to 8/4/22. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review showed no documentation of skin assessments or wound measurements for the resident's pressure ulcer on the coccyx from 8/4/22 to 8/8/22. Review of the resident's TAR for August 2022 showed on 8/8/22 at 2:14 A.M. staff applied [MEDICATION(S)] topical ointment to (rash). PRN reason: pressure ulcer to coccyx. Record review showed no documentation of skin assessments or wound measurements for the resident's pressure ulcer on the coccyx from 8/8/22 to 8/11/22. Review of the resident's nurse's note, written by the DON and dated 8/11/22 at 10:41 A.M. showed the resident was assisted to the bathroom. The resident's bottom/coccyx area reddened with complaints of pain. The area was cleansed and covered with a thick layer of protective ointment. The resident was incontinent of bowel and bladder at times and often refused to get clothing changed when offered. Discussed the risk of further breakdown, understanding voiced. Skin redness reported to the hospice nurse, who replied to continue using protective ointment and encouraging the resident to lay down when willing. Further review of the resident's TAR for August 2022 showed the following: -On 8/12/22 at 1:19 A.M. staff applied [MEDICATION(S)] topical ointment to (rash). PRN reason: pressure ulcer to coccyx and skin breakdown to buttocks; -On 8/16/22 at 3:53 A.M. staff applied [MEDICATION(S)] topical ointment to (rash). PRN reason: pressure ulcer to coccyx. Record review showed no documentation of skin assessments or wound measurements for the resident's pressure ulcer on the coccyx from 8/12/22 to 8/18/22. During an interview on 8/18/22 at 3:20 P.M. the resident said he/she had a wound on his/her bottom. No one had put anything on the wound today or yesterday and the area was uncomfortable. Observation on 8/18/22 at 3:30 P.M. showed the following: -Licensed Practical Nurse (LPN) A and LPN B assisted the resident to the bathroom in his/her wheelchair; -LPN A and LPN B assisted the resident to transfer to the toilet with a gait belt; -LPN B lowered the resident's pants and incontinent brief; -The resident's brief was wet with urine and smeared with bowel movement; -There was a large foam dressing in place to the resident's coccyx. The dressing was undated and soiled and what appeared to be dried bowel movement on the bottom of the dressing; -LPN B assisted the resident to sit on the toilet; -The resident was unable to urinate; -LPN A and LPN B assisted the resident to stand and LPN A removed the foam dressing from the resident's coccyx; -There was a quarter sized open area with yellow slough (yellow/white material in the wound bed; it is usually wet, but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound exudate) on the resident's coccyx. There was a second open area under the coccyx wound that was approximately 3.0 centimeters (cm) long by approximately 0.5 cm in width with shallow depth. This wound had a pink/red wound bed with clear drainage; -There was no [MEDICATION(S)] (which is peach/pink in color) present on the resident's wounds or surrounding skin; -LPN A cleansed the resident's buttocks with disposable wipes; -LPN A and LPN B assisted the resident to back onto the toilet; -LPN A left the bathroom to check the resident's orders; -LPN A returned a few minutes later with barrier cream and a foam dressing; -LPN A applied barrier cream and a foam dressing to the resident's wounds. During an interview on 8/18/22 at 2:30 P.M. Certified Nurse Aide (CNA) C said Resident #1 was alert and was able to voice what he/she needed. Resident #1 required assistance with toileting and transfers, was incontinent of bowel and bladder at times, and wore incontinent briefs. Resident #1 could tell staff when he/she needed to use the bathroom. Resident #1 was generally agreeable and would not refuse care. CNA C was not aware of the resident having any wounds. CNA C thought the resident's bottom was red and the nurses applied a cream for this. During an interview on 8/18/22 at 3:40 P.M. LPN A said the resident's order for the foam dressing was discontinued on 8/4/22. LPN A said the resident had a quarter sized open area to his/her coccyx with yellow slough and a second open area, under the first open area with clear drainage. The foam dressing LPN A removed from the resident's coccyx was not dated and was soiled. The resident did not have any calmospetine on his/her coccyx/buttocks. The resident was currently out of [MEDICATION(S)] and that's why LPN A applied the clear house barrier cream. LPN A would re-order the resident's calmospetine and inform hospice of the wounds. During an interview on 8/18/22 at 3:55 P.M. the resident's hospice Registered Nurse (RN) said Resident #1 did have a Stage II pressure ulcer on his/her coccyx. The resident's wound treatment order was for [MEDICATION(S)] and a foam dressing daily and as needed. The hospice RN did not assess the wound with each visit unless the resident was in bed or requested to be toileted. The last couple of times the hospice RN saw the resident's wound he/she left off the foam dressing because the skin surrounding the wound was becoming macerated (soften or become softened by soaking in a liquid). The hospice RN first measured the resident's coccyx wound on 8/3/22 and it measured 0.5 cm by 0.5 cm with superficial depth and no drainage. The hospice RN next measured the wound on 8/15/22 and it measured 2.2 cm by 3.0 cm with superficial depth. The wound had some slight drainage. The hospice RN had not noted any yellow slough in the wound. During an interview on 8/18/22 at 2:20 P.M. and 3:00 P.M., and 8/25/22 at 10:56 A.M., the DON said the facility's wound nurse quit at the end of March 2022. The DON had been trying to keep up with the wounds since the wound nurse quit. Resident #1 had a reddened area on his/her bottom. Skin issues were identified generally during residents' showers. Previously the wound nurse completed weekly skin assessments. Residents' skin was now assessed during showers. The CNA's would let the nurse know immediately when there were any concerns with a resident's skin. Resident #1's coccyx wound was no longer open. The DON had last seen the resident's coccyx on 8/11/22 when the DON assisted the resident to lay down. The licensed nurses did not complete weekly skin assessments for the residents. The DON did not have measurements of Resident #1's wound. Wound measurements were usually obtained