Every finding on record at Manor at Elfindale, The

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to consistently date opened foods and properly close frozen foods to prevent freezer burn; stored a measuring cup in the thickener container, and did not close the container; failed to clean the fans inside of the refrigerator; and failed to clean the deflector shield in the ice machine located in the kitchen. The facility census was 94.1. Review of the 2013 Food Code, issued by the Food and Drug Administration (FDA), showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.Review showed the facility did not provide a policy regarding the use of hair net restraints.Observations on 09/15/25, beginning at 9:05 A.M., showed the Dietary Manager (DM) in the kitchen with facial hair observed on his/her chin. The DM prepared mashed potatoes. The DM did not wear a hair net over the exposed hair.Observations on 09/17/25, beginning at 10:35 A.M., showed the DM in the kitchen with facial hair observed on his/her chin. The DM did not wear a hair net over the exposed hair.During an observation and interview on 09/17/25, at 1:37 P.M., Culinary [NAME] (CC) A was in the kitchen, wearing a beard net that covered his/her beard. CC A had a mustache that was not covered by a hair net. He/she was peeling potatoes. He/she said staff were expected to wear a hair net when in the kitchen, and hair nets should cover all facial hair, including the beard and mustache.During an interview on 09/17/25, at 1:44 P.M., Culinary Aide (CA) B said hair nets should be wore when staff are in the kitchen. The hair nets should cover all hair, including any facial hair.During an interview on 09/17/25, at 1:44 P.M., CA B said hair nets should be wore when staff are in the kitchen. The hair nets should cover all hair, including any facial hair.During an interview on 09/17/25, at 1:48 P.M., CC C said hair nets should be on while in the kitchen. The hair nets should cover all hair, including beards and mustaches.During an interview on 09/17/25, at 1:51 P.M., CA D said staff should put on hair nets as soon as they walk into the kitchen. The hair nets should cover all hair, including facial hair. Staff should wear a beard net if they have a beard or mustache.During an interview on 09/18/25, at 8:51 A.M., the DM said staff should be wearing a hair net as soon as they step into the kitchen. The hair nets should cover any facial hair and the hair on top of the head.During an interview on 09/18/25, at 9:05 A.M., the Administrator said staff should be wearing hairnets when in the kitchen. The hair nets should cover the hair on top of the head. 2. Review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contaminationReview showed the facility did not provide a policy on storing opened foods or dating open foods.Observations on 09/15/25, beginning at 9:05 A.M., showed the following:-A box of hamburger patties in the walk-in freezer. The patties were in a bag, inside of the box. The bag was opened, and the patties exposed, some patties had white substance on them. There were approximately 15 patties in the bag;-One large container of garlic, opened and approximately 1/3 of the item remaining. It had no open date or use by date.Observations on 09/17/25, beginning at 10:35 A.M., showed the following:-One large container of garlic, opened and approximately 1/3 of the item remaining. Had no open date or use by date.During an interview on 09/17/25, at 1:37 P.M., CC A said once food items are opened, they should be resealed or put in a new container. The item should be sealed up, so it doesn't get freezer burnt. The garlic and sauces should also have open and use by dates.During an interview on 09/17/25, at 1:44 P.M., CA B said when opening packages of food, they should be resealed and labeled with the open date. All foods should have an open date on them after they're opened. so you know how long you have to use them.During an interview on 09/17/25, at 1:48 P.M., CC C said when he/she opened a food, and it's not all used, he/she wraps the food item back up, and marks with a sharpie, the open date.During an interview on 09/17/25, at 1:51 P.M., CA D said foods that are opened, and have some left, should be wrapped up or put into another container, labeled and dated with the date it's opened.During an interview on 09/18/25, at 8:51 A.M., DM said foods that are opened, and have some left should be sealed good and the date it's opened written on the item. All foods should have a date opened on them so staff know when to discard. During an interview on 9/18/25, at 9:05 A.M., the Administrator said staff should close food items remaining and they should have an open date on them.3. Observations on 09/15/25, beginning at 9:05 A.M., showed a container of thickening powder, with open and a measuring cup stored in the thickener. The measuring scoop was down in the thickener about 1 inch.Observation on 09/17/25, at 10:27 A. M., showed the thickening powder open.During an interview on 09/17/25, at 1:37 P.M., CC A said scoops should not be stored in dried foods and the dried food containers should be closed so nothing can get into the food. During an interview on 09/17/25, at 1:48 P.M., CC C said scoops should not be left in the containers, such as the thickening powder, and the containers should always be closed.During an interview on 09/17/25, at 1:51 P.M., CA D said scoops should not be left in the dried foods and they containers should be closed.During an interview on 09/18/25, at 8:51 A.M., DM said scoops should be kept outside of dried foods, and the dried foods should be closed after getting out what's needed to prevent something from falling into the food. During an interview on 09/18/25, at 9:05 A.M., the Administrator said dried foods should be closed after use.4. Observations on 09/15/25, beginning at 9:05 A.M., and on 09/17/25 at 10:35 A.M., showed the refrigerator, located to the left upon entering the kitchen. The refrigerator held milk products. The two fans located at the top of the refrigerator, had a black substance on the outside of both fans.Review of the cleaning schedule for September 2025 showed the following:-Empty and wipe out the milk cooler on Thursday and Sunday;-The week of 09/01/25, staff signed off as emptying and wiping out the milk cooler on Thursday and Sunday;-The week of 09/08/25, staff signed off as emptying and wiping out the milk cooler.During an interview on 09/17/25, at 1:37 P.M., CC A said he/she didn't know anything about fans inside of the refrigerator that holds milk products. He/she wipes the inside out, but maintenance would probably be responsible for cleaning the fans. They have a cleaning list they are expected to complete daily and weeklyDuring an interview on 09/17/25, at 1:44 P.M., CA B said he/she isn't sure who would clean the fans in the refrigerator, but they shouldn't have black stuff on them.During an interview on 09/17/25, at 1:48 P.M., CC C said possibly maintenance cleans the fans in the small refrigerator, but he/she was not sure.During an interview on 09/17/25, at 1:51 P.M., CA D said he/she wiped down the inside of the refrigerator, but he/she did not know who cleaned the fans. It may have been maintenance. The fans shouldn't have black stuff on them. During an interview on 09/18/25, at 8:51 A.M., the DM said the kitchen staff can wipe down the fans in the refrigerator, or maintenance. He/she did not know they had black stuff on them. He/she monitored the cleaning schedules. Staff were to initial as they complete tasks.During an interview on 09/18/25, at 9:05 A.M., the Administrator said the fans in the refrigerator should be clean.During an interview on 09/18/25, at 3:17 P.M., the Maintenance Director said the two fans in the small refrigerator should be cleaned by kitchen staff.5. Observations on 09/5/25, beginning at 9:05 A.M., showed five spots of a black substance on the deflector shield in the ice machine located in the kitchen. There was a brown substance on the right top side of the deflector shield, about six inches along the crevasse.Review of the cleaning schedule for September 2025 showed the following:-The night shift was to wipe down the ice machine ice reflector guard on Fridays;-The week of 09/01/25, no staff initialed completing this task;-The week of 09/08/25, no staff initialed completing this task.During an interview on 09/17/25, at 1:37 P.M., CC A said the DM drained the ice machine and cleaned the inside. He/she believes the DM did this one time per week. They have a cleaning list they are expected to complete daily and weekly. The ice guard shouldn't have black spots on the inside.During an interview on 09/17/25, at 1:44 P.M., CA B said the kitchen staff clean the ice machine. It was included in the cleaning schedule, but he/she was not sure how often it's done.During an interview on 09/17/25, at 1:48 P.M., CC C said maintenance cleaned the inside of the ice machine. They have a schedule. He/she was not sure how often this was completed. The ice machine should be clean.During an interview on 09/17/25, at 1:51 P.M., CA D said maintenance cleans the inside of the ice machine, but he/she doesn't know how often.During an interview on 09/18/25, at 8:51 A.M., the DM said every six months maintenance drains the ice machine, takes all of the ice out, and sanitizes everything. He/she was not aware of any black or brown substance on the deflector shield. He/she monitored the cleaning schedules. Staff were to initial as they complete tasks.During an interview on 09/18/25, at 9:05 A.M., the Administrator said the ice machine was on a schedule for maintenance to clean.During an interview on 09/18/25, at 3:17 P.M., the Maintenance Director said he/she cleaned the inside of the ice machine. He/she descaled the inside by removing the ice and running a chemical through the machine. This was on the cleaning list to do every two to three months. He/she had not noticed any black spots on the deflector shield.

Based on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when the outside of the ice machine had drips of lime down the side, the ice machine vent had fuzzy lint present, and one knob was missing from the cook stove. The facility census was 94.1. Review showed the facility did not provide a policy regarding cleaning the ice machine. Review of the cleaning schedule for September 2025 showed the following:-The September cleaning schedules showed the night shift was to wipe down the ice machine and ice reflector guard on Fridays;-The week of 09/01/25, no staff initialed completing this task;-The week of 09/08/25, no staff initialed completing this task.Observations on 09/15/25, at 9:05 A.M., and on 09/17/25, at 10:35 A.M., showed three drips of a white substance down the left side of the ice machine.During an interview on 09/17/25, at 1:37 P.M., [NAME] A said the Dietary Manage (DM) cleans the outside of the ice machine one time per week. It was on the cleaning schedule.During an interview on 09/17/25, at 1:44 P.M., Culinary Assistant (CA) B said anyone can clean the outside of the ice machine. The kitchen staff have that on the cleaning list.During an interview on 9/17/25, at 1:48 P.M., [NAME] C said he/she was unsure who was responsible for cleaning the outside of the ice machine.During an interview on 9/17/25, at 1:51 P.M., CA D said maintenance cleaned the outside of the ice machine. He/she was not sure how often, but it was probably on a cleaning list.During an interview on 9/18/25, at 8:51 A.M., DM said the kitchen staff were responsible for wiping down the outside of the ice machine. This was on the cleaning schedule that he/she monitors.During an interview on 09/18/25, at 9:05 A.M., the Administrator said maintenance cleans the outside of the ice machine. It was on a cleaning schedule.During an interview on 09/18/25, at 3:17 P.M., the Maintenance Director said kitchen staff can wipe down the ice machine. He/she also does it when it's descaled.2. Observations on 09/15/25, beginning at 9:05 A.M., and on 09/17/25, at 10:35 A.M., showed the vent on the left side of the ice machine, had fuzzy lint present.During an interview on 09/17/25, at 1:37 P.M., CC A said cleaning the vents on the ice machine was part of the entire cleaning process and the DM did this one time per week.During an interview on 09/17/25, at 1:44 P.M., CA B said he/she didn't know who was responsible for cleaning the vents on the outside of the ice machine. They should not have lint on them.During an interview on 09/17/25, at 1:48 P.M., [NAME] C said he/she was not sure who cleaned the vents on the outside of the ice machine.During an interview on 09/17/25, at 1:51 P.M., CA D said maintenance cleaned the vents on the ice machine. He/she was not sure how often this was completed.During an interview on 09/18/25, at 8:51 A.M., the DM said maintenance cleaned the vents when he/she descaled the ice machine.During an interview on 09/18/25, at 9:05 A.M., the Administrator said maintenance was responsible for cleaning the outside of the ice machine.During an interview on 09/18/25, at 3:17 P.M., the Maintenance Director said maintenance cleaned the vents on the ice machine. 3. Observations on 09/15/25, beginning at 9:05 A.M., and on 09/17/25, at 10:35 A.M., showed no knob on the seventh control post of the stove missing.During an interview on 09/17/25, at 1:37 P.M., [NAME] A said the knob for the burner had been missing awhile. He/she was still able to turn the burner on and off.During an interview on 09/17/25, at 1:48 P.M., [NAME] C said the knob had been missing a while. The burner still turns on and off without it.During an interview on 09/18/25, at 8:51 A.M., the DM said the knob had been missing awhile. He/she had looked for a replacement, but the stove was older, and he/she hadn't been able to locate one.During an interview on 09/18/25, at 9:05 A.M., the Administrator said he/she would get a knob for the stove.

Based on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to obtain orders for the use of oxygen and care plan the use of oxygen for one resident (Resident #3). The facility census was 94.Review showed the facility did not provide a policy regarding oxygen therapy.1. Review of Resident #3's face sheet (a general information sheet) showed the following:-admission date of 03/06/25;-Diagnoses included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), respiratory failure with hypoxia (low levels of oxygen) and hypercapnia (high levels of carbon dioxide in blood), congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply), and chronic kidney disease.Review of the resident's significant change Minimum Data Sheet (MDS - a federally mandated comprehensive assessment instrument completed by facility staff),dated 07/30/25, showed the resident did not use oxygen.Review of the resident's current Physician Order Sheet (POS) showed no order for oxygen.Review of the resident's care plan, updated 08/11/25, showed staff did not care plan related to oxygen use. Review of the resident's progress note, dated 09/12/2025, showed the resident's oxygen saturation was 82% on room air, Staff applied oxygen at 3 liters per minute (lpm) to bring saturation to 90%. Staff notified hospice of the change in condition and made a visit with resident. (Staff did not document physician notification or obtaining an order for oxygen use.) Review of the resident's progress note, dated 09/13/25, showed the resident had no signs or symptoms of pain or distress and vital signs stable on oxygen via nasal cannula.Review of the resident's oxygen saturation readings, dated September 2025, showed the resident was wearing oxygen on 09/13/25 and 09/14/25.Review of the resident's progress note, dated 09/15/25, showed the resident's respirations were slightly labored with minimal activity and on oxygen on as needed.Observation on 09/15/25 at 9:33 A.M., showed the resident asleep in recliner with oxygen in place at 3 lpm via nasal cannula.Observation on 09/18/25, at 3:43 P.M., showed the resident in bed with oxygen in place via nasal cannula at 3 lpmDuring an interview on 09/18/25, at 1:44 P.M., Certified Nurse Assistant (CNA) E said he/she had observed the resident wearing oxygen when he/she cared for them. The nurse reported the resident's oxygen saturation was low and he/she needed oxygen. The care plan tells the staff what the resident needs are and oxygen use should be included.During an interview on 09/18/25, at 1:49 P.M., Certified Medication Technician (CMT) J said care plans tell staff how to care for residents and should include oxygen.During an interview on 09/18/25, at 3:11 P.M., MDS Coordinator D said oxygen should be included on the care plan. He/she was not informed the resident was utilizing oxygen.During an interview on 09/18/25, at 3:46 P.M., Licensed Practical Nurse (LPN) M said oxygen was considered a medication and should have an order for use. A care plan would tell staff how to care for a resident and oxygen use should be on it. During an interview on 09/19/25, at 9:00 A.M., Registered Nurse (RN) L said oxygen was a medication and they should have an order for use. He/she remembered the resident using oxygen when he/she cared for them. There were no standing orders for oxygen use from the physician. Staff do not know what the oxygen is indicated for or the flow rate of oxygen if there is no order. During an interview on 09/19/25, at 9:10 A.M., RN K said oxygen should have orders and be included on the care plan. The resident had been using oxygen intermittently and should have had an order. During an interview on 09/19/25, at 9:50 A.M., the Assistant Director of Nursing (ADON) said oxygen required an order, but a nurse can initiate it based on nursing judgement. The physician should be called within 15 to 20 minutes of application of oxygen to obtain an order. The care plan is used to identify what interventions are needed to care for a resident and oxygen should be included. He/she was unaware the resident utilized oxygen.During an interview on 09/19/25, at 10:41 A.M., the Administrator said there should be an order for oxygen if a resident was using it. He/she expected care plans to be updated so staff can care for the residents.