by the nurse practitioner. The DON expected both the hospice staff and facility staff to bring any skin issues or wounds to the charge nurse's attention as soon as they were identified during routine care so the charge nurse could obtain treatment orders. The DON expected the facility licensed nursing staff to obtain measurements and document an assessment of any wound at least weekly and would expect staff to follow the facility's policy on skin and wound care. Review of an email sent by the facility administrator on 8/19/22 at 1:35 P.M. showed the facility did not have any documented shower sheets for Resident #1 because the hospice group was responsible to completing the resident's showers. During an interview on 8/19/22 at 1:42 P.M. the hospice director said the resident's physician would have expected the facility staff to notify hospice staff of the resident's wounds so hospice staff could notify the physician and obtain treatment orders. The hospice staff did not assess wounds with each visit. It would depend on what the resident was doing at the time of the hospice visit whether the hospice nurse would be able to visualize the wound. The facility staff should notify the hospice staff with any changes in a resident's wound or skin and the hospice staff would then contact the physician for treatment orders. The facility staff was responsible for the wound assessments and completing treatments in between hospice visits or when the hospice nurse was not able to complete the treatment during his/her visit. During an interview on 8/25/22 at 10:49 A.M., the administrator said he expected facility staff to follow the facility protocol for skin and wound care. Facility staff should be inspecting residents' skin routinely, at least weekly, with any abnormalities reported to the charge nurse who would notify the physician and obtain treatment orders. Hospice staff should also report any skin issues or concerns to the facility charge nurse. The facility staff should follow the facility policy for wound care for any existing wound. During an interview on 8/26/22 at 9:03 P.M., the resident's physician said he would expect the facility staff to inform the hospice staff of any skin concerns or wounds identified and the hospice staff would contact him to obtain treatment orders. The resident's physician would expect the facility staff to follow the facility's policies and protocols related to skin inspections and wound care, assessment, and treatment. MO 2

Based on interview and record review, the facility failed to provide adequate supervision while providing care to one dependent resident (Resident #1), of seven sampled residents to prevent accidents. The facility assessed the resident required extensive assistance of two staff for bed mobility and hygiene. The facility planned care for staff to utilize one to two staff for repositioning, but also reported the assistance required was dependent on the resident at any point in time as the resident's abilities varied. During the night shift one staff provided perineal care and change of pads and linens with the resident positioned to his/her side on the edge of the bed with the bed in an elevated position. Another staff member witnessed the unsafe situation, but did not intervene to assist. The resident fell to the floor and sustained a head injury. The resident expired as a result of the injury. The census was 57. The administrator was notified on [DATE] at 4:17 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. 1. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Brief Interview for Mental Status (BIMS) of 12, indicating mild cognitive impairment; -Required two person assistance for bed mobility; -Total dependence on two staff for assistance with transfer; -Unable to walk; -Required extensive assistance of two or more staff for personal hygiene; -Always incontinent of bladder and frequently incontinent of bowel; -Impairment in range of motion of a lower extremity; -Height 66 inches, weight 179 pounds. Review of the resident's care plan, last updated [DATE], showed the following: -Resident has a self care deficit due to a fractured bilateral lower extremity requiring surgery; -Required assistance of two staff and a mechanical lift for all transfers; -At risk for falls due to a history of falls and limited mobility; -Required assist of two with a mechanical lift for toileting; -Provide assistance of one to two staff to turn and reposition at least every two hours; -Wears briefs at all times due to incontinence; -Update [DATE] due to Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister), left heel pressure ulcer; -Keep peri area clean and dry with incontinence. Peri care every two hours during turn and reposition; -The resident was at risk for bleeding due to daily long-term use of anticoagulant medication (blood thinning medication) and bruises easily; -Directed staff to be careful during transfers and not to injure the resident. Review of the resident's electronic medical record (EMR), undated, showed the resident with [DIAGNOSES REDACTED]. to perform everyday activities), lack of coordination and long-term use of anticoagulants. Review of the resident's current physician orders, dated [DATE]-[DATE], showed the resident required a mechanical lift for transfers, was non-weight bearing to the right ankle and should be turned and repositioned every two hours. The resident was on blood thinning medication including [MEDICATION NAME] (anticoagulant) 4.5 milligrams (mg) on Monday through Saturday, and [MEDICATION NAME] 3 mg on Sunday. Review of the resident's Point of Care notes, dated [DATE], showed the following: -On [DATE] at 4:23 [NAME]M., bed mobility required limited assistance of two or more staff; -On [DATE] at 4:24 [NAME]M., transfer did not occur; -On [DATE] at 4:24 [NAME]M., total care to toilet with two or more staff; -No other activities documented for the third shift on [DATE]. Review of the resident's Nursing Progress Notes showed the following: -Entry, dated [DATE] at 6:32:52 (6:32 [NAME]M.), by Licensed Practical Nurse (LPN) A and entire entry lined through; -Entry read resident noted to be laying on floor next to bed, full head to toe assessment completed. Resident noted to have an extra large egg size hematoma (a collection of blood outside of blood vessels. Most commonly, hematomas are caused by an injury to the wall of a blood vessel, prompting blood to seep out of the blood vessel into the surrounding tissues) on the right side, back of head. Resident complaint of head and neck pain, eight to nine on a scale of ten. Received order to send to the emergency room for evaluation and treatment. 911 called. Ambulance arrived and resident enroute at 2:40 [NAME]M.; -An additional entry entered [DATE] at 11:24:29 P.M. by LPN A with the same information as noted on the [DATE] note, but with information the resident was enroute with the ambulance at 5:40 [NAME]M. (rather than 2:40 [NAME]M. as documented in the prior [DATE] note). Review of the resident's Ambulance Service Record, dated [DATE], showed the following: -Call received at 5:34:38 [NAME]M. and on scene at 5:41:43 [NAME]M.; -Dispatched to the facility, staff state resident rolled out of bed, landing on the floor on his/her right side; -Resident has a large hematoma, just superior to the temporal (near the temple, side of the head) region on the right side; -Resident complains of pain to the right side of his/her head, upper and middle back. Review of the resident's Emergency Department Aware Note, dated [DATE], showed chief complaint of fall with presenting symptoms of hematoma to the right head and pain to the mid back and head area with sudden onset. Review of the resident's Radiology report, dated [DATE], showed the following: -8:02 [NAME]M., CT of the brain (a noninvasive diagnostic imaging procedure that uses special X-rays measurements to produce horizontal, or axial, images (often called slices) of the brain), showed significant extra-axial hemorrhage (bleed) along the right cerebral hemisphere (the brain is formed by two cerebral hemispheres that are separated by a groove, the longitudinal fissure), with a lenticular (lentil shaped) shape at the apex (top or point), which is concerning for subdural hematoma (collection of blood outside of the brain), with an [MEDICATION NAME] component (collection of blood between the skull and covering of the brain). There is significant mass effect (Mass effect is a phenomenon in which a focal lesion or contusion causes surrounding areas of brain tissue or brain structures to be compressed and injured due to the degree of space that is leaking blood, which takes up within the restricted skull space) on the right cerebral hemisphere with a right to left midline shift measuring 1.2 centimeters. Review of the resident's hospital Progress Note, dated [DATE], showed the following: -Resident was on [MEDICATION NAME] for [MEDICAL CONDITION] for some time. Resident was reportedly initially alert and appropriate, but rapidly became less responsive after arrival to the emergency department; -Resident's CT scan showed a large right sided holohemispheric acute subdural hematoma (brain bleed), as well as a thin left holohemispheric subdural hematoma. There was a significant right to left shift of midline structures with evident consistent with herniation (brain herniation is a potentially deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull); -The resident would have virtually no chance for meaningful recovery and very little chance for survival at his/her age with his/her associated comorbidities (simultaneous presence of two chronic diseases). Review of the resident's Emergency Department Aware Note, dated [DATE], showed the following: -At 8:15 [NAME]M., resident with snoring respirations, pupil fixed and dilated on the right, no response to verbal or painful stimuli; -At 8:39 [NAME]M., resident's family would like the resident placed on comfort care measures only; -At 11:05 [NAME]M., resident is pulseless and has no spontaneous respirations. Review of the facility's Fall Investigation, dated [DATE], showed the following: -Date of fall [DATE]; -Fall occurred in room, resident rolled out of bed; -Assisted per care plan; -Anticoagulant given in the last eight hours. Review of a facility acquired written statement, undated, showed Certified Nurse Aide (CNA) A wrote the following: -5:40 [NAME]M.; -We were changing the resident's bed because it was wet; -The resident was rolled on his/her left side while he/she was cleaned; -CNA B was picking up the clothes from the ground and took them to the dirty clothes; -The resident rolled right off the side of the bed and hit the floor. Review of a facility acquired written statement, dated [DATE], showed CNA B wrote the following: -He/She was in another room, finished and went to Resident #1's room; -He/She picked a pad and brief up off of the resident's floor and put them in the trash; -He/She went back into Resident #1's room and the resident was on the floor. During interview on [DATE] at 11:50 [NAME]M., CNA B said the following: -On [DATE] at about 5:00 [NAME]M., a call light came on in the hall (same hall Resident #1 resided on); -This resident only needed one staff member for assistance, so he/she told CNA A to wait a bit before going on (down the hall to care for residents); -CNA B figured CNA A would wait for him/her to finish. He/She took the resident who needed assistance to the toilet and put him/her back to bed; -He/She came out of this resident's room and went to Resident #1's room as it was close; -As he/she went into Resident #1's room, the door was wide open and no curtain pulled; -There was a pad and brief on the floor soiled with feces, (CNA A had performed peri care and was changing the resident); -Resident #1's bed was next to the room door and he/she saw the resident in bed rolled over on his/her side toward the window; -It looked like the resident was on the edge of the bed, CNA A was on the opposite side of the bed (side closest to the room door) changing a sheet, the sheet was half on and half off the bed, the resident's arms were at his/her side; -CNA A held the resident over on his/her side with CNA A's left arm on the resident's shoulder/mid back area; -The resident could not roll side to side and required assistance of two staff; -The resident had a half bed rail located on the side of the bed away from the front of the resident and not in the resident's reach; -The bed was elevated about waist level, usually the bed was lowered; -The resident was pretty heavy, when rolled over toward his/her bed rail he/she would hold onto the rail, staff would have to move the resident's legs; -He/She picked the dirty linens up off the floor, left the room, and put them in the hamper in the hall; -He/She heard a noise, Ahh!; -Before he/she closed the lid on the hamper the resident was on the floor; -CNA A was still