Based on record review and interview, the facility failed to complete the baseline care plans for all residents within 48 hours of admission and failed to document resident and/or representative was provided a copy of the baseline care plan when staff did not complete a full baseline care plans within 48 hours of admission for two residents (Residents #37 and #95) and failed to document representative or resident notification of the care plan for the residents. A sample of 19 residents was selected for review in a facility with a census of 94. Review showed the facility did not provide a policy related to Baseline Care Plans.1. Review of Resident #37's facility face sheet (admission information) showed the following information:-admission date of 09/04/25;-Diagnoses included history of head and face injury with fracture, diabetes type 2, depression, reduced mobility;-Resident was cognitively intact.Review of the resident's admission (baseline) care plan, created 09/10/25, showed the following information:-Staff care planned related to resident personal preferences (such as activities, etc.);-Staff care planned related to resident's history prior to being admitted to the facility;-Staff did not care plan regarding other care needs (such as diabetes or depressions) of the resident;-The care plan did not have a signature of the resident or a resident representative confirming receipt of a copy of the baseline care plan or a summary of the baseline care plan.2. Review of Resident #95's facility face sheet showed the following information:-admission date of 09/03/25;-Diagnoses included history of leg fracture, heart disease, and weakness;-Resident was cognitively intact.Review of the resident's admission (baseline) care plan, created 09/09/25, showed the following information:-Staff care planned related to the resident's personal preferences (such as activities, etc.);-Staff care planned related to part of the resident's history prior to being admitted to the facility;-Staff care planned the resident was at risk for poor nutrition;-Staff did not care plan related to other care needs (such as leg fracture and weakenss) of the resident;-The care plan did not have a signature of the resident or a resident representative confirming receipt of a copy of the baseline care plan or a summary of the baseline care plan.3. During an interview on 09/19/25, at 9:13 A.M., Life Enrichment Aide P said for care and needs for a specific resident, facility nurses have access to the information. For what residents like and don't like he/she must learn through experience with the resident. He/She was able to look through the electronic medical records (EMR) at times, but he/she did not know of a specific area to look for care needs.During an interview on 09/19/25, at 9:19 A.M., Certified Nurse Aide (CNA) Q said for a newer resident, he/she would have to talk to a nurse about the resident needs. For a resident in memory care, staff can't always ask them directly. This staff would need to get information from therapy or other staff. For charting on resident needs and activities, he/she does not have direct access to things like resident being continent or not, requiring assistance with transfers or not, etc. He/She did have access to some things in the EMR and could see some basic info on the residents. However, that is not always available for new admissions. He/She thought he/she might be able to see care plans, but is unsure. During an interview on 09/19/25, at 9:39 A.M., CNA R said for resident needs and care information, he/she usually discusses information with the resident. For more specific resident information, he/she will ask the nurses. During an interview on 09/19/25, at 9:50 A.M., Certified Medication Tech (CMT) O said the Kardex (located in the resident electronic medical records) is available for information on residents and will tell the resident story, plus limitations and expectations. The Kardex is in the EMR and he/she believed all staff were able to access this information. As far as care plans, he/she doesn't ever access them. The Kardex is where he/she goes for resident information. During an interview on 09/19/25, at 10:26 A.M., the Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) Coordinator A said resident allergies are listed on the face sheet in the EMR. Resident preferences are listed on Care Plans. Nurses and department heads can put information on the Care Plans. Floor nurses can put in information in the Care Plan, but often information is put in by the MDS Coordinators after inter-disciplinary (IDT) or other meetings. For the full Care Plan, it can take up to 21 days for staff to complete them. That Care Plan should include resident medication and allergies and likes and dislikes. Sometimes pain issues are addressed there as well. Care Plans should include special medications, or resident is continent or not, plus unique concerns and problems. For new residents, staff build the Care Plan as we go along. Staff usually complete care plans after the first MDS assessment at 8 to 10 days after admission. For rehabilitation residents, staff should complete Baseline Care Plans immediately The nurses build up the Baseline Care Plan based on some guided questions. General questions answered for the baseline include all of the assistance with daily tasks questions and specialty items. Things like IV therapy, oxygen use, transfusions, specific medications, pain, or fall history should all be on a resident Baseline Care Plan. Staff have up to 21 days to complete comprehensive Care Plans, but staff should have completed Baseline Care Plans by 24 hours. During an interview on 09/19/25, at 10:50 A.M., the Administrator said the facility policy for completing Care Plans is based on Centers for Medicaid and Medicare Services (CMS) guidelines.

Based on interview, and record review, the facility failed to develop and implement a complete comprehensive person-centered care plan for all residents when staff did not care plan relating to a wound for one resident (Resident # 5), did not care plan oxygen usage for one resident (Resident #101), and did not care plan regarding a fracture for one resident (Resident #38). The facility census was 94.Review of facility policy titled Comprehensive Care Plans, dated November 2016, showed the following:-It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, and mental, and psychosocial needs that are identified in the resident's comprehensive assessment;-The care planning process will include an assessment of the resident's strengths and needs;-The comprehensive care plan will describe, at a minimum services that are to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial wellbeing; any services that would otherwise be furnished; any specialized services the facility will provide; and the resident's goals for admission, desired outcomes, and preferences for future discharge; -The comprehensive care plan will be prepared by an interdisciplinary team;-The comprehensive care plan will include measurable goals and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment;-Team members responsible for carrying out interventions in the care plan will be notifies of their roles and responsibilities for carrying out the interventions.1. Review of the Resident #5's face sheet (a document that gives a resident's information at a quick glance) showed the following:-An admission date of 10/18/24;-Diagnoses included congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs) and chronic kidney disease (CKD - disease characterized by progressive damage and loss of function in the kidneys).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 07/31/25, showed the following information: -Cognitively intact;-Independent with activities of daily living (ADL - basic self-care tasks essential for independence)-Used a walker for mobility;-Resident was at risk for pressure ulcers;-Resident had one stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present). Review of resident's July 2025 Physician Order Sheet (POS) showed an order, dated 07/29/25, to cleanse area to left second toe, apply skin prep, and leave open to air, one time a day for scabbed area to left second toe. Staff to discontinue when resolved.Review of the resident's pressure ulcer record, dated 07/29/25, showed the resident had a facility acquired stage 3 pressure wound to the left toe. Summary indicated the area started as a dry scab. The wound area to the left second toe was approximately 0.4 centimeters (cm) by 0.4 cm by 0.2 cm. The area is 100% pink with scant bloody drainage. The surrounding skin was pink dry and intact. Treatment orders in place and will continue to monitor.Review of the resident's pressure ulcer record, dated 08/05/25, showed resident had a facility acquired stage 3 pressure wound to the left toe. Summary indicated the area started as a dry scab. The wound area to the left 2nd toe is approximately 0.4 cm by 0.4 cm by 0.1 cm. The area is 100% pink with scant yellow drainage. The surrounding skin is pink dry and intact.Review of the resident's pressure ulcer record, dated 09/16/25, showed resident had a facility acquired stage 3 pressure wound. The area to the left 2nd toe was approximately 0.3 cm by 0.3 cm. The area was a dry intact dark brown scab. The surrounding skin was dry, intact and blanches without pain.Review of the resident's care plan, revised on 4/07/25, showed staff did not update the care plan to address the wound to the resident's left toe.2. Review of the Resident #101's face sheet showed the following:-An admission date of 10/23/2024;-Diagnoses included CHF and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment;-Dependent with transfers, showers, dressing, and toileting;-Used a wheelchair for mobility;-Did not use oxygen or a continuous positive airway pressure (CPAP - a machine to deliver air pressure to help you breathe during sleep). Review of the resident's current POS showed the following:-An order, dated 09/08/25, for oxygen at 2 liters per minute via nasal canula as needed for shortness of breath to maintain oxygen saturation above 90% related to respiratory failure;-An order, dated 09/08/25, for CPAP to be applied and checked on during the night.Review of the resident's progress note, dated 09/04/25, showed the resident had audible wheezing noted with accessory muscle use also noted. Oxygen saturation was 91% on room air. Staff applied oxygen applied at 4 liters.Review of the resident's progress note, dated 09/08/25, showed resident was on oxygen at 2 liters per minute via nasal cannula.Review of the resident's care plan, dated 11/15/24, showed the following:-At risk for altered respiratory function related to COPD and asthma;-Resident will display optimal breathing patterns daily;-Assess respiratory status such as depth, rate, presence of breath sounds, dyspnea,shortness of breath, and cough as needed;-Check oxygen saturation as required;-Head of bed elevated as needed;-Maintain a clear airway and encourage to cough to clear secretions as needed.(Staff did not care plan related to the resident's oxygen or CPAP usage.)During an interview on 09/18/25, at 3:11 P.M., MDS Coordinator B said the resident should have his/her CPAP and oxygen included on the care plan. 3. Review of Resident #38 's face sheet showed the following:-admission date of 03/14/23;-Diagnoses included atrial fibrillation (irregular heartbeat), vascular dementia (brain disorder that occurs when blood flow to the brain is reduced leading to cell damage and memory loss), unspecified fall, weakness, depression (feelings of sadness), and anxiety (excessive and persistent worry or fear).Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Partial assistance with toileting, showers, upper and lower body dressing;-Set up with personal hygiene.Review of the resident's progress note, dated 05/07/25, showed the following:-On 05/07/25, at 10:41 A.M., certified nurse aides (CNA) observed the resident on the floor and called the nurse. Resident on her stomach, complaining of pain to left hip/leg. Resident was able to roll him/herself onto his/her back. Resident was unable to straighten left leg. Nurse noted shortening and outward rotation. Resident was unable to sit up or stand. Resident assisted to bed with two CNAs and a gait belt. Resident rated pain 10/10 and was asking for pain medication. Resident given as needed medications. Staff notified family and Nurse Practitioner (NP) and order obtained to have left hip X-ray done; -On 05/07/25, at 11:10 A.M., X-ray technician in the facility and completed the X-ray. Tech states to call the doctor and not wait for the x-ray results as this is a bad fracture, and the resident needed to go to the hospital;-On 05/07/25, at 11:44 A.M., called emergency medical services to requested ambulance for transport;-On 05/07/25, at 12:01 P.M., resident left via ambulance;-On 05/07/25, at 9:29 P.M., resident admitted to the hospital, waiting for orthopedic to see if resident a candidate for surgery. Review of the resident's care plan, last updated 07/14/25, showed the following:-ADL self care performance deficit related to musculoskeletal impairment. Needs assistance with washing back and hard to reach areas. Required assist with reposition self in bed. Used a walker. Requires assistance with toileting and transfers;-History and/or has potential for falls related to incontinence. Anticipate and meet resident's needs as needed. Call light in reach and encourage use. Continue to anticipate resident needs. Educate resident to turn the light on in the bathroom prior to sitting on the toilet. Maintain clutter free environment. Place items frequently used by resident within easy reach. Therapy to screen/evaluate for skilled services upon return;(Staff did not update the care plan to reflect the fall with fracture.) During an interview on 09/18/25, at 9:43 A.M., Licensed Practical Nurse (LPN) H said they have a risk management meeting and any falls are discussed in this meeting. The MDS Coordinators are involved in this meeting so they would know when to update the care plans for falls and additional interventions. 4. During an interview on 09/18/25, at 1:44 P.M., Certified Nurse Assistant (CNA) E said a care plan informs staff how to care for a resident. The care plan should include if a resident had a wound or utilized oxygen or a CPAP.During an interview on 09/18/25, at 1:49 P.M., Certified Medication Technician (CMT) J said a care plan was used to tell staff how to care for a resident. Care plans should include information on wounds, oxygen, and CPAP usage.During an interview on 09/18/25, at 3:11 P.M., MDS Coordinator B said staff have an interdisciplinary team (IDT) meeting daily and discuss resident changes such as falls and skin issues. The care plan is updated during the IDT meeting. The nurses tell him/her of resident changes in oxygen or medication and they would appear on the electronic charting system dashboard. During an interview on 09/18/25, at 3:30 P.M., CMT O said a care plan showed how to care for the resident, what they like, and preferences including activities. Oxygen use should be included on the care plan, but he/she was unsure of including CPAP use. He/she would want a wound to be included on the care plan. During an interview on 09/18/25, at 3:46 P.M., Licensed Practical Nurse (LPN) M said a care plan showed how staff should care for a resident. A care plan should include information on diagnoses, assistance needs, mental status, oxygen, CPAP use, and wounds. The facility has care plan meetings with the family to update care plan. Nurses complete a 24-hour report sheet that informs staff of any resident changes including medication changes. He/she would notify the Assistant Director of Nursing (ADON) about any updates needed to the care plan. During an interview on 09/19/25, at 9:50 A.M., the ADON said a care plan was used to identify what interventions were needed to care for the resident. Staff should be able to look at the care plan and know how to care for that resident. Wounds, CPAP use, and oxygen should be included in the care plan. The nurses fill out a risk assessment on residents and the MDS Coordinators use those to make care plans. Care plans are reviewed during IDT meetings for any updates and to ensure interventions are appropriate.During an interview on 09/19/25, at 10:41 A.M., the Administrator said he/she expected care plans to be updated so staff can care for the residents.