on the opposite side of the bed; -He/She went to get the nurse and returned to the room; -The resident was on the floor on his/her back; -There were no covers around the resident and no furniture located on the side of the bed where the resident rolled out; -The resident was alert and said, Am I dead?; -The resident said his/her head hurt, the resident had an egg size bump on the right side of his/her head; -The floor was hard and had no carpet; -He/She and CNA A did not move the resident and the ambulance arrived; -He/She gave CNA A a ride home and CNA A did not say why he/she provided care by his/herself; -CNA B said he/she did not tell CNA A to put the resident on his/her back when he/she saw the resident rolled to the side of the bed. He/She wished he/she had walked to the other side of the bed and ignored the dirty pad on the floor; -CNA B had seen CNA A check and change all of the residents on the hall by him/herself (hall where Resident #1 resided); -This hall had five to six residents who required two staff assistance; -CNA B had voiced his/her opinion about this to other CNA's, but could not recall if he/she had reported to a nurse. -Resident #1 required two staff assistance with bed mobility and personal hygiene. During interview on [DATE] at 2:10 P.M., LPN B said the following: -He/She worked the night of the resident's fall and was the charge nurse on a different hall; -CNA B came up the resident's hall to the geri center (a common area with seating) where LPN B was located and said a resident was on the floor; -Both he/she and LPN A responded; -Resident #1 was on the floor in his/her room on his/her back and said his/her neck and head hurt; -He/She called the physician; -The resident was alert at the time the ambulance arrived; -He/She had CNA A and CNA B write statements; -CNA A would not say much; -CNA B said he/she was in another resident's room helping the resident to the bathroom. When finished he/she went to Resident #1's room, gathered linens and took them to a hamper; -LPN B understood CNA A was in the resident's room by him/herself with the resident; -Prior to the resident's fall no staff had come to him/her with concerns about CNA A; -After the resident's fall he/she was told Resident #5 reported CNA A completed resident care for residents (needing two staff assist), by him/herself all the time. During interview on [DATE] at 10:50 [NAME]M., LPN A said the following: -He/She was the charge nurse on Resident #1's hall at the time of the resident's fall; -The resident required assistance to turn and could not turn to his/her side by him/herself; -He/She had finished passing medications at about 4:,[DATE]:00 [NAME]M. and was at the nurse's desk and geri center with LPN B; -CNA B came to them and said the resident was on the floor; -LPN A responded and found the resident in his/her room on his/her back on the floor between the resident's and his/her roommate's bed; -CNA A was in the room and he/she asked CNA A what happened. CNA A said he/she had turned the resident and the resident fell out of the bed; -The resident complained of head and neck pain, the resident had a hematoma located on the right side of his/her head behind the ear; -The resident described his/her pain as an eight to nine on a scale of ten being the worst pain; -He/She notified the physician and family and called 911; -The resident was sent to the hospital via ambulance. During interview on [DATE] at 9:25 [NAME]M., the resident's physician said the following: -The facility called and notified him the resident had fallen, was screaming in pain and needed to be sent out; -The hospitalist (physician) called him and shared the resident's condition; -The resident could not purposefully move him/herself; -The resident had complex medical problems and took blood thinning medication; -A fall from bed with head trauma would result in a bleed. During interview on [DATE] at 11:00 [NAME]M. the MDS coordinator said the following: -The resident had a grab bar on one side of the bed and could use the bar at times; -With the grab bar, one staff might be able to perform turning and repositioning of the resident; -In regards to the MDS assessment showing the resident required two staff assistance for bed mobility and hygiene, and the care plan noting one to two staff to perform these activities, he/she said the resident's abilities depended on his/her status at the time. The resident's status varied throughout the day and might even depend on the resident's mood or on the resident's quality of sleep; -With peri care and check and change activities, the resident was dependent on two staff. During interviews on [DATE] at 1:23 P.M., [DATE] at 1:25 P.M. and [DATE] at 11:15 [NAME]M., the Director of Nurses (DON) said the following: -She understood, in regards to the resident's fall, that the two aides were both in the room providing care, one staff left the room with linens, staff had positioned the resident on his/her side, and the aide left in the room could not catch the resident; -The fall occurred because the second aide left the room; -The resident could move his/her arms, but could not roll independently; -The resident's needed level of assistance depended upon the resident's status at the time. During interviews on [DATE] at 2:50 P.M., [DATE] at 3:30 P.M., and [DATE] at 10:45 [NAME]M., the facility administrator said the following: -Staff reported to him on [DATE] a CNA had been providing care to the resident and a second aide left the room to put linens in a hamper. When the second aide returned to the room the resident was on the floor. The resident sustained [REDACTED]. -He viewed the video from that hall and saw the two aides doing rounds, one aide went into the resident's room, a second aide went in and came out of the room with linens and put them in the linen basket; -The resident fell to the floor next to his/her bed on his/her back, the bed had been raised for care; -He talked with CNA A that evening, the day of the incident, and CNA A would not say where he/she was positioned relative to the resident at the time of the fall; -He knew the second CNA was not in the room at the time of the fall and assumed the aides had positioned the resident on his/her side and not on his/her back when the resident fell ; -Through his investigation he concluded that both CNA's were in the room with the resident when care was initiated and were providing care with one staff as clean and one staff as dirty as with residents who are dependent on staff for care; -He felt the root cause of the fall was the second CNA left the room; -If staff rolled a resident onto their side and one staff left the room, staff should not continue to provide care. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level [NAME] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 6