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made three errors out of 31 opportunities resulting in an 9.67% error rate when facility staff failed to administer one medication and administered a medication that did not indicate a dosage to one resident (Resident #47) and failed to prime an insulin pen to ensure an accurate dose to one resident (Resident #52) during medication pass observations. The facility had a census of 94.1. Review of the facility procedure titled Safe Administration Practiced, Long-Term Care, dated 05/19/25, showed the following:-Be sure to administer daily ,weekly, and monthly medications within two hours of the scheduled administration time;-Consult the practitioner if there are unresolved concerns related to prescribed medications;-Documentation associated with safe medication administration would include medication name, strength, and dose.Review of resident #47's face sheet showed the following:-admission date of 08/28/24;-Diagnoses included high blood pressure and pulmonary fibrosis (chronic lung disease that causes lung tissues to become scarred and damaged, making it harder to breathe).Review of the resident's current POS showed the following:-An order, dated 08/28/24, for B-Complex (supplement) tablet, give one tablet by mouth one time a day related to vitamin B deficiency;-An order, dated 09/27/24, for Allegra (allergy medication) allergy tablet, give one tablet by mouth one time a day related to allergies (no dosage listed);-An order, dated 09/27/24, for fexofenadine HCl (generic brand for Allegra) tablet 180 milligrams (mg), give one tablet by mouth as needed for allergies. Up to once a day.Review of the resident's September 2025 Medication Administration Record (MAR) showed an order, dated 09/27/24, for Allegra allergy tablet, give 1 tablet by mouth one time a day (no dosage listed). The MAR showed the medication was documented as administered seventeen days in the month without a listed dosage.Observation of a medication pass on 09/17/25, at 9:50 A.M., showed Certified Medication Tech (CMT) N sanitized his/her hands and started to prepare medications to administer to the resident. The order for the resident's Allegra was noted to be an incomplete order with no dosage listed on the MAR. The CMT pulled the Allegra card from the medication cart, and it had a dosage of 180 mg and a sticker stating PRN at the top of the card. The CMT placed the Allegra in the medication cup to administer. The B complex vitamin was not in the medication cart and unavailable for administration at the ordered time. The CMT reported the facility was waiting for the medication to be delivered from the pharmacy and indicated a note stating medication was not available in the MAR. The CMT then entered the resident's room and administered the medications.During an interview and observation on 09/17/25, at 11:46 A.M., CMT N said the dose of the medication should be indicated on the order and included on the MAR. The Allegra had a standard dose, so it was not indicated in the order. The CMT then looked up the medication on his/her phone and reported the standard dosage as 180 mg.During an interview on 09/18/25, at 1:49 PM., CMT J said the CMT should write a progress note and alert the nurse if a medication was not available. He/she would consider it to be a medication error if the medication is not given at the ordered time. He/she would not give a medication that did not have a dosage listed. He/she would not know if it was the correct dosage to administer if it did not indicate it on the order. It would be a medication error if a medication was administered without a dosage.During an interview on 09/18/25, at 3:30 P.M., CMT O said a medication order should include the resident's name, medication name, dosage, time, and route. He/she would notify the nurse if a medication did not have a listed dose. He/she would not give the dose if it did not include a dosage because it would be a medication error. He/she would contact the pharmacy if a medication was not available and put a note indicating why it was not given. He/she is unsure if this would be a medication error as it had never occurred.During an interview on 09/18/25, at 3:46 P.M., Licensed Practical Nurse (LPN) M said a medication order should have medication name, dosage, how many pills to be administered, route, how many times a day, and a diagnosis. He/she would call the physician to ascertain the medication dosage prior to administering. He/she would not give a medication without a dosage as it would be an error. He/she would contact the pharmacy if a medication was unavailable at the administration time. It might be a medication error if not given on time. During an interview on 09/19/25, at 9:00 A.M., Registered Nurse (RN) L said a medication order should include the medication name, dosage, time to administer, and the form. He/she would call the physician to get the correct dose if it was missing on an order. He/she would not give a medication without a listed dose. It would be a medication error if a medication was given without a dosage listed. It would be a medication error if a medication was not given at the right time. He/she would call the pharmacy to obtain medication as soon as possible. During an interview on 09/19/25, at 9:10 A.M., RN K said a medication order should contain the resident name, drug, route, and time. He/she would call the physician for clarification if a medication did not indicate the dose. It is a medication error if a medication is given without the dose listed. He/she would contact the pharmacy and have the medication sent right away if it was not available for administration. It would be a medication error if a medication was not given at the ordered time. During an interview on 09/19/25, at 9:50 A.M., the Assistant Director of Nursing (ADON) B said medication orders should include the name, dosage, route, and time to administer. Staff should call and clarify with the physician any medication that does not include a dosage. If a medication was administered without a dose indicated, it would be a medication error. Staff should call the pharmacy and look in the overflow medications for any medication not available. It would be a medication error if a medication was not administered at the ordered time.During an interview on 09/19/2025 at 10:41 A.M., the Administrator said staff should have complete orders, including dosage, prior to administering medication. Staff should order a medication and administer it on time for any medication that is unavailable. 2. Review of the facility procedure titled Insulin Pen Use, dated 05/19/25, showed staff should prime the insulin pen by pointing it up in the air, dialing one or two units on the insulin pen, and then fully press the plunger. A drop of insulin should appear at the needle tip. Repeat the priming procedure until a drop appears.Review of the Humalog (fast acting insulin) Kwikpen packet insert, dated March 2023, showed the following: -Prime before each injection;-To prime turn the dose knob to select 2 units, hold pen with the Needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, and push the dose knob in until it stops, and a 0 is seen in the dose window. A stream of insulin should be seen from the needle. If a stream of insulin is not seen, repeat steps no more than 4 times;-Priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use;-If you do not prime before each injection, you may get too much or too little insulin.Review of Resident #52's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 01/31/25;-Diagnoses included diabetes (chronic condition that affects how the body uses glucose (blood sugar)) and dementia (group of thinking and social symptoms that interfere with daily functioning). Review of the resident current Physician Order Sheet (POS) showed an order, dated 01/31/24, for Humalog (fast acting insulin) injection solution 100 unit per milliliter, inject subcutaneously with meals per the following sliding scale: -If blood glucose reading is 0 milligrams/deciliter (mg/dL) to 175 mg/dL, administer 0 units of insulin;-If blood glucose reading is 176 mg/dL to 200 mg/dL, administer 1 unit of insulin;-If blood glucose reading is 201 mg/dL to 250 mg/dL, administer 2 units of insulin;-If blood glucose reading is 251 mg/dL to 299 mg/dL, administer 3 units of insulin;-If blood glucose reading is 300 mg/dL to 399 mg/dL, administer 4 unites of insulin; 40-If blood glucose reading is 400 mg/dL or higher, notify the physician.Observation of insulin administration on 09/18/25, at 11:00 A.M., showed Licensed Practical Nurse (LPN) G returned to the medication cart after obtaining the resident's blood sugar. The blood sugar reported as 232 mg/dL. The LPN reported the resident would need 2 units of insulin per physician order. The nurse obtained the insulin pen from the cart and placed a needle on the end of the pen. LPN G dialed the pen to a line in between 2 and 4 on the pen which indicated 3 units of medication. He/she then asked the surveyor if this indicated 2 units of insulin. The surveyor asked the LPN how many units the pen was dialed to, and he/she reported it was two units. The surveyor then asked where 3 were on the pen if the line in between 2 and 4 units indicated 2 units to him/her. LPN G adjusted the dial to 2 units and reported he/she guessed it was 2 units. The LPN did not prime the pen to expel any air out of the needle and then proceeded to the resident's room and administered the medication.During an interview on 09/18/25, at 3:46 P.M., LPN M said an insulin pen should be primed prior to administering. I would be a medication error if an insulin pen was not primed. He/she would ask another nurse or nurse manager if he/she was unsure of an insulin dosage.During an interview on 09/19/25, at 9:00 A.M., RN L the insulin pen should be primed with two units prior to dialing dose amount. If an insulin pen was not primed it would have air in the needle. It would be an error to not prime an insulin pen.During an interview on 09/19/25, at 9:10 A.M., RN K said an insulin pen should be primed with two units prior to dialing it to the correct dosage. It would be an error If staff do not prime the pen, as the resident would be getting air instead of medication. The smaller unlabeled lines on the insulin pen indicate odd numbers. The line located between two and four on the insulin pen would indicate three units. The nurse should contact the nurse manager for any medication or insulin pen questions.During an interview on 09/19/25, at 9:50 A.M., the ADON B said staff should prime the insulin pen with two units prior to dialing the indicated amount. The pen would administer air and not the indicated dose if not primed first which would be a medication error. The smaller lines on the insulin pen would indicate odd numbers and the even numbers are printed to select correct dose. The nurse should ask nursing management or another nurse if they have a question regarding medication.During an interview on 09/19/25, at 10:41 A.M., the Administrator staff should follow professional standards when administering insulin.

Based on observation, interview, and record review, the facility staff failed ensure all residents were free of significant medication errors when staff failed to prime one resident's (Resident #52) insulin pen prior to insulin administration to ensure accurate dosing. The facility census was 94.Review of the facility procedure titled Insulin Pen Use, dated 05/19/25, showed staff should prime the insulin pen by pointing it up in the air, dialing one or two units on the insulin pen, and then fully press the plunger. A drop of insulin should appear at the needle tip. Repeat the priming procedure until a drop appears.Review of the Humalog (fast acting insulin) Kwikpen packet insert, dated March 2023, showed the following: -Prime before each injection;-To prime turn the dose knob to select 2 units, hold pen with the Needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, and push the dose knob in until it stops, and a 0 is seen in the dose window. A stream of insulin should be seen from the needle. If a stream of insulin is not seen, repeat steps no more than 4 times;-Priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use;-If you do not prime before each injection, you may get too much or too little insulin.1. Review of Resident #52's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 01/31/25;-Diagnoses included diabetes (chronic condition that affects how the body uses glucose (blood sugar)) and dementia (group of thinking and social symptoms that interfere with daily functioning). Review of the resident current Physician Order Sheet (POS) showed an order, dated 01/31/24, for Humalog (fast acting insulin) injection solution 100 unit per milliliter, inject subcutaneously with meals per the following sliding scale: -If blood glucose reading is 0 milligrams/deciliter (mg/dL) to 175 mg/dL, administer 0 units of insulin;-If blood glucose reading is 176 mg/dL to 200 mg/dL, administer 1 unit of insulin;-If blood glucose reading is 201 mg/dL to 250 mg/dL, administer 2 units of insulin;-If blood glucose reading is 251 mg/dL to 299 mg/dL, administer 3 units of insulin;-If blood glucose reading is 300 mg/dL to 399 mg/dL, administer 4 unites of insulin; 40-If blood glucose reading is 400 mg/dL or higher, notify the physician.Observation of insulin administration on 09/18/25, at 11:00 A.M., showed Licensed Practical Nurse (LPN) G returned to the medication cart after obtaining the resident's blood sugar. The blood sugar reported as 232 mg/dL. The LPN reported the resident would need 2 units of insulin per physician order. The nurse obtained the insulin pen from the cart and placed a needle on the end of the pen. LPN G dialed the pen to a line in between 2 and 4 on the pen which indicated 3 units of medication. He/she then asked the surveyor if this indicated 2 units of insulin. The surveyor asked the LPN how many units the pen was dialed to, and he/she reported it was two units. The surveyor then asked where 3 were on the pen if the line in between 2 and 4 units indicated 2 units to him/her. LPN G adjusted the dial to 2 units and reported he/she guessed it was 2 units. The LPN did not prime the pen to expel any air out of the needle and then proceeded to the resident's room and administered the medication.During an interview on 09/18/25, at 3:46 P.M., LPN M said an insulin pen should be primed prior to administering. I would be a medication error if an insulin pen was not primed. He/she would ask another nurse or nurse manager if he/she was unsure of an insulin dosage.During an interview on 09/19/25, at 9:00 A.M., Registered Nurse (RN) L the insulin pen should be primed with two units prior to dialing dose amount. If an insulin pen was not primed it would have air in the needle. It would be an error to not prime an insulin pen.During an interview on 09/19/25, at 9:10 A.M., RN K said an insulin pen should be primed with two units prior to dialing it to the correct dosage. It would be an error If staff do not prime the pen, as the resident would be getting air instead of medication. The smaller unlabeled lines on the insulin pen indicate odd numbers. The line located between two and four on the insulin pen would indicate three units. The nurse should contact the nurse manager for any medication or insulin pen questions.During an interview on 09/19/25, at 9:50 A.M., the Assistant Director of Nursing (ADON) B said staff should prime the insulin pen with two units prior to dialing the indicated amount. The pen would administer air and not the indicated dose if not primed first which would be a medication error. The smaller lines on the insulin pen would indicate odd numbers and the even numbers are printed to select correct dose. The nurse should ask nursing management or another nurse if they have a question regarding medication.During an interview on 09/19/25, at 10:41 A.M., the Administrator staff should follow professional standards when administering insulin.

Based on observation, interview, and record review, the facility failed to maintain the ice machine in a clean manner when the ice reflector shield in the ice machine located in the kitchen had a build-up of a black substance that appeared to be mold on the ice reflector shield, failed to ensure the air cooling vent in the walk in freezer was free of lint which could blow on to food stored in the walk-in freezer, and failed to ensure two fluorescent light fixtures in the dry storage pantry had covers and one cover for a fluorescent light fixture was broken. If the light bulbs were to shatter or break, food stored in the dry pantry could be contaminated by broken glass. The facility census was 90. The facility did not have a policy for the kitchen cleanliness. Record review of the Missouri 2013 Food code, showed the following information: -The purpose of this Code is to safeguard public health and provide to consumers food that is safe, unadulterated, and honestly presented; -(2) Bears or contains any added poisonous or added deleterious substance which is unsafe; (3) Consists, in whole or in part, of any diseased, contaminated, filthy, putrid, or decomposed substance, or if it is otherwise unfit for food; or (4) Has been produced, prepared, packed, or held under unsanitary conditions whereby it may have become contaminated with filth or whereby it may have been rendered diseased, unwholesome, or injurious to health. 1. Observation on 11/29/2021, beginning at 9:29 A.M., showed the ice machine, located in the kitchen near the entrance to the kitchen, ice reflector shield in the interior portion of the ice machine, had a black substance across the ice reflector shield which appeared to be mold. Observation on 12/1/2021, beginning at 10:54 A.M., showed the ice reflector shield had been cleaned and the black substance had been removed from the ice reflector shield. During an interview on 12/2/2021, at 9:16 A.M., Dietary Staff (DS) C said he/she thought maintenance checked and cleaned the ice machine reflector shield monthly. He/he did not know dietary staff should monitor for cleanliness of the interior of the ice machine or the ice reflector shield and report this to maintenance if the ice machine or ice reflector shield was dirty. During an interview on 12/2/2021, at 9:22 A.M., DS D said the maintenance staff clean the ice machine. He/she did not know how often maintenance cleaned the ice machine and the ice reflector shield. During an interview on 12/2/2021, at 9:32 A.M., the Dietary Manager (DM) said maintenance is responsible for cleaning the ice machine and the ice reflector shield on a monthly basis. If she saw the ice reflector shield had a build-up of a black substance on the ice reflector shield in between cleanings, she would put a work order in for maintenance to clean it. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director (MD) said if there was an issue in the kitchen, maintenance needed to clean or fix, dietary staff should put in a work order in Tels (a work order system for maintenance where staff should report issues that maintenance needs to repair or clean) so maintenance could clean or fix it. Maintenance cleans the ice machine and the ice reflector shield monthly and it was on the maintenance monthly check list. Dietary staff see the ice machine daily and would know if it needed to be cleaned in between the monthly scheduled cleanings. If it is dirty prior to the next month cleaning, the dietary staff should report this so maintenance can clean it. 2. Observation on 11/29/2021, beginning at 9:29 A.M., showed two fluorescent light fixtures in the dry pantry area that had missing covers. Stored beneath the fluorescent light fixtures that had missing covers were boxes of uncovered uncooked sweet potatoes, russet potatoes, and golden russet potatoes. One fluorescent light fixture cover near the walk in freezer and walk-in cooler had a cracked and broken surface. Observation on 12/1/2021, at 10:54 A.M., showed the covers for the two fluorescent light fixtures in the dry pantry area were still missing and the fluorescent light cover fixture near walk-in cooler and walk-in freezer was still broken. During an interview on 12/2/2021, at 9:16 A.M., DS C said he/she would put in a work order through Tels to notify maintenance of missing or broken light fixture covers. He/she had not noticed the fluorescent light fixtures in the dry pantry area were missing or that the light fixture cover near the walk-ins was broken. During an interview on 12/2/2021, at 9:23 A.M., DS D said if he/she saw a fluorescent light fixture in the kitchen had missing light covers or a broken light cover, he/she should put in a Tels order for maintenance so they could replace the covers on the light fixtures. He/she had not noticed the fluorescent light fixtures in the dry pantry did not have covers and had not noticed the fluorescent light fixture near the walk-ins was broken. During an interview on 12/2/2021, at 9:32 A.M., the DM said if light fixtures in the kitchen were missing covers or if covers for light fixtures were broken, staff should report this to maintenance so maintenance could replace the light covers. He/she had not noticed the fluorescent light fixtures in the dry pantry were missing covers or the cover for the fluorescent light fixture near the walk-ins was broken. When she or her dietary staff find missing or broken light covers, they should put in a work order with Tels so the maintenance staff know to replace these covers. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director said he had been told about the broken and missing light covers in the kitchen approximately five minutes ago. He had covers for the fluorescent light fixtures that were missing or broken and he would change them. Staff should put in a work order for anything in the kitchen that needs to be repaired so he is aware of of it. 3. Observation on 11/29/2021, beginning at 9:29 A.M., showed the air exchange vent in the walk-in freezer had a build-up of lint that had the potential to blow onto the surfaces of food packaging container and when staff opened the containers to prepare the food the lint had the potential to contaminate the food. Stored underneath the air exchange vent in the walk-in freezer was a box of uncovered onions. The lint had the potential to be blown into the box of unions and contaminate the food. Observation on 12/1/2021, beginning at 10:54 A.M., showed the air exchange vent in the walk-in freezer remained dirty with a build-up of lint. During an interview on 12/2/2021, at 9:16 A.M., DS C said he/she did not know to look to see if the air exchange vent in the walk-in freezer was dirty and to report this to maintenance. During an interview on 12/2/2021, at 9:23 A.M., DS D said he/she did not know the air exchange vent in the walk-in freezer had a build-up of lint. This should be reported to maintenance to clean. During an interview on 12/2/2021, at 9:32 A.M., the DM said he/she did not know the air exchange vent in the walk-in cooler or freezer could get dirty. He/she would put in a work order for maintenance to clean this since it has a motor. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director said the cooling fans (air exchange vents) were visually inspected monthly and cleaned as needed. 4. During an interview on 12/2/2021, at 10:14 A.M., the Maintenance Director said if there was something in the kitchen, maintenance needed to fix or repair, dietary staff should put in a work order in Tels so maintenance knew of the issue and could fix it. 5. During an interview on 12/02/2021, at 09:45 A.M., the administrator said he knows maintenance cleans the ice reflector shield monthly so the facility may need to replace this part. He did not know there were missing covers for fluorescent light fixtures or that one in the kitchen was broken and he would make sure these were replaced. He would make sure the air exchange vent in the walk-in freezer was cleaned.

Based on observation, interview, and record review, the facility staff failed to document completion of measurements to ensure there were no gaps that could potentially cause injury or entrapment and failed to obtain signed consent for the use of side rails for eight residents (Resident #5, #12, #36, #65, #71, #73, #76, and #80) out of a sample selection of 18 residents. The facility census was 90. Record review of the facility's policy titled, Restrictive Device Determination Guideline, showed the following information: -Prior to the initiation of any potentially restraining device being implemented, a designated member of the nursing team, with interdisciplinary Team involvement, will complete the Pre-Restraining Evaluation and request therapy screen and/or evaluation; -Alternatives to these devices will be considered; -If the resident can remove, release or freely move about, the device is not restrictive and not determined to be a restraint; -The interdisciplinary team will complete the summary of the evaluation and will carry interventions to the activity of daily living section of the resident's comprehensive care plan; -If the device is considered to be a restraint, the nurse will initially obtain and review the informed consent for use of restraints with the resident/responsible party, discussing the benefits and potential risks; -Assist Bar Sizing and Use Guidelines: Zone 1: within the rail, <120 mm (<4 ¾) Zone 2: Under the rail, between rail supports or next to a single rail support, <120mm (<4 ¾) Zone 3: Between rail and mattress, <120 mm (<4 ¾) Zone 4: Under the rail, at the ends of the rail, (60 mm (<2 3/8) AND >60 angle) -Measurements for assist bars need to be documented on the Pre-Restraining Evaluation and then quarterly and as needed (PRN) on the Physical Restraint Elimination Review; -Evaluate the need for assist bars. If not needed, please remove them; -The need for assist bars should be assessed and documented at least quarterly in conjunction with the resident's care planning/MDS cycle. This can be completed during a therapy screen, or by the nurse that is responsible for overseeing restorative. 1. Record review of Resident #71's face sheet (basic resident information sheet) showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Pre-Restraining Evaluation, dated 5/21/2021, showed the following information: -Oriented to time and place; -Disoriented/confused; -Wheelchair mobility; -Bed alarm, and chair alarm. -Resident evaluated for bilateral turn rails, and alarm at all times. Record review of the resident's care plan, revised on 8/24/2021, showed the following information: -Experienced cognitive impairment, dementia. -At risk for falls related to impaired gait/balance and weakness; -Quarterly review of turn rails/bolster mattress; -Pre-restraining evaluation/enabler complete; -Use turn rail to assist with repositioning and will be removed when possible. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/21/2021, showed the following information: -Memory problems, modified independence; -Fall risk; -Required extensive assistance, two person assist with bed mobility, transfer, and mobility; -Bed rails not used. Record review of the current physician order sheet (POS) did not show an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that could potentially cause injury or entrapment. Record review of the resident's medical record showed the facility did not obtain written consent from the resident, or resident representative, prior to placing the side rails. Observation on 11/29/2021, at 9:11 A.M., showed Resident #71's bed had quarter side rails on both sides, in the raised position. Resident sat in his/her wheelchair. Observation on 11/30/2021, at 7:45 A.M., showed quarter side rails on both sides of the bed, in the raised position, and the resident rested in the bed. Observation on 11/30/2021, at 12:05 P.M., showed quarter side rails on both sides of the bed, in the raised position, and the resident rested in bed. During an interview on 12/2/2021, at 9:00 A.M., Certified Nurse's Aide (CNA) A said the following: -A resident that's had a stroke and paralysis, would use the side rail to reposition and be more independent; -Resident # 71 doesn't use the side rail as much as he/she used to; but, he/she does still use the rail to assist with turning in bed. During an interview on 12/2/2021, at 9:39 A.M., the MDS Coordinator, said he/she is unsure how Resident # 71, came to have sides rails as he/she does not assess residents on that hall. The other MDS coordinator that assesses this resident's hall, had not been at the facility long and would not have completed the evaluation for the use of side rails for this resident. During an interview on 12/2/2021, at 10:20 A.M., the maintenance supervisor said he does not have documented gap measurements for Resident # 71's side rails. 2. Record review of Resident #5's face sheet showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's significant change (major decline or improvement in the resident's status) MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive staff assistance of two staff for bed mobility, transfer, dressing, and toilet use; -Bed rails not used. Record review of the resident's care plan, dated 4/17/2017 and last revised on 11/11/2021, showed the following information: -The resident had self-care deficits with activities of daily living (ADLs) to include bed mobility, transfers, dressing, mobility, hygiene, and toileting, related to disease process; -One turn rail on bed to assist with repositioning; -Experienced cognitive impairment related to dementia. Observation on 11/29/2021, at 10:20 A.M., showed the resident up in his/her wheelchair in his/her room. The resident had one turn rail (grab bar) to the left side of his/her bed. The turn rail was in the raised position. Observation on 11/29/2021, at 2:56 P.M., showed the resident in bed with one turn rail (grab bar) to the left side of his/her bed. The turn rail was in the raised position. Record review of the resident's November 2021 POS showed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's medical record showed the following: -A pre-restraint evaluation and risk versus benefits, dated 8/23/2021, for the turn rail; -No consent for the turn rail; -No gap measurements for the turn rail. During an interview on 12/2/2021, at 2:35 P.M., CNA J said the facility does not use side rails, just enablers (turn rails). He/she has seen Resident #5 use the enabler to assist when staff reposition the resident to his/her wheel chair. During an interview on 12/2/2021, at 2:40 P.M., Licensed Practical Nurse (LPN) K said the facility did not use side rails and only used the enablers (turn rails). He/she calls the enablers grab bars. He/she has not seen Resident #5 use the enabler to reposition. 3. Record review of Resident #73's face sheet showed the following information: -admitted to facility on 5/7/2021; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 5/20/2021, showed the following information: -Self-care performance deficit related to being a fall risk; -Required extensive assistance of two staff for bed mobility, dressing, transfers, and toileting; -Turn rails to bed for repositioning. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive assistance of two staff for transfers, dressing, toileting, and hygiene; -No bed rails used. Observation on 11/29/2021, at approximately 10:40 A.M., showed the resident asleep in his/her wheel chair in his/her room. The resident had turn rails (grab bars) on both sides of the bed. Both turn rails were in the raised position. Observation on 11/29/2021, at 1:42 P.M., showed the resident was not in his/her room. The resident had enablers (grab bars) on both sides of his/her bed. Both side rails were in the raised position. Record review of the resident's November 2021 POS showed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's medical record showed the following information: -A pre-restraint evaluation and risk versus benefits, dated 8/18/2021, for the two turn rails; -No consent for the turn rails; -No gap measurements for the turn rails. During an interview on 12/2/2021, at 2:35 P.M., CNA J said he/she has seen Res #73 use the enabler (turn rail) to assist when staff reposition. During an interview on 12/2/2021, at 2:40 P.M., LPN K said he/she saw Res #73 use the enabler to reposition last night. 4. Record review of Resident #76's face sheet showed the following information: -admitted to facility on 2/20/2019; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 5/21/2021, showed the following information; -ADL self-care performance deficit related to weakness and Alzheimer's disease; -Supervision of one staff for bed mobility, transfers, dressing, and hygiene; -Turn rail on one side for repositioning. Record review of the resident's annual MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Required supervision of one staff for bed mobility, transfers, dressing, and toileting; -Bed rails not used. Observation on 11/29/2021, at 10:35 A.M., showed the resident in bed asleep. The resident had one turn rail (grab bar) on one side of the bed. The turn rail was in the raised position. Observation on 11/29/2021, at 3:25 P.M., showed the resident was not in his/her room. The resident had one turn rail (grab bar) to one side of the bed. The turn rail was in the raised position. Record review of the resident's November 2021 POS showed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's medical record showed the following information: -A pre-restraint evaluation and risk versus benefits, dated 5/21/2021, for one turn rail; -No consent for the turn rail; -No gap measurements for the turn rail. During an interview on 12/2/2021, at 2:35 P.M., CNA J said Resident #76 was independent and used the turn rail for repositioning and to get out of bed. During an interview on 12/2/2021, at 2:40 P.M., LPN K said he/she had seen Resident #76 use the enabler to get to a sitting position in bed and to get out of bed. 5. Record review of Resident #12's face sheet showed the following information: -The resident admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -The resident did not use bed rails. Record review of the resident's current care plan, showed the following interventions initiated on 12/17/2020: -Total assist with bed mobility; -Turn rails on bed. The resident's medical record did not have a consent form for bed rails or documented gap measurements, Observations on 11/29/2021, at 3:15 P.M., showed the resident resting in bed with bilateral (on both sides) grab bars in the up position. Observations on 12/1/2021, at 2:00 P.M., showed the resident resting in bed with bilateral grab bars in the up position. Observations on 12/2/2021, at 8:58 A.M., showed the resident resting in bed with bilateral grab bars in the up position. Observations on 12/3/2021, at 8:25 A.M., showed the resident resting in bed with bilateral grab bars in the up position. During an interview on 12/2/2021, at 1:09 P.M., CNA H said Resident #12 uses his/her grab bars for positioning only. A staff member comes and measures the bars frequently. The aide believes it may be monthly. He/she is not sure where the measurements are documented. 6. Record review of Resident #36's face sheet showed the following information: -The resident admitted to the facility on [DATE]; -His/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -The resident did not use bed rails. Record review of the resident's current care plan, showed the following interventions, dated 10/15/2021: -Extensive two person assistance for bed mobility; -Bilateral turn rails on the bed. The resident's medical record did not have a consent form for the turn rails or documented gap measurements. Observations on 11/30/2021, at 2:49 P.M., showed the bilateral grab bars in the up position. The resident rested in the recliner next to the bed. Observations on 12/1/2021, at 12:28 P.M., showed the resident up in his/her wheelchair. The bilateral grab bars were in the up position on the bed. Observations on 12/2/2021, at 9:03 A.M., showed the resident resting in the recliner. The bilateral grab bars were in the up position on the bed. Observations on 12/3/2021, at 8:24 A.M., showed the bilateral grab bars in the up position on the bed. The resident was not in the room at the time. During an interview on 12/2/2021, at 12:20 P.M., LPN J said Resident #36 uses his/her grab bars for positioning only. He/she uses them to turn and was assessed by the MDS coordinator. He/she thinks the resident's family signed a consent form, but is not sure. Maintenance installed the bars and comes monthly and makes sure they fit properly. The rails are never used to keep a resident in bed. 7. Record review of Resident #65's face sheet showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Pre-Restraining Evaluation (evaluation of need for restraints) dated 1/11/2021, showed the following information: -Oriented to time and place at times; -Gait unsteady; -Balance unstable; -Unstable when making transfers; -Recommendation for positioning rail to be placed with bolster air mattress (a mattress with defined raised edges which help prevent the resident from falling out of bed) to aid in positioning and assist with pain. Record review of the resident's care plan dated 9/15/2021, showed the following information: -Bolster air mattress/right side positioning bar; - Mattress will decrease back pain through the next review; -Assess pain improvement in quarterly MDS; -Restraint review will be completed annually; -Potential for fall related to [CONDITION(S)] disease. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Mild depression; -Required extensive assistance, two person assist with bed mobility, transfers, dressing, and toileting; -Required use of wheelchair and walker for mobility; -No restraints. Record review of the current POS did not show an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's medical record showed facility staff did not obtain a consent form for bed rails. Record review of the resident's medical record showed the facility staff did not document completion of gap measurements. Observation on 11/30/2021, at 9:51 A.M., showed the resident had a raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed. The resident was not in the bed. During an interview on 12/2/2021, at 11:35 A.M., the resident said he/she does not remember who ordered the side rails and does not remember signing a consent form. He/she sometimes uses the rail to pull him/herself up further in the bed. He/she has not had any accidents or gotten stuck. During an interview on 12/2/2021, at 10:50 A.M., LPN D said he/she did not obtain consent for side rails from the resident. During an interview on 12/2/2021, at 10:25 A.M., the maintenance supervisor said he completed gap measurements for the resident's mattress and grab bar. He did not document the measurements anywhere nor did he document if the measurements were pass/fail. 8. Record review of Resident #80's face sheet showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance, two person assist with bed mobility, transfers, and toileting; -Required use of wheelchair and walker for mobility; -No restraints. Record review of the resident's care plan, dated 11/17/2021, showed the following information: -Bed mobility: limited one person assist-right side positioning rail; -Potential risk for falls; -Potential for alteration in comfort related to [CONDITION(S)]/pain. Record review of the resident's Pre-Restraining Evaluation dated 11/21/2021, showed the following information: -Oriented to time and place; -Poor muscle control; -Engaged in physical and occupational therapy; -Recommendation for right side position rail to assist with bed mobility. Record review of the current POS did not show an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's medical record showed facility staff did not obtain a consent form for bed rails. Record review of the resident's medical record showed the facility staff did not document completion of gap measurements. Observation on 11/29/2021, at 3:15 P.M., showed the resident had a raised grab bar (u-shaped bar measuring approximately 5 inches wide) on the right side of the bed. The resident was not in the bed. During an interview on 12/2/2021, at 11:45, the resident said he/she did not sign a consent form, did not request the side rail and does not know if his/her family did. Staff came in one day and installed it. It works well for him/her to move in and out of the bed. He/she uses one at home. During an interview on 12/2/2021, at 11:00 A.M., CNA F said he/she has observed the resident use his/her side rails safely. During an interview on 12/2/21, at 10:25 A.M., the maintenance supervisor said he completed gap measurements for the resident's mattress and grab bar. He did not document the measurements anywhere nor did he document if the measurements were pass/fail. 9. During an interview on 12/2/21, at 10:45 A.M., CNA E said he/she does not participate in the process of placing side rails on resident's beds, he/she does not obtain consent forms nor take part in gap measurements. Residents must have the ability to use their arms to move in bed to have side rails. Documentation would be in the chart. 10. During an interview on 12/2/21, at 11:00 A.M., CNA F said he/she only works on the 700 hall. He/she does not know where documents are related to side rails such as consent forms and gap measurements. Side rails are a resident/family preference or ordered by therapy. 11. During an interview on 12/02/2021, at 2:35 P.M., CNA J said if a resident or family member requests an enabler for a resident, a request should be put in for the physician to approve the device. Once the physician approved the enabler, then a work order should be placed for maintenance to put the enabler on the bed. He/she did not know what other paperwork was required for the enablers since this would be the nurse or maintenance's responsibility. 12. During an interview on 12/02/21, at 9:25 A.M., Certified Medication Technician (CMT B) said the following: -Side rails require a physician's order; -Keeps residents from rolling out of bed. 13. During an interview on 12/02/2021, at 2:40 P.M., LPN K said the facility did not use side rails and only used the enablers (turn rails). He/she calls the enablers grab bars. If a resident or family member request the enabler, the nurse would put in a request for the enabler and get a physician's order from the physician for the enabler. Once an order is obtained, then the nurse should put a work order in for maintenance to apply the enabler. He/she did not know what paperwork should be completed for the enablers and would have to ask a nurse who had been there longer. 14. During an interview on 12/2/21, at 10:50 A.M., LPN D said he/she has obtained consents from residents for side rails. Therapy recommends side rails and maintenance installs them. Consents would be scanned into the chart now that the facility is paperless. He/she doesn't deal with gap measurements and are not sure where they are located. 15. During an interview on 12/02/21, at 9:39 A.M., the MDS Coordinator, said the following: -Residents request side rails and these usually come through therapy. -This request is discussed with therapy, nurses, and those part of the medical team. -He/she puts the request in the Tell's system (a work order system for maintenance where staff should report issues that maintenance needs to repair, clean, or respond to) and a work order is created. -The Pre- Restraining Evaluation form is completed through this process and thereafter annually. -Every quarterly care plan they review the need for the side rails. -Residents sometimes request side rails as it makes them feel safer. 16. During an interview on 12/01/21, at 12:05 P.M., the Director of Nursing (DON) said they do not have consents for the side rails because they're considered enablers and not restraints. The side rails are placed at the resident's request. Once requested from the resident, the nurse and MDS coordinator complete their assessment and the maintenance department does their process after that. The maintenance department completes monthly checks of the side rails. 17. During an interview on 12/01/21, at 1:53 P.M., the maintenance supervisor said he/she measures the gaps between the side rails and mattresses. The measurements are not documented unless the computer systems tells him/her to document. The system has not prompted the need to document so the gap measurements are not documented. The measurements could be documented if this is required. 18. During an interview on 12/2/2021, at 3:10 P.M., the administrator said he believed the facility had assessed the turn rails prior to them being installed on the bed. Staff complete a risk versus benefits assessment. Maintenance completes the gap measurements prior to putting the turn rail on but he did not know maintenance did not record the measurements. He did not know there had to be a consent.