Based on observation, interview and record review, the facility failed to provide adequate monitoring and failed to evaluate the effectiveness of current fall interventions or modify the interventions as necessary to prevent further falls for one resident (Resident #1) in a review of five sampled residents. The resident fell fifteen times from 7/10/18-9/9/18, sustaining a nasal fracture, hemorrhagic contusion (bruise to the brain tissue) and a nondisplaced distal femur fracture (fracture to thigh bone that occurs just above the knee joint). The facility census was 53. 1. Record review of the facility's fall assessment policy dated 2/24/18 showed the following: -Purpose: To provide care by assessment, documentation and to provide intervention to ensure the safety of the resident who has sustained a fall; -Fall Definition: A fall is described as a drop down from a higher place, or position; -Procedure: Charge nurse immediately assess the resident; -The charge nurse will complete an incident/accident report and a post fall assessment form; -The physician and responsible party will be notified of the fall; -The Director of Nursing (DON) will be notified of all falls and the administrator will be notified if the resident sustains injury; -The charge nurse will document the circumstances of the fall in the resident's medical record; -The facility will implement fall precautions such as low beds, mats on the floor, skid free socks, toileting schedule or positioning; -The facility will note the fall and resident's status in the communication book; -The DON will ensure the minimum data set (MDS) a federally mandated assessment tool required to be filled out by facility staff, coordinator is aware so as to make adjustments to the care plan; -The MDS coordinator will update the care plan. 2. Record review of Resident #1's care plan dated 5/25/18 showed the following: -Problem: The resident had chronic cognitive deficit secondary to dementia; -Short term memory loss and impaired safety awareness; -High risk for falls; -Multiple falls due to confusion and attempting to ambulate by self; -Approaches: Call the resident by name and explain all tasks prior to beginning; -Keep a calendar in the resident's room to aid with orientation to day; -Monitor for changes in cognitive function, assess and notify the physician as needed; -Provide limited assist of one staff with grooming, toileting, clothing management and peri care every shift; -Provide assist of one staff with bathing per bathing schedule; -Provide skilled occupational and physical therapy as needed; -Up with a walker and assist with one staff for all transfers and ambulation and monitor for safety; -Ensure the resident has appropriate footwear for all transfers/ambulation; -Keep call light easily accessible at all times and answer all calls for assistance promptly; -Monitor for complaints of pain and address complaints of pain as they arise; -Monitor for changes in cognitive and functional status every shift and notify the charge nurse; -On 7/5/18, the resident was lowered to the floor by nursing staff while ambulating him/herself; -The resident had attempted to sit on the toilet and fell ; -On 7/10/18, the resident was found sitting on his/her buttocks in the doorway of the bathroom; he/she was attempting to transfer him/herself to the toilet; -On 7/12/18, the resident fell while attempting to ambulate him/herself. Record review of the resident's nurse's note dated 7/30/18 at 11:40 A.M. showed the resident was found on the floor. Record review of the resident's care plan, updated 7/30/18, showed: -The resident was found sitting on the floor; -The resident said he/she hit his/her head; -The resident was sent to the emergency room for evaluation and treatment. Record review of the resident's nurse note dated 8/1/18 at 4:45 A.M. showed: -The resident was found on the floor; -The resident had a 2.5 cm. (centimeter) by 1.0 cm. open area to the back of his/her head; -The resident was sent to the emergency room for treatment and was admitted to the hospital. Review review showed no documentation the resident's care plan was updated to include the 8/1/18 fall or any new fall interventions. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's nurse note dated 8/5/18 at 2:20 A.M. showed the resident was witnessed sliding out of his/her recliner. Record review of the resident's care plan, updated 8/5/18, showed the resident slid out of his /her chair and landed on his/her buttocks while attempting to get up without assistance. Record review of the resident's care plan, updated 8/13/18, showed: -The resident gets up on his/her own often but was unsteady and high risk for falls; -Interventions: Wear shoes at all times when out of bed; -The staff should provide limited assistance of one staff for ambulation with a walker; -The staff should attempt redirection when the resident is wandering and provide the assistance of one staff. Record review of the resident 's 14 day MDS dated [DATE] showed the following: -The resident was severely cognitively impaired; -The resident required extensive assistance of two staff for transfers, ambulation, dressing, and toileting; -The resident was frequently incontinent of bowel and bladder. Record review of the resident's nurse's note dated 8/18/18 at 5:55 A.M. showed: -The staff was called to the resident 's room by the resident's roommate: -The resident was found sitting on his/her buttocks beside the bed, in front of the recliner. Review review showed no documentation the resident's care plan was updated to include the 8/18/18 fall or any new fall interventions. Record review of the resident's nurse's note dated 8/23/18 at 11:30 A.M. showed the following: -The resident was found sitting on his/her buttocks in front of the recliner; -The resident was noted to have two small skin tears to his/her left elbow. Record review of the resident's care plan, updated 8/24/18, showed the resident's mattress was placed on the floor for safety due to frequent falls. Record review of the resident's nurse's note dated 8/27/18 at 2:30 A.M. showed