Based on interview and record review, the facility failed to report an allegation of abuse involving two residents (Resident #8 and Resident #58) to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of receiving the allegation. A sample of 18 residents was selected for review. The facility census was 90. Record review of the facility's policy titled, Abuse and Neglect Prevention Standard, showed the following information: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms; -It is the responsibility of all team members to immediately report any act of witnessed, suspected or reported abuse to the administrator or their supervisor. Under the Elder Justice Act, it is every individual's responsibility to ensure that suspected crimes are reported; -All allegations of abuse and/or neglect will be investigated and reported in accordance with the state and federal laws; -Report all alleged violations involving abuse immediately, but no later than two hours after the allegation has been made; -All resident to resident altercations must be reported immediately but no later than two hours after the allegation has been made; -After conducting an internal investigation, you must submit a report of all investigation results to the state within five working days. 1. Record review of Resident #8's face sheet (a brief resident profile sheet) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress note showed the following information: -On 7/20/2021, at 5:30 P.M., Resident #8 was in the hallway with other residents. Staff assisted other residents in rooms. Resident # 8 started yelling, Help me, help me. Staff responded and observed Resident #58 squeezing and twisting Resident # 8's right forearm. Staff assisted both residents to other areas of the hall. Resident #8's right forearm had redness. Resident #8 reported pain to the area. Resident #8 had limited mobility to his/her right lower arm. (Staff did not document notifying DHSS of the allegation of possible abuse.) Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/2021, showed the following information: -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfer, locomotion on the unit, and dressing. Record review of the resident's care plan, revised on 11/11/2021, showed the following information; -Activities of daily living skills (ADL - dressing, grooming, bathing, eating, and toileting), self-care performance deficit related to confusion, dementia, fall risk and incontinence; -Cognitive impairment related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Unaware of safety needs, unsteadiness, and lack of coordination. Record review of the DHSS records showed no report received from facility staff regarding the alleged possible abuse involving Resident #8 and Resident #58. 2. Record review of Resident #58's face sheet showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's progress note showed the following information: -On 7/20/2021, at 5:30 P.M., Resident #58 was in the hallway with other residents. Staff assisted other residents in rooms when staff heard Resident #8 yell, help me, help me. Staff went to the hallway and observed Resident #58 holding Resident #8's arm and twisting it. Resident #58 refused to let go. Resident #8 called out in pain. Staff convinced Resident #58 to let go of Resident #8's arm. Staff separated Resident #58 from other residents and staff attempted to calm Resident #8. Staff notified the physician on call of the resident's behavior and of the resident's refusal to take medications this shift. (Staff did not document notifying DHSS of the allegation of possible abuse.) Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Required extensive assistance with transfer, bed mobility, and (use past tense) wheelchair for ambulation. Record review of the resident's care plan, revised on 11/28/2021, showed the following information: -Experienced cognitive impairment, dementia; -Displayed out-of-character responses due to dementia-related diagnosis. Resident at risk for being verbally aggressive and physically aggressive with cares. Record review of the DHSS records showed staff did not self-report the alleged possible abuse involving Resident #58 and Resident #8. 3. During an interview on 12/2/2021, at 9:00 A.M., Certified Nursing Assistant (CNA) A, said the following: -He/she had received training on abuse and neglect, the types are financial, emotional, verbal and sexual. Resident to resident abuse should be considered abuse; -He/she did not witness the resident to resident altercation between Resident #8 and Resident #58. The incident would be considered abuse and should be reported to the supervisor and the state. 4. During an interview on 12/2/2021, at 1:09 P.M., CNA H said the following: -He/she would separate residents during an altercation and report to the supervisor. The report goes on up the chain and the State Agency is to be called within two hours. He/she would consider it abuse if residents hurt each other physically. The staff have in-services about abuse frequently. The types of abuse are physical, mental, sexual, and financial. 5. During an interview on 12/2/2021, at 1:13 P.M., CNA I said the following: -If residents have an altercation, staff should separate the residents, makes sure they are safe, and let the supervisor know. The staff gets multiple in-services during the year regarding abuse and neglect. He/she would consider resident physical altercations abuse. Social Services Director is the abuse coordinator. The administrator and DON are contacted. The State Agency is contacted within two hours. 6. During an interview on 12/2/2021, at 1:25 P.M., Housekeeping K, said the following: -If residents are in an altercation, he/she would separate them, make sure they are safe, and get a nurse immediately. The supervisor reports on up the chain and the State Agency should be notified within two hours. 7. During an interview on 12/2/2021, at 9:25 A.M., Certified Medication Technician (CMT) B said the following: -He/she received training on abuse, but not a lot. Types of abuse are verbal, sexual, isolation, and physical. Resident to resident altercations would also be abuse. Abuse should be reported to the charge nurse and the state within two hours. 8. During an interview on 12/2/2021, at 1:19 P.M., Licensed Practical Nurse (LPN) J said the following: -If residents have an altercation, staff should separate them, make sure they are safe, and call the supervisor. The staff gets multiple in-services regarding abuse and neglect throughout the year. He/she would consider it abuse for residents to be in physical altercations with each other. The abuse coordinator is the Social Services Director. 9. During an interview on 12/2/2021, at 9:33 A.M., LPN G, said the following: -He/she receives training at least quarterly on abuse, neglect, exploitation. Types of abuse are neglect, verbal, sexual, isolation and physical. Resident to resident altercations would be abuse; -He/she would report abuse to his/her supervisor, complete an investigation and notify the state within two hours. 10. During an interview on 12/2/2021, at 10:31 A.M., the MDS Coordinator said the following: -He/she received abuse training, at least annually and upon hire. Types of abuse are verbal, physical, emotional, neglect, financial and sexual. Resident to resident altercations would also be considered abuse and all abuse should be reported to supervisor. 11. During an interview on 12/2/2021, at 3:00 P.M., the Social Services Director said the following: -He/she receives abuse and neglect training, and all staff receive it when hired, annually and when there are incidents of abuse; -Types of abuse are neglect, physical, mental, verbal, misappropriation of funds, involuntary seclusion, sexual. Resident to resident would also be considered abuse; -He/she would report suspected abuse to his/her supervisor immediately, the responsible party is also contacted, and the state is notified within two hours; -He/she did not know about the incident between Resident #8 and Resident #58. 12. During an interview on 12/2/2021, at 10:52 A.M., the Director of Nursing (DON) said the following: -Prior to COVID, abuse trainings were held monthly, now there's more paperwork in-services. Training is provided when hired and held at least every two to three months thereafter; -Types of abuse are physical, mental, involuntary seclusion, sexual, neglect, misappropriation. Resident to Resident altercations could be abuse when someone is unsafe; -Staff should report abuse to the DON. If the DON is not available, then staff should report abuse to the supervisor. If after hours, there is an on call nurse available to notify; -Abuse must be reported to the state within two hours, and an investigation started. -The incident between Resident #8 and Resident #58 should be reported to the state within two hours. 13. During an interview on 12/3/2021, at 10:30 A.M., the administrator said the following: -He/she would expect resident to resident altercations to be reported to him/her. -He/she will report these incidents to the state in the future. -The incident between Resident #8 and Resident #58 should have been reported to the state.

Based on interview and record review, the facility failed to report an allegation of abuse made by one resident (Resident #1) to the state licensing agency (Department of Health and Senior Services- DHSS) within the required two time frame. A sample of four residents was selected in a facility with a census of 100. Record review of the facility's abuse prevention policy, revised (MONTH) (YEAR), labeled Abuse and Neglect Prevention Standard (VII Reporting/Response) showed the following information: -Reporting must be made to the administrator or designee and other officials (including State Survey Agency and/or APS (Adult Protective Services) where state law provides for jurisdiction in LTC (Long Term Care) facilities) in accordance with state law through established procedures. Follow the state's specific reporting guidelines and requirements. -Any alleged physical, mental, verbal or sexual abuse: mistreatment, neglect, misappropriation of resident's property, exploitation, or involuntary seclusion of a resident by a team member is to be reported to proper authorities. Please note that there is no minimum cost or number of items related to reporting criteria, all resident misappropriation of property needs to be reported; -Report all alleged violations involving abuse (physical, mental, verbal or sexual) immediately, but no later than two hours after the allegation has been made; -Report all alleged violations involving neglect, exploitation, mistreatment, including injuries of unknown source, and misappropriation of resident property, if the allegation involved results in serious bodily injury immediately, but no later than 2 hours. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/20/18, showed the following: -Resident severely cognitively impaired; -No behaviors; -No hallucinations/delusions; -Supervision required with bed mobility, transfer, personal hygiene. and toilet use. Record review of the resident's care plan, revised on 7/23/2018, showed the following information: -The resident experiences cognitive impairment related to [DIAGNOSES REDACTED]. -An updated 9/4/2018, resident is at risk for displaying out-of-character responses due to dementia-related diagnosis. Resident may have delusions and paranoia (looks for people or watching for people). Record review of the resident's nurse's notes, from 6/3/2018 to 9/26/2018, showed the facility staff did not document any information regarding resident stating allegations of sexual abuse or people in doorway with inappropriate sexual behavior. Record review of Certified Nurse Assistant (CNA) A's written statement, dated 9/12/18 and untimed, showed the following information: -CNA A wrote last night, around 10:20 P.M.-10:25 P.M., he/she was passing ice water to resident and resident reported a man was in front of doorway jacking off' and resident had undergarments on. CNA A went to LPN B and told him/her. The resident didn't name a who it was. Record review of LPN B's statement, dated 9/12/18 and untimed, showed LPN B said CNA A reported to him/her that the resident said a man was at his/her door with his pants down around his ankles and resident was afraid. LPN B said he/she knew that the nurse was aware. Record review of LPN C's written statement, dated 9/12/2018 and untimed, showed during report around 6:15 A.M. LPN B reported that the resident was in his/her underwear getting ready for bed and the male was in the doorway to his/her room, masturbating. LPN C called on call nurse and reported incident. Record review of the facility's investigation, received on 9/14/18, showed the administrator notified DHSS of the allegation on 9/12/18 at 7:30 A.M. (nine hours after the allegation was made). Record review of DHSS records showed the facility reported an allegation of abuse to DHSS on 9/12/18 at 7:30 A.M. During an interview on 9/26/18, at 3:15 P.M., CNA A said the following information: -Types of abuse include verbal, physical, and mental. The definition of sexual abuse is touching residents; -Staff should report immediately to the charge nurse; -He/she was passing ice water on the night shift and between 9:30 P.M. and 10:15 P.M. The resident reported a man was in his/her doorway with his/her pants down jacking off'. The resident was shaken up and the resident didn't know the man; -He/she reported to LPN B and the nurses were talking about the allegation when she went to report it. During a phone interview on 9/26/18, at 3:26 P.M., LPN B said the following information: -Types of abuse include emotional, physical, and mental and staff should repot to on call nurse immediately; -LPN B said sexual abuse is defined as a person inappropriately touching someone or having their clothes off; -On 9/11/18, at 10:00 P.M., staff reported of the incident, but didn't' say what time it happened. LPN B said CNA A told LPN B said he/she assumed this happened earlier in the day. During a phone interview on 9/26/18, at 4:04 P.M., Registered Nurse (RN) C said the following information: -On 9/12/18, at 6:15 A.M., night shift staff reported that a man was in the doorway of the resident's room and had his pants down around his ankles and masturbating; -RN C said he/she asked LPN B if it was reported and LPN B was not sure. RN C said the information was not found in chart note or report sheet; -On 9/12/18, at 6:35 A.M., RN C called on call nurse regarding allegation of abuse. During an interview on 9/27/18, at 12:11 P.M., the Director of nursing (DON) said the following information: -Types of abuse include physical, emotional, and verbal; -An allegation of abuse is to be reported to DHSS within two hours; -Social services completes most of the abuse investigation; -The allegation of abuse should have been reported to DHSS within two hours. During interviews on 9/27/18, at 12:11 P.M. and 12:55 P.M., the Social Services Director said the following information: -The resident's responsible party said it was not unusual for the resident to say men were masturbating and more prominent since his/her spouse passed away; -This is the first time she was aware of this; -The allegation of abuse should have been reported to DHSS within two hours. MO 222

Based on observation, interview, and record review, the facility failed to maintain a safe cold storage temperature (under 41 degrees Fahrenheit (F)) in the walk-in refrigeration unit where the facility stored potentially hazardous foods when staff identified the temperature as being over 41 degrees F and failed to put measures in place to correct the problem for at least 24 hours. This deficient practice had the potential to cause food borne illnesses for all the residents. The facility census was 92. Record review of the Missouri Department of Health and Senior Services Food Code, published June 2013, showed: -Cold holding for potentially hazardous food shall be maintained at 41 degrees F. Food shall have an internal temperature of 41 degrees or less when removed from cold holding. 1. Observation on 5/23/16, at 5:50 A.M., showed the following: -The walk-in refrigeration unit's external digital thermometer showed 47 degrees F; -The thermometer inside the front (closest to the door) of the walk-in refrigeration unit showed 49 degrees F; -The walk-in refrigeration unit contained numerous food items, including fresh produce items and potentially hazardous foods such as fully cooked ready-to eat deli meats, raw eggs and meats, and dairy products. Observations and interview on 5/24/16, beginning at 8:02 A.M., showed the following: -The walk-in refrigeration unit's external digital thermometer showed 48 degrees; -The facility dietary manager identified some of the food products in the refrigeration unit as products stored in the unit for an extended time; -He took the internal temperatures of some of the identified products; -His thermometer showed the internal temperature of a large commercial block of cream cheese was 49 degrees F; -His thermometer showed the internal temperature of a four-ounce container of yogurt was 48 degrees F; -The dietary manager took the internal temperature of a bottle of blue cheese salad dressing; his thermometer read 48 degrees F for the product; -The dietary manager used the surveyor's thermometer to check to double check the internal temperature for the same bottle of blue cheese salad dressing. The surveyor's thermometer showed 48.8 degrees. During an interview 5/24/16, at 8:20 A.M., the dietary manager said the following: -He called maintenance staff and they would be working to repair the walk-in refrigeration unit so that proper (colder) temperature could be maintained; -Maintenance also directed the dietary manager to prop open the walk-in freezer door six inches to assist with cooling the walk-in refrigeration unit (the walk in freezer is inside of the walk-in refrigeration unit); -Dietary staff checked the refrigeration unit's temperatures twice per day and documented them on a posted log; -Dietary staff had not notified the manager the walk-in refrigeration unit was at an unsafe temperature. Record review on 5/24/16, at 8:37 A.M., of the posted cold storage log temperatures showed the following: -Staff recorded the morning walk-in refrigeration unit temperature for 5/23/16 as 48 degrees F. -Staff recorded the evening temperature for walk-in unit the same day as 40 degrees F; -Staff recorded the morning walk-in refrigeration unit temperature for 5/24/16 as 48 degrees F; During an interview on 5/24/16, at 8:50 A.M., the dietary manager said the following: -He had contacted the facility's consulting registered dietitian (RD). She had directed him to throw out all potentially hazardous food from the walk-in refrigeration unit. She said the fresh produce was the only products that she considered safe because they did not know the time frame they had stored potentially hazardous foods at unsafe temperatures. During an interview on 5/25/16, at 2:50 P.M., the RD said that the dietary manager had thrown out all of the potentially hazardous food on 5/24/15 from the walk-in refrigeration unit; he kept only fresh produce.

Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry to ensure all new staff did not have a Federal Indicator (a marker given to staff who have committed abuse, neglect, or misappropriation of resident property against residents). Staff did not check the registry for three of eight sampled employees. The facility census was 93. 1. Record review of Registered Nurse (RN) A employee records showed: -Hire date of 02/16/15; -Staff did not check the NA registry for a federal marker. 2. Record review of Receptionist B employee records showed: -Hire date of 01/19/15; -Staff did not check the NA registry for a federal marker. 3. Record review of social service assistant C employee records showed: -Hire date of 01/19/15; -Staff did not check the NA registry for a federal marker. 4. During an interview on 03/12/15, at 1:10 P.M., business office manager D said he/she performed new employee background checks, but had not checked the Nurse Aide Registry for federal indicators on all new employees. The office manager did not know he/she needed to check all employees. The office manager said he/she was responsible for the checks during December 2014 through January/February, 2015. 5. During an interview on 03/13/15 at 11:55 A.M., the administrator said the business office manager was responsible for performing background checks on new employees. The administrator was unaware the facility needed to check the NA registry for all new employees. He said he thought the family care safety registry took the place of the NA registry.

Based on observation and interview the facility failed to provide care in a manner to promote one resident's (Resident #14) dignity out of two sampled residents in a facility with a census of 95. 1. Record review of the resident's annual Minimum Data Set (MDS) a federally mandated assessment tool required to be completed by facility staff dated 7/11/12, showed the following information: -Severely impaired cognitive skills; -Total dependence for bed mobility, transfers, dressing, and locomotion on and off unit, toilet use and personal hygiene; -Always incontinent of bowel; -Indwelling urinary catheter. Record review of the resident's care plan dated 9/10/09, and updated on 8/16/12, showed the following information: -Indwelling catheter due to [MEDICAL CONDITION]; -Pericare with catheter care every shift; -Place catheter bag in dignity bag. Observation and interview on 8/16/12, beginning at 9:20 A.M., the Director of Nurses (DON) and the medical records licensed practical nurse (LPN) stood in the hall in front of the resident's room with the door open. Two surveyors looked inside the resident's room and saw the resident lying in bed uncovered with his/her pants down to approximately six inches above the knees. The resident's genital area was exposed to any staff or visitors in the hallway. The DON quickly closed the resident's door. The DON, LPN, and the two surveyors then entered the resident's room. Without first covering the resident, the LPN opened the door and left the room. The LPN then re-entered the room a few minutes later. The resident continued to lay in bed with his/her pants pulled down which exposed the resident to any staff or visitors in the hallway during the opening of the door. Staff did not attempt to cover the resident. The DON donned sterile gloves and secured the resident's indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). Without first covering the resident, the LPN opened the door and left the resident's room again to obtain more supplies. The LPN then re-entered a few minutes later. The resident continued to lay exposed. The LPN said he/she was unable to find the needed supplies. The DON opened the door and left the room then re-entered a few minutes later, again exposing the resident to anyone in hallway. While the DON discussed the resident's care with the two surveyors, the resident continued to be exposed. Staff did not attempt to cover the resident. After being exposed for approximately 13 minutes, the DON covered the resident with a blanket. During an interview on 8/16/12, at 3:30 P.M., the DON said the facility's policy is to provide care to each resident with dignity to provide a high quality of life. The DON said, "I was disrespectful to the resident by not covering him/her up".

Based on record review and interview the facility failed to contact one resident's (Resident #14) physician after staff found the urinary catheter out/dislodged of the resident, on three occasions, that caused trauma (bleeding) and failed to obtain an order to place a different size indwelling catheter, or to test for possible urinary tract infection. A sample of two residents with urinary catheters were chosen for review in this facility with a census of 95. 1. Record review of Resident #14's admission face sheet showed the facility admitted the resident on 8/29/08 and readmitted on [DATE], after a hospital stay. The resident had [DIAGNOSES REDACTED]. Record review of the resident's acute care plan, (used by the facility staff to update the resident's care plan with approaches for current problems, such as infections), showed the resident had a urinary tract infection on 4/2/12, 5/3/12, 6/3/12 and 6/27/12. Record review of the resident's annual Minimum Data Set (MDS) a federally mandated assessment tool required to be completed by facility staff, dated 7/11/12, showed the following information: -Severely impaired cognitive skills; -No behaviors; -Total dependence for bed mobility, transfers, dressing, and locomotion on and off unit, toilet use and personal hygiene; -Always incontinent of bowel; -Indwelling urinary catheter; -Infections. Record review of the physician's orders [REDACTED]. -Change catheter with a 16 French (F) five cc bulb every month and as needed; -Change catheter, secure (anchor) weekly. Record review of the nurses' notes dated 8/9/12, at 2:15 A.M., showed the following: -Staff found the indwelling catheter out of the resident with the bulb intact and noted a small amount of blood (staff did not specify the location of the bleeding); -Staff replaced the catheter with a 18 French (the physician ordered a size 16 French catheter) with a five cc bulb; -Staff did not notify the physician of the staff finding the catheter out with bleeding noted and did not receive a new physician order [REDACTED]. -Staff did not document in the nurses' notes until 8/13/12; Review of nurses notes dated 8/13/12, at 1:00 P.M., showed the certified nursing assistant (CNA) notified the nurse that the indwelling catheter was pulled out with the bulb inflated; -Staff reinserted a 16F catheter with a five cc bulb (correct size); -Small amount of bleeding to the meatus (opening of the urethral canal) -Staff did not notify the physician the indwelling catheter was pulled out or that the resident had bleeding from the meatus; Review of nurses notes dated 8/16/12, at 4:15 A.M., showed a CNA called the nurse to the resident's room and reported a large amount of blood around the vaginal area; -The nurse assessed the resident and saw the catheter bulb still inflated at the opening of the vagina; -The resident had a large bowel movement; -After providing pericare, the nurse reinserted the indwelling catheter with a 16 F catheter and a 30 cc bulb (the physician ordered a five cc bulb); -Staff did not notify the physician the indwelling catheter was out or that the resident had a large amount of blood around the vaginal area, and did not obtain an order to insert a catheter with a different size bulb. During an interview on 8/16/12, beginning at 9:15 A.M., the Director of Nursing (DON) said she was unaware the resident had pulled the indwelling catheter out three times. She said the facility only had indwelling catheters with either a five cc or a ten cc bulb. The DON said she was contacting the physician to get an order to check the indwelling catheter to see how much water the nurse inserted into the bulb. The DON said staff should have reported to the physician and to her about the large amount of bleeding after staff found the catheter out. During observation and interview on 8/16/12, beginning at 9:20 A.M., the DON prepared to check the resident's urinary catheter. The DON said the staff should have checked with the physician before they changed the catheter or bulb size and should have reported the bleeding. During an interview on 8/16/12, at 11:48 A.M., the resident's physician said the staff made him aware of the indwelling catheter issues today, especially documenting the 30 cc bulb. He said if the staff had reported new behaviors (pulling on the catheter) or trauma (bleeding from the meatus) to the DON or him, he would want to see what was causing the behaviors, such as possible urinary tract infection. If staff thought the resident had a possible infection, the best time to obtain the urine specimen would have been when they reinserted the catheter. Record review of the resident's care plan dated 9/10/09, and updated on 8/16/12, showed the following information (in part): -Indwelling catheter due to [MEDICAL CONDITION]; -Change catheter every month and as needed; -Communicate with the physician when the resident exhibited signs of urinary tract infection; -16 French (the size of the diameter of the catheter) catheter with five cubic centimeter (cc) bulb (a balloon at the end of the catheter that is inflated with sterile water to hold the catheter in place), changed on 8/16/12, to 10 cc bulb; -At risk for bleeding related to Aspirin therapy; -Medicate as ordered; -Assess for bleeding and bruising; -Communicate with physician as needed.