the following: -The resident was found by the physical therapist standing up in his/her room; -The resident was trying to go to the bathroom; -The resident was very wobbly and unsteady. Record review of the resident's nurse note dated 8/28/18 at 6:30 A.M. showed the following: -The resident was found on the floor beside his/her recliner; -The resident sustained [REDACTED]. Record review of the resident's nurse note dated 8/28/18 at 2:44 P.M. showed: -The resident was noted to be up one time by his/herself; -The staff continue to encourage the resident to use the call light. Record review of the resident's nurse's note dated 8/28/18 at 11:21 P.M. showed the following: -The resident was found on the floor in his/her doorway; -The resident had bruising and a 4.0 cm by 1.5 cm. skin tear to his/her right knee. Review review showed no documentation the resident's care plan was updated to include the 8/28/18 falls or any new fall interventions. Record review of the resident's nurse note dated 8/31/18 showed : -The resident scooted himself/herself to the mattress on the floor by the bed; -The resident is given the call light each time the staff leaves the room, but the resident does not use the call light. Review review showed no documentation the resident's care plan was updated to include the 8/31/18 fall or any new fall interventions. Record review of the resident's nurse's note, dated 9/4/18 at 5:44 P.M., showed staff found the resident sitting on his/her buttocks on the floor in the bathroom. Review review showed no documentation the resident's care plan was updated to include the 9/4/18 fall or any new fall interventions. Record review of the resident's nurse's note, dated 9/5/18 at 10:26 P.M., showed at 4:30 P.M., staff found the resident sitting in an upright position on the mattress (on the floor) in front of his/her recliner. Review showed no documentation the resident's care plan was updated to include the 9/5/18 fall or any new fall interventions. Record review of the resident's nurse's note, dated 9/9/18 at 3:25 P.M., showed: -The resident was very restless and attempting to get up from his/her recliner without assist multiple times; -The nurse witnessed the resident sliding from the chair to the floor. Review review showed no documentation the resident's care plan was updated to include the 9/9/18 fall or any new fall interventions. Record review of the resident's nurse's note, dated 9/9/18 at 9:22 P.M., showed: -At approximately 8:30 P.M., staff left the resident's room; -At 9:15 P.M., staff found the resident on the floor beside the mattress (located on the floor next to his/her bed), laying on his/her right side with a puddle of blood surrounding his/her head; -On assessment his/her nose appeared to be broken and there was deep blue bruising to his/her right eye; -Staff called the paramedics and once the resident was moved he/she said his/her hip and back hurt. Record review of the resident's hospital emergency room records, dated 9/9/18 at 10:00 P.M., showed the following: -Chief Complaint Details: The resident was found on the floor; -The nursing facility was concerned the resident broke his/her nose; -The resident was in the emergency department several days ago for a similar episode; -General: There was a 1 cm (centimeter) vertically oriented laceration (a deep cut or tear) over the nasal bridge (upper bony part of the nose) with palpable (able to be felt) nasal bone tenderness; -Significant ecchymosis (bruising) adjacent to his/her right zygomatic process (projection of the temporal bone), 0.5 cm laceration inside of his/her upper lip as well as the inside of his/her lower lip; -Healing abrasion over the left knee associated with bruising; -Treatment Plan/Medical Decision Making: The resident presented with an unwitnessed fall and the resident had multiple falls recently; -There was a concern for nasal bone fracture as well as potential zygomatic (cheekbone) complex fracture; -The resident had a intraoral (within the mouth) and a nasal laceration that required repair which was performed with 5-0 [MEDICATION NAME] gut suture (a type of surgical suture); -The resident will be transferred to another hospital due to the resident requiring trauma care. Record review of the resident's emergency department nurse assessment, dated 9/9/18 at 11:36 P.M., showed: -Complaint: The resident presented to emergency department after an unwitnessed fall in his/her room; -The resident has dementia/Alzheimer's and does not communicate well verbally and this was his/her normal mental status; -The resident presented with a laceration to top and bottom lip and nose; -There was a large bruise on right side of face surrounding the right eye; -Presenting symptoms: Bleeding, bruising, confusion, discoloration, laceration, musculoskeletal pain and redness; -The resident's pain scale was 10 of 10 (pain scale 0-10 with 10 being the worst pain). Record review of the resident's hospital progress note, dated 9/9/18 at 11:38 P.M., showed: -The resident had evidence of a right subdural hematoma (a pool of blood between the brain and its outermost covering) and subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); -The resident was being transferred to another hospital as a trauma case; -Fall risk high. Record review of resident's CT (computed tomography scan, makes use of computer-processed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas of a scanned object, allowing the user to see inside the object without cutting) of facial bone without contrast (a special dye), dated 9/10/18 at 7:35 A.M., showed the following: -History: Right facial pain after fall to nursing home with laceration to the face and nose; -Findings: Facial bones: There was bilateral comminuted (into small fragments) and angulated fractures (type of fracture displacement where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction) of the nasal bone with displacement to the right and associated air in the overlying soft tissues consistent with laceration; Impression: Nasal fracture. Record review of the resident's CT of head without contrast, dated 9/10/18 at 7:45 A.M., showed: -History: status [REDACTED]. -Impression: Probable hemorrhagic contusion (a bruise to the brain tissue) in the right frontal lobe (located near the forehead) versus less likely, subarachnoid hemorrhage. Record review of the resident's X-ray (imaging test) knee three views, dated 9/10/18 at 7:59 A.M. showed: -History: Left knee