This deficiency is uncorrected. For previous examples see the Statement of Deficiencies dated 6/22/12. Based on observation, interview and record review, the facility failed to ensure staff followed a physician's orders [REDACTED].#14) indwelling urinary catheter. The facility failed to take appropriate action on three occasions when staff identified the dislodgement Resident #14's urinary catheter and the presence of abnormal bleeding from the resident's urinary meatus (opening to the urinary tract). In addition, the facility failed to ensure the staff handled Resident #14's catheter in accordance with current nursing standards of care when staff held the catheter bag and tubing above the level of the resident's bladder while transferring him/her from bed to a chair. A sample of two residents, who had indwelling urinary catheters, were chosen for review in this facility with a census of 95. 1. Record review of Resident #14's admission face sheet showed the facility admitted the resident on 8/29/08, and readmitted on [DATE], after a hospital stay. The resident had [DIAGNOSES REDACTED]. Record review of the resident's acute care plan, (used by the facility staff to update the resident's care plan with approaches for current problems, such as infections), showed the resident had urinary tract infections on 4/2/12, 5/3/12, 6/3/12 and 6/27/12. Record review of the resident's annual Minimum Data Set (MDS) a federally mandated assessment tool required to be completed by facility staff dated 7/11/12, showed the following information: -Severely impaired cognitive skills; -No behaviors; -Total dependence for bed mobility, transfers, dressing, and locomotion on and off unit, toilet use and personal hygiene; -Always incontinent of bowel; -Indwelling urinary catheter. Record review of the resident's care plan, dated 9/10/09, and updated on 8/16/12, showed the following information: -Indwelling catheter due to [MEDICAL CONDITION]; -Pericare with catheter care every shift; -Encourage fluids; -Keep catheter bag below level of bladder; -Change catheter every month and as needed; -Communicate with the physician when the resident exhibited signs of urinary tract infection; -Empty catheter bag and document cubic centimeters (cc) at end of each shift; -Place catheter bag in dignity bag; -16 French (the size of the diameter of the catheter) catheter with a five cc bulb (a balloon at the end of the catheter that is inflated with sterile water to hold the catheter in place); -Anchor catheter tubing to prevent tugging; -Empty catheter bag before each transfer; -At risk for bleeding related to aspirin therapy; -Medicate as ordered; -Assess for bleeding and bruising; -Communicate with physician as needed. Record review of the physician's orders [REDACTED]. -Push fluids; -Cranberry tablet one everyday; -Change catheter with 16 French (F) five cc bulb every month and as needed; -Change catheter, secure (anchor) weekly; - the following pain medications: --[MEDICATION NAME] 100 mg BID (twice a day); --[MEDICATION NAME] 10/325 mg every 4 hours, as needed for pain; --Tylenol 325 mg 1 tab, every 4-6 hours, as needed for pain/temp; --Tylenol 325 mg 2 tabs, every 4-6 hours as needed for pain/temp; --[MEDICATION NAME] 10/325 mg 1 tab, four times a day. Record review of the nurses' notes dated 8/09/12, at 2:15 A.M., showed the following: -Staff found the indwelling catheter out of the resident with bulb intact and noted a small amount of blood (Staff did not specify the location of the bleeding.); -Staff replaced the catheter with a size 18 French (the physician ordered a size 16 French catheter) with a five cc bulb; -Staff did not notify the physician of staff finding the catheter out with bleeding noted and did not receive a new physician order [REDACTED]. -Staff made no documentation or interventions in the resident's care plan that instructed staff to monitor the resident for pulling on the indwelling catheter or to monitor for bleeding related to staff finding the catheter out of the resident; -Staff did not document in the nurses' notes until 8/13/12; -On 8/13/12, at 1:00 P.M., the certified nursing assistant (CNA) notified the nurse that the resident's indwelling catheter was pulled out with the bulb inflated; -Staff reinserted a 16F catheter with a five cc bulb (correct size); -A small amount of bleeding was noted to the resident's urinary meatus; -Staff did not notify the physician the indwelling catheter was pulled out or that the resident had bleeding from the meatus; -Staff did not document in the resident's care plan to instruct staff to monitor the resident for pulling on, or dislodging, the indwelling catheter or to monitor for bleeding related to pulling on, or dislodging, the indwelling catheter; -On 8/16/12, at 4:15 A.M., a CNA called the nurse to the resident's room and reported a large amount of blood around the resident's vaginal area; -The nurse assessed the resident and saw the catheter bulb, still inflated, out of the resident's bladder and at the opening of the vagina; -The resident had a large bowel movement; -After providing pericare, the nurse reinserted the indwelling catheter with a 16 F catheter and a 30 cc bulb (the physician ordered a five cc bulb); -Staff did not notify the physician staff found the indwelling catheter was out or that the resident had a large amount of blood around the vaginal area, and did not obtain an order to insert a catheter with a different size bulb; -Staff did not document in the resident's care plan that instructed staff to monitor the resident for pulling on, or dislodging, the indwelling catheter or to monitor for bleeding related to the indwelling catheter being dislodged. During an interview on 8/16/12, beginning at 9:15 A.M., the Director of Nursing (DON) said she was unaware the resident pulled the indwelling catheter out three times. She said the facility only had indwelling catheters with either a five cc or a ten cc bulb. The DON said she was contacting the physician to get a physician order [REDACTED]. The DON said staff should have reported to the physician and to her about the large amount of bleeding after staff found the catheter out. Observation and interview on 8/16/12, beginning at 9:20 A.M., showed theDON, LPN, and two surveyors entered the resident's room. The DON said the staff should have checked with the physician before they changed the catheter or bulb size and should have reported the bleeding. Observation of the indwelling catheter inserted by the staff on 8/16/12, showed the resident had a 16 F catheter with a 10 cc bulb (the physician ordered a five cc bulb). The DON donned sterile gloves and secured the indwelling catheter with her left hand at the resident's urinary meatus while the LPN removed 10 cc of water from the bulb (the physician order [REDACTED]. The DON said staff were going to assess the resident to discontinue the indwelling catheter. The DON said the resident pulling at the indwelling catheter was a new behavior. The resident had never pulled at the indwelling catheter before. The DON also said the facility had a new policy for transferring Resident #14. Staff were to drain the indwelling catheter bag and tubing completely before they transferred the resident with the mechanical lift. Staff would place the indwelling catheter bag on the resident's lap (this would continue to place the indwelling catheter bag above the bladder and allow the backflow of residual urine in the bag and tubing into the bladder) and then transfer him/her. Observation on 8/16/12, beginning at 11:09 A.M., showed CNA A and CNA B entered the resident's room to transfer the resident from bed to his/her Broda (specialized recliner type chair) chair. Staff positioned the resident on his/her back with the indwelling catheter bag below the end of the bed. Staff positioned the Broda chair next to the resident's bed and washed their hands. Staff turned the resident from side to side to place the mechanical lift sling underneath the resident. CNA B emptied the indwelling catheter bag into a plastic container. Observation showed approximately 30 ccs of urine left in the indwelling catheter bag and 10 cc left in the tubing. The CNA then raised the tubing to drain the urine out of the tubing by lifting the tubing above the bladder. Observation showed the residual urine flowed back into the resident's bladder. Staff placed the catheter bag on the bed then fastened the mechanical lift straps to the lift sling. Staff placed the indwelling catheter bag in the resident's lap above the level of the bladder (which could possibly allow urine and bacteria to flow back into the bladder) and transferred her/him to the Broda chair. Review of Lippincott's Nursing Procedures, 5th edition, 2009, showed the care of an indwelling urinary catheter system included the following special consideration: "Avoid raising the drainage bag above bladder level. This prevents the reflux of urine, which may contain bacteria". During an interview on 8/16/12, at 11:48 A.M., the resident's physician said the staff made him aware of the resident's indwelling catheter issues today, especially documenting the 30 cc bulb. The physician said he would want to be notified of any new behavior, such as pulling out the catheter. He said if the staff had reported the resident's behaviors to the DON or to him, he would have wanted to see what was causing the behaviors, such as an urinary tract infection. The physician said if the staff thought the resident had a possible urinary tract infection, the right time to get the urine specimen for testing would have been when the staff reinserted the indwelling catheter. The physician said the staff should have notified him of any trauma as indicated by the resident's bleeding from the meatus. Review of the plan of care update 8/16/12 showed resident's catheter changed to a 16 French (the size of the diameter of the catheter) with a 10 cc bulb, (a balloon at the end of the catheter that is inflated with sterile water to hold the catheter in place). During a telephone interview on 8/20/12, beginning at 9:05 A.M., the DON said,the nurse who inserted the 18 F indwelling catheter on 8/9/12 said that was the only size catheter in stock, so that is what he/she used. During an interview on 8/21/12, at 11:40 A.M., the DON said after she reviewing documentation in the resident's medical record she could not confirm the resident pulled the urinary catheter out him/herself. Staff documented the catheter was out, but did not document how the catheter came out. The DON said she talked with the resident, who told her he/she did not pull the catheter out. The DON said the resident's behavioral monitoring records did not indicate the resident had pulled on the catheter. The DON talked with the nurse who was present on 8/16/12, who said the resident had a firm bowel movement and felt the catheter had been pushed out at that time. Record review of a written statement dated 8/20/12, showed LPN D said, on 8/16/12, he/she observed the resident had a firm formed bowel movement at which time the urinary catheter bulb was pushed out to the opening of the vagina. The resident did not pull the urinary catheter out. The nurse placed only 10 ccs of water in the catheter bulb, not the 30 ccs he/she documented in the nurses' notes dated 8/16/12. During an interview on 8/21/12, at approximately 12:10 P.M., the DON said the statement made by LPN D regarding the resident pulling the catheter out was incorrect. The nurse did not know this for a fact. Record review of a written statement, dated 8/21/12, showed LPN C said on 8/9/12, the CNA told him/her there was no urine in the resident's catheter collection bag. LPN C asked the CNA to come with him/her to see if they could adjust or possibly irrigate it. LPN C observed the balloon at least half way out with the tip in place and told the CNA it would have to be replaced. LPN C said he/she checked the treatment book and saw the resident had a prn (as needed) order. When he/she gathered the supplies, his/her choices were between a 16 F silicone catheter with a five cc bulb which is very stiff and unbending, or an 18 F latex catheter with a five cc bulb. The nurse said he/she chose the 18 F latex catheter and inserted it into the resident. When he/she removed the old catheter, the nurse said he/she noted a small amount of blood but no further bleeding was reported.

Based on closed record review and interview the facility failed to ensure staff followed physician orders [REDACTED]. 1. Record review of the April, 2012 physician orders [REDACTED]. -On 4/10/12 an order to discontinue the urinary catheter (a sterile tube inserted into the bladder to drain urine); -On 4/11/12 an order for [REDACTED]. -On 4/11/12 an order for [REDACTED]. Record review of the nurse's notes dated 4/11/12, showed the following information: -At 5:10 A.M., staff discontinued the urinary catheter. The resident tolerated the procedure well. Staff encouraged the resident to drink lots of fluids to help with voiding (urinating). The resident had 400 ccs of clear yellow urine in the drainage bag. Staff would continue to monitor the resident's voiding. -At 4:50 P.M., the resident had not voided. Staff paged the physician and waited for a response. The resident denied pain or urge to void. -At 5:00 P.M., (12 hours since the resident last voided) staff received an order for [REDACTED]. -At 8:55 P.M., (almost four more hours since staff received the order for straight catheterization) staff performed a straight catheterization on the resident with a return of 950 ccs of clear amber urine. The resident tolerated the process without complaint and stated he/she felt much better. Record review of the care plan dated 4/11/12 did not direct staff regarding catheter care or in and out straight catheterizations. During an interview on 6/22/12. at 10:00 A.M., the DON said she would have called the physician and clarified the order regarding the bladder scan. Since the facility did not have a bladder scanner staff should have called the physician with an assessment of the resident and ask if the physician wanted the resident sent out for the bladder scan or do an in and out catheterization. She would have expected staff to initiate the in and out catheterization then every six hours as needed.