pain and bruising from fall; -Impression: Suspected nondisplaced distal femur fracture ([MEDICAL CONDITION] that occur just above the knee joint); -Soft tissue swelling. During interview on 9/7/18 at 1:45 P.M. Certified Nurse Assistant (CNA) C and CNA D said the following: -The resident was sitting in her recliner today and within 1/2 hour the housekeeper found the resident sitting in a folding chair in the room; -The resident has fallen because there was not enough staff to sit 1:1 with the resident; -The facility tries to put wedges beside the resident in bed but he/she crawled over them. During interview on 9/7/18 at 11:00 A.M. Licensed Practical Nurse (LPN) B said the following: -The facility asked the resident's family to sit with him/her due to the resident being confused, getting up alone and falling: -The staff put a mat by the resident's bed and did frequent visual checks but this didn't work. During interview on 9/25/18 at 10:12 A.M. LPN E said the following: -When a resident falls the incident report comes to LPN E; -The DON chooses an intervention; -If a resident had frequent falls a meeting would be held to choose an intervention; -The resident was lowered to the floor on 7/5/18, there was no new intervention; -The resident fell on [DATE] and the family was asked to sit with the resident; -The resident slid off the recliner on 8/5/18 and there was no new intervention; -The resident slid out of the recliner on 8/23/18 and there was no new intervention; -The only intervention that was effective was 1:1, the facility was not staffed for 1:1. During interview on 9/25/18 at 4:00 P.M. LPN A said the resident required 1:1 monitoring and the facility couldn't do this. During interview on 9/25/18 at 9:00 A.M. the DON said the following: -Resident families are told at admission that the facility does not provide 1:1 monitoring; -The resident had severe dementia; -The family was asked to come in and sit with the resident 1:1, sometimes they would come in and sometimes they would not; -The resident needed 1:1 (monitoring) non-stop. During interview on 10/2/18 at 8:00 A.M. the DON said the following: -When a resident falls the DON expects the resident's care plan to be updated with an intervention; -There was staff assigned to sit with the resident 1:1 but not for an entire shift. During interview on 9/24/18 at 10:55 A.M. and 5:47 P.M., the administrator said: -The resident attempted to get out of bed and go to the bathroom and would fall; -The initial preventative action was a fall mat and bed lowered; -The resident became more confused; -They placed a mattress on the floor and the resident wasn't able to get up so they stopped using the mattress; -The facility attempted 1:1 supervision but didn't offer this as a long term solution; -The resident's most recent fall was 9/9/18 and the resident was sent to the emergency room ; -The resident sustained [REDACTED]. -The resident had a subdural hematoma and broken nose; -Prior to the fall he/she asked a CNA to sit with the resident until he/she fell asleep due to the resident's increased agitation; -The resident fell asleep and the CNA left the room and turned off the lights; -Approximately one hour after the CNA left the room staff found the resident on the floor. MO 6, MO 9, MO 0, MO , MO 3, MO 7, MO 1

Based on observation, interview and record review, the facility failed to plan and provide adequate supervison, and assistance to prevent falls with and without injuries for two (Resident #6 and #13) of 15 sampled residents. The facility census was 59. 1. Review of Resident #6's fall risk assessment dated [DATE] showed the facility assessed the resident with a score of eight indicating the resident at low fall risk. There were no further updates to the assessment. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 1/24/12, showed the resident had one fall since admission to the facility. His/her BIMS (brief interview for mental status),score was 13 indicating that his/her mental status was good. He/she did not need assistance with most activities of daily living including ambulation. His/her balance was described as stable. Staff assessed the resident with full range of motion for upper and lower body. Review of the resident's nurses notes dated 2/12/12 (untimed), showed staff noted the resident found sitting on the floor. Resident reported missing his/her chair. Assessment showed no injury. Review of his/her care plan updated on 2/12/12, showed the approach for ambulation was a wheeled walker with a assistance of one certified nursing assistant. The care plan noted the fall of 2/12/12 with no changes to the plan. Review of the physician orders [REDACTED]. During the initial tour of the facility on 3/12/12 at 10:17 A.M., the Director of Nursing (DON), said the resident fell in his/her room shortly after midnight (on 3/12/12). She said that the resident was an independent person and fell while trying to go to the bathroom rather than waiting for staff assistance. Review of the resident's nurses notes dated 3/12/12 at 12:10 A.M., showed the following: -The resident was found on the floor in his/her room with lacerations to the left side of his/her forehead. He/she was evaluated by Licensed Practical Nurse (LPN) L. The on call physician was notified and the resident was transported to the hospital for evaluation and treatment. The resident had computer aided tomography (CT) and sutures to the lacerations on his/her forehead. Acetaminophen was given to the resident. He/she returned to the facility at 5:50 A.M. with his/her family member; -At 11:00 A.M. staff noted large dark purple bruise to the left elbow and an abrasion to the left knee. Observation of the resident on 3/12/12 at 3:07 P.M. and 4:20 P.M. showed the following: -On 3/12/12 at 3:07 P.M. the resident in his/her room with a bandage on his/her forehead with his/her family member who said the resident does not respond positively to suggestions from family or others. The family member noted that the resident was reluctant to accept help. This was an old problem in caring for the resident, (review of the care plan showed no notation regarding resident's reluctance to ask for assistance); -On 3/12/12 at 4:20 P.M. resident noted ambulating unassisted with his/her walker. The resident's arms and legs were visibly tremulous. His/her movements with the walker were slow and shaky. The resident continued to ambulate to the dining room without assistance. After eating the resident left the dining room and walked back to his/her room using the walker. His/Her arms and legs remained visibly tremulous. His/her movements with the walker were slow and shaky. Review of the resident's nurses notes dated 3/13/12 showed the following: -At 9:00 A.M. staff noted after ambulating to the PT (physical therapy) room (therapy services are located on the end of the 300 hall, approximately twice the distance of resident's walk to the dining room), and exercising with the restorative program, the resident ambulated back to his/her room. The resident sat on the floor at the doorway to his/her room and stated, "I just couldn't make it." Staff noted no new injuries. -At 11:00 A.M. the DON reviewed the resident's need to use the call light when wanting to get up to ambulate and toilet Direct care staff to use a gait belt to assist the resident with ambulation. -On 3/13/12 at 1:00 P.M. Certified Nurse Aide (CNA) H walked the resident using a gait belt back to his/her room from the dining room. He/she described the resident's fall on 3/13/12 as a controlled fall where the resident slid to the floor. CNA H noted the resident usually walked around independently using the walker. He/she stated that he/she was helping the resident at the resident's request. He/she said the resident's legs were weaker. Review of resident's resorative therapy notes dated effective 3/14/12 showed restorative services were ended at request of the resident's family, with reason noted the distance for the resident to ambulate to the therapy offices was too great. (Review of the resident's care plan, last updated on 02/12/2012, showed no new interventions to address the resident's fall risk, actual fall with injury or weakness). 2. Review of Resident #13's admission nursing assessment dated [DATE] showed the following: -Pain daily in lower back and hips; -Required assistance of two to transfer; -Full weight bearing; -Used walker for short distances, wheelchair for longer distances; -High risk for falls; -High risk for pressure sores; -Incontinent of bowel and bladder at times. Review of Resident #13's fall risk assessment dated [DATE] identified the resident as being a high risk for falls related to the following: -Falls in past 3 months, -Chair bound; -Required use of assitve devices; -Prescribed medications; -Predicisposing diseases. Review of Resident #13's admission MDS dated [DATE] showed the following: -admitted from acute care hospital; -Highly impaired-absense of useful hearing; -Wears glasses; -Moderately impaired cognitive skills for daily decision making; -Mild Depression; -Assist of one staff with transfers, locomotion off unit, dressing, toilet use and personal hygiene; -Assist of two staff with walking in room and corridor; -No limitations in range of motion; -Mobility devices of walker and wheelchair; -Occasionally incontinent of bowel and bladder; -Constant pain in the past five days; -Falls in past month prior to admission; -No falls since admisstion; -Medications received in the past 7 days included antianxiety, antibiotic and diurietic. Review of Resident #13's physician orders [REDACTED]. -admitted to facility on 2/24/2012; -[DIAGNOSES REDACTED]. -Fall Precaution Orders; 25-OH Vitamin D level after every fall unless level obtained within last 60 days and is on vitamin D supplement or a documented level within past 12 months above 30 mg. (milligrams)/ml. (milliliter). -Out of bed to chair/wheelchair with assist. -Ativan (antianxiety) 0.5 mg., one tablet by mouth at bedtime. -Lasix (diurtetic) 20 mg., take 1/2 tablet by mouth once daily. -Increase Lasix 20 mg. from 1/2 tablet to one tablet once daily and start Ativan 1 mg. one by mouth three times daily. May give additional 1 mg. of Ativan at HS (hour of sleep) or during night as needed for insomnia. Review of Resident #13's physician orders [REDACTED]., one by mouth twice daily. Review of Resident #13's care plan dated 03/06/2012 showed the following: -Cognition: Identified the resident on the medication Ativan (antianxiety). Staff documented this medication could increase drowsiness and/or unsteadyness. Facility staff to monitor for safety. Assist resident to sitting from lying position slowly to avoid light-headedness. -Falls: Goal: no injuries with falls through the next review. Intervenions included: - Answer call light promptly as possible; - Has tried to transfer self. Very independent minded; - Do not leave during care or when in bathroom for safety; - Do not let resident ambulate alone; - Instruct resident to seek assistance with ambulation/transfers; - Keep bed at lowest level at all times; - Keep call light and personal items within reach; - PT/OT as ordered; -Use of diuretic and antianxiety may increase risk of falls. Review of Resident #13's physician orders, dated 03/08/2012 showed orders to decrease Lasix to 20 mg., one by mouth daily. Review of Resident #13's nurnes notes dated 03/14/2012 at 9:20 A.M., showed the resident was found in the bathroom sitting on the floor with his/her back against wall, lateral legs bent. Found sitting across from toilet. Resident stated he/she took him/herself to toilet, became unsteady and fell . Resident was informed that assistance is required. Resident stated "I know". Resident has full range of motion to all extremities. Denies hitting head. Full body assessment performed. Observation on 03/14/2012 at 9:30 A.M., showed Resident #13 in his/her wheelchair close to the nurses station. PTA (Physical Therapy Aide) F asked the resident how he/she was. The resident replied that he/she was not very good because he/she had just fallen when he/she was going to the bathroom. The resident told PTA F that it takes "forever" for anyone to come and help him/her. During interview on 03/15/2012 at 8:55 A.M., the DON (Director of Nursing) said the facility tries to ensure that the environment is safe to prevent residents from falling. 3. Review of the resident council monthly meeting minutes dated 03/05/2012 under the section of "old business", showed residents reported to staff that they felt the assistance was getting better, but sometimes had to wait awhile to get help. 4. Review of the facility's fall assessment policy, dated 08/31/09, showed the facility would prevent falls by the following: -Assisting residents who require assistance; -Answer call lights promptly; -Toilet residents promptly; -Monitor any new medications used and document and report changes to physician.