Based on observation, interview and record review the facility failed to ensure staff followed a physician's order to remove one resident's (Resident #15) indwelling urinary catheter. Staff failed to obtain an order to continue the use of the indwelling catheter. Staff failed to obtain a [DIAGNOSES REDACTED]. The facility failed to ensure staff obtained orders regarding when to change one resident's (Resident #14) urinary catheter, size of urinary catheter to be used, and failed to develop a care plan with interventions for staff to follow related to the urinary catheter. The facility failed to ensure staff handled two residents' (Residents #14 and #15) catheters in accordance with current nursing standards of care when staff held the catheter above the level of the resident's bladder and failed to ensure staff placed the catheter off the floor while the resident lay in bed for one resident (Resident #14). Residents #14 and #15 had histories of urinary tract infections in a sample of 16 residents in a facility with a census of 95. 1. Record review of Resident #15's admission Minimum data Set (MDS), a federally mandated comprehensive tool completed by facility staff, dated 5/1/12, showed the following information: -The resident requires extensive assistance with eating, dressing, toileting and personal hygiene; -The resident has an indwelling catheter. Record review of the care plan, dated 5/23/12, showed it directed staff to perform the following: -Make sure the resident's leg strap is in place to prevent tugging; -Remind the resident to not pull on the catheter; -Change the Foley(catheter) per order; -Perform catheter care every shift. Record review of the medical record showed a discharge summary from the hospital, dated 4/24/12, instructing the facility to remove the Foley catheter five days after discharge from the hospital. Record review of the physician order sheet (POS), dated April 2012, showed the following: -On 4/24/12, Admit to facility; -16 french Foley catheter, staff to remove on 4/29/12; -The POS did not direct staff to perform catheter care every shift or to change the catheter; -The POS did not have a [DIAGNOSES REDACTED]. -On 4/25/12 orders obtained to perform a urinalysis with culture and sensitivity; -On 4/27/12, orders obtained to start the resident on the [MEDICATION NAME] milligrams (mg) by mouth, two times daily for seven days. The nurse failed to document the [DIAGNOSES REDACTED]. Record review of the urinalysis lab records, dated 4/27/12, showed the resident has a urinary tract infection [MEDICAL CONDITION]. The culture report showed a growth of yeast. As a result of the urinalysis report the physician started the resident on Cipro. Record review of the April nurses' notes showed the following: -From 4/27/12- 5/5/12 the resident was receiving the [MEDICATION NAME] the [DIAGNOSES REDACTED]. -On 4/27/12 at 6:35 A.M., the resident's catheter patent and draining dark urine to gravity; -On 4/28/12 at 1:30 P.M., the resident's foley is patent and draining dark amber urine to bed side drainage bag; -On 4/29/12 at 4:10 A.M., the resident's Foley catheter is patent and draining cloudy amber urine with sediment in it. At 4:30 A.M. the resident only had 100 cc of output in the foley catheter with a small clot noted. The nurse documented he/she irrigated the catheter without resistance. The nurse documented from 7:30 A.M. to 9:00 A.M., the resident's Foley catheter is patent and draining amber urine to bed side drainage bag. At 7:00 P.M., the nurse documented he/she has an order to remove the Foley catheter today. The resident's daughter states to leave it in and that the resident "cannot go without it". The resident pulls at the catheter and wants it out. The Assistant Director of Nursing (ADON) is aware and will speak with the family on Monday 4/30/12. Record Review of the POS [REDACTED] -The original POS does not direct staff to perform catheter care or change the catheter; -The POS did not have a [DIAGNOSES REDACTED]. -On 5/1/12 orders received to discontinued the resident's [MEDICATION NAME] (a medication used to improve urination in men with [MEDICAL CONDITION]) order; -On 5/2/12 orders received for a basic metabolic panel (BMP) lab (lab that shows the current status of kidneys, blood sugar and electrolyte and acid/base balance) due to decreased urinary output; -On 5/6/12 at 2:50 P.M. orders received to irrigate the Foley with 60 milliliters (mL) due to no urinary output on 5/6/12 and to perform another BMP the morning of 5/7/12. At 3:45 P.M., the nurse obtained orders to change the Foley catheter as needed due to decreased urinary output; -On 5/7/12 orders received to perform a urinalysis with a culture and sensitivity report and to started the resident on the [MEDICATION NAME] mg by mouth, two times daily for seven days. The nurse did not document the [DIAGNOSES REDACTED]. -On 5/8/12 orders received for Foley catheter care every shift and to change the Foley catheter every month with a 16 french. The nurse failed to document the [DIAGNOSES REDACTED]. -On 5/16/12 orders received to start the resident on the antibiotic [MEDICATION NAME] 500 mg by mouth daily for seven days. The nurse failed to document the [DIAGNOSES REDACTED]. Record review of the physician progress notes [REDACTED]. Record review of the physician progress notes [REDACTED]. Record review of the May nurse notes showed the following: -On 5/1/12 at 7:10 A.M., the resident's catheter has pink (the nurse did not specify what the "pink" referred to) in the tube with small clots. At 3:00 P.M. the physician saw the resident and discontinued the resident's [MEDICATION NAME] order; -On 5/2/12 at 6:00 A.M., the resident has 150 cc of dark amber colored urine output. At 6:55 A.M. the nurse documented the resident's urine output was dark and brownish red in color with low urine output. At 9:40 P.M., the nurse documented he/she notified the resident's physician regarding the decreased urine output and received orders to have the BMP lab drawn; -On 5/3/12 at 11:30 A.M. the resident's Foley catheter was patent and draining dark yellow urine with sediment in the urine collection bag and tubing; -On 5/4/12 at 2:45 A.M., faxed the BMP results to the resident's physician. At 1:00 P.M. the resident's Foley is patent and draining, urine has scant hematuria (blood in the urine) and sediment; -On 5/5/12 at 7:10 A.M. the resident's urine is dark and cloudy with slight tinge of pink; -On 5/6/12 at 5:00 A.M. the resident's Foley catheter drained dark yellow urine. At 3:15 P.M. the nurse documented he/she received new orders to irrigate the catheter with 60 mL due to decreased urine output from 6:00 A.M. to 2:00 P.M. and to have lab draw a BMP on 5/7/12 in the morning. At 3:35 P.M. the nurse documented he/she attempted to irrigate the resident's foley catheter. The irrigation flowed with slight pressure and minimal urine/ irrigation backflow. The resident complained of the need to urinate while the nurse palpated the resident's lower abdomen. The nurse documented the resident's abdomen was flat but hard under palpation. The nurse paged the physician. At 4:00 P.M. received orders from the physician to change the resident's catheter as needed due to decreased urine output. At 7:45 P.M. the resident has roughly 35-50 mL of amber colored urine output and will wait to change the catheter until necessary. At 9:30 P.M. the resident has had no further urine output and changed the catheter with ease. The resident has minimal amount of urine output. The nurse documented he/she would notify the oncoming shift of decreased urine output; -On 5/7/12 at 4:30 A.M. the resident has 350 cc tea colored urine post 3 days from antibiotic therapy for a UTI. At 7:05 A.M. the resident's catheter drained tea colored and dark pink urine. At 5:15 P.M. the nurse documented he/she obtained orders to perform a urinalysis with culture and sensitivity and to start the resident on the [MEDICATION NAME] mg by mouth two times daily for seven days. Record review of the urinalysis lab records, dated 5/8/12, showed the resident had a urinary tract infection [MEDICAL CONDITION]. The culture report showed a growth of heavy yeast. As a result of the urinalysis report the physician started the resident on Cipro. Record review of the May nurses' notes showed the following: -From 5/7/12- 5/14/12 the resident was receiving antibiotic therapy for the [DIAGNOSES REDACTED]. -On 5/8/12 at 3:00 A.M. the resident's Foley catheter is patent and draining dark tea colored urine; -On 5/14/12 at 6:50 A.M. the resident's Foley is patent and draining dark to light brown, clear colored urine; -On 5/16/12 at 2:30 P.M. the resident left the facility via ambulance as ordered by the physician for nausea and vomiting throughout the day. At 9:45 P.M. the resident returned to the facility with a [DIAGNOSES REDACTED]. Record review of the Mercy discharge summary, dated 5/16/12, showed the resident received a [DIAGNOSES REDACTED]. Record review of the May nurse notes showed the following: -From 5/16/12 to 5/22/12 the resident was receiving antibiotic therapy for the [DIAGNOSES REDACTED]. -On 5/21/12 the resident received a fleets enema at 9:50 P.M. At 10:00 a certified nurse aide (CNA) called the nurse to the resident's room. When the nurse entered the room the resident was sitting on the toilet and the resident's catheter pulled out from the resident's penis. The nurse documented the catheter bulb remained intact and attached to the resident's leg strap. The nurse documented the resident's penis bled profusely. The nurse documented that pressure was applied to the resident's penis and calls placed to the physician and family. The nurse sent the resident to emergency room via ambulance at 10:35 P.M.; -On 5/22/12 at 5:15 A.M. the resident returned to the facility with a Foley catheter in place draining straw colored urine; -From 5/22/12 to 5/31/12 nurses documented periodically the resident's urine was dark yellow or amber in color. Record Review of the POS [REDACTED] -The POS did not have a [DIAGNOSES REDACTED]. -On 6/17/12 orders received to perform a urinalysis with culture and sensitivity and to start the resident [MEDICATION NAME] mg two times daily for seven days; -On 6/18/12 orders received to change the antibiotic to Bactrim DS two times daily for ten days. Record review of the June, 2012 nurse notes showed the following: -On 6/16/12 at 9:00 P.M. the resident's Foley drained cloudy urine with sediment and small amounts of blood present. The nurse notified the physician and received an order for [REDACTED]. -On 6/17/12 at 5:50 A.M. the resident's Foley was patent and draining cloudy yellow urine with sediment and a large amount of mucus. The nurse documented the urinalysis results were positive and faxed to the physician. At 8:10 P.M. the nurse started the resident [MEDICATION NAME] mg at 4:00 P.M.; -On 6/18/12 at 11:00 A.M. The nurse received the sensitivity report back on the urinalysis and the organism is resistant to Cipro. The nurse notified the physician of the results and the physician ordered Bactrim for the resident. Record review of the urinalysis lab records, dated 6/15/12, showed the resident had a urinary tract infection [MEDICAL CONDITION]. The culture report showed a growth of proteus mirabilis (a type of organism). As a result of the urinalysis report the physician started the resident on Cipro. After the sensitivity report was completed the physician ordered Bactrim for the resident. Record review of the medical record showed facility staff initiated an acute care plan for urinary tract infections, dated 6/18/12. The care plan directed staff to encourage fluids, give medications as ordered by the physician, follow up urinalysis with culture and sensitivity as ordered by the physician and observe for effectiveness of the medication and possible adverse reactions to medications. Record review of the medical record showed no further documentation regarding follow up with the family regarding their wishes to leave the catheter in place since 4/29/12, or follow up with the physician regarding the family's wishes. Observations on 6/21/12 at 12:50 P.M. showed CNA C in the resident's room assisting with a transfer from the wheelchair to the recliner. While assisting with the transfer the CNA removed the catheter bag from the dignity bag hanging from the bottom of the wheelchair. As the resident stood, the CNA raised his/her hand holding the catheter bag causing the catheter bag to be above the resident's head. During the transfer the CNA had the catheter tubing pulled up raising the resident's pant leg to approximately his knee. During an interview on 6/22/12 at 8:02 A.M., CNA C said the catheter bag should always remain below the resident's bladder at all times. During an interview on 6/22/12 at 8:30 A.M., LPN A said during a transfer he/she would expect the aide to keep the catheter collection bag below the resident bladder to prevent back flow into the bladder and to not pull on the catheter bag. During an interview on 6/22/12 at 8:38 A.M. the DON said the following: -If a resident is admitted with a catheter, the facility tries to remove the catheter. If they meet resistance from the family not wasting it removed, then the nurse should notify the physician; -The nurse receiving orders to continue a catheter or place a catheter should get full complete orders including the [DIAGNOSES REDACTED]. The DON expects the [DIAGNOSES REDACTED]. -During transfers she expects the aides to keep the catheter collection bag below the resident bladder to prevent back flow; -The DON said she can see that the catheter still being inserted is a problem with the lack of documentation in the resident's chart. She had struggled with the nurses documenting in the nurse's notes and had inserviced the nursing staff. The DON said while questioning the nursing staff regarding the resident's catheter the morning of 6/22/12, a nurse told her the physician rounded the next day, (4/30/12) and said to leave the resident's catheter in. Nothing is charted regarding the orders to keep the catheter. She is unsure if Resident #15's catheter has been removed for a trial period since his admitted in April. During an interview on 6/25/12 at 3:22 P.M., LPN B said the resident was transferring without assistance when the catheter was pulled out on 5/12/12. The LPN said he/she had administered an enema to the resident and had left the resident laying on his/her side with the call light on the bed. The LPN said a couple minutes later an aide asked for assistance and he/she found the resident on the bed side commode with the catheter pulled out from his penis; balloon still intact and attached to the leg strap. During record review and interview on 6/29/12 the DON said the facility has no formal policy regarding urinary catheters for residents. She faxed a facility form titled "Catheter Assessment" that showed a list of assessment questions for the use of a catheter. The DON said the nurse is required to fill the assessment out when a resident is admitted with a catheter and the assessment tool is then kept in the resident's chart. The DON said this was a fairly new tool for the facility. The form listed the following questions: -Does the resident have an indwelling catheter?; -If the nurse answered yes to question one, is it expected that the resident will have the catheter longer than 14 days?; -If you answered yes to question two, the nurse is to give the [DIAGNOSES REDACTED]. -If the catheter is to remain in place and the resident does not have an appropriate diagnosis, the nurse is to then contact the physician to obtain a [DIAGNOSES REDACTED]. -The assessment tool then directs the nurse to care plan the appropriate approaches for the catheter use. 2. Record review of Resident #14's physician progress notes [REDACTED]. Record review of the nurses' notes showed the following information: -On 2/21/12, the nurse practitioner ordered to discontinue the urinary catheter and may reinsert for [MEDICAL CONDITION]. -On 2/22/12, staff received an order from the nurse practitioner for [MEDICATION NAME] (antibiotic) ER (extended release) 100 milligrams (mg) two times a day for seven days for a UTI. -On 2/23/12, at 3:30 A.M., the resident had not urinated. Staff reinserted the urinary catheter per physician order. Staff used a size 18 french (the diameter size of the catheter) 10 cc balloon (a balloon at the end of the catheter that is inflated with sterile water to hold the catheter in the bladder) catheter. Urine return was 375 cc's. Staff faxed the above information to the physician. -On 4/8/12, staff reported the urinary catheter leaked onto the bedding. Staff discontinued the urinary catheter and reinserted a size 16 french (a larger size catheter) urinary catheter. Record review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 4/18/12, showed the following information: -Intact cognitive abilities; -Totally dependent for transfers, dressing, personal hygiene, and bathing; -Had an indwelling urinary catheter. Record review of the care plan dated 4/25/12, showed staff did not include the resident's use of a urinary catheter with care interventions for staff to follow related to the catheter. Record review of the interdisciplinary care conference worksheet dated 4/26/12, showed the resident had a urinary catheter and needed a [DIAGNOSES REDACTED]. Record review of the nurses' notes dated 4/26/12, showed staff received a [DIAGNOSES REDACTED]. Record review of the physician order sheet (POS) dated April, 2012, showed an order with an original date of 2/1/12, for staff to reinsert the urinary catheter if [MEDICAL CONDITION] occurred and an order dated 2/23/12, for catheter cares every shift. The orders did not include what size catheter to use or when staff should change the catheter. Record Review of the POS [REDACTED]. Record review of the nurses' notes showed the following information: -On 6/1/12, staff obtained a urine specimen. -On 6/1/12, staff changed the urinary catheter and inserted a size 16 french catheter. -On 6/3/12, the physician ordered Bactrim DS (antibiotic) two times a day for seven days for a urinary tract infection. Hold the [MEDICATION NAME] until the Bactrim DS was completed. Record Review of the POS [REDACTED]. The order did not specify what size catheter to use or when staff should change the catheter. Record review of the care plan dated 6/21/12 (almost four months since staff placed the urinary catheter on 2/23/12), showed staff identified the resident had an indwelling urinary catheter due to [MEDICAL CONDITION]. Interventions included for staff to provide pericare (cleansing of the genitalia and surrounding skin) with catheter care (cleansing around the insertion site of the catheter and catheter tubing) every shift, encourage fluids, keep the catheter bag below the level of the bladder, change the catheter monthly and as needed, communicate with the physician when the resident exhibited signs and symptoms of urinary tract infection, empty the catheter bag and document how much urinary output the resident had at the end of the shift, and place the urinary catheter bag in a dignity bag (a bag that provides a covering for the urinary catheter bag). Observation showed on 6/21/12, at 12:50 P.M., Certified Nursing Assistant (CNA) C and CNA E transferred the resident from a wheelchair to bed with a Hoyer lift (mechanical lift). Staff placed the catheter on the Hoyer sling strap above the level of the bladder during the transfer which could allow urine and bacteria to flow back into the bladder. During an interview on 6/22/12, at 8:30 A.M., Licensed Practical Nurse (LPN) A said if staff had to place a urinary catheter they would ask the physician for what size to use and ask if they wanted it changed monthly. They documented changing the catheter on the treatment record. The charge nurses normally updated the care plans. During a Hoyer lift transfer staff should place the catheter on the sling or hold it out of the way so it did not pull. Staff should keep the catheter below the level of the bladder. During an interview on 6/22/12, at 8:40 A.M., LPN F said if a resident needed a catheter they would call the physician to get an order to place it. They would either get an order for [REDACTED]. Staff used nursing judgment for what size catheter to use. Staff would get an order from the physician for changing the catheter. When they got a new order for a catheter the charge nurse would write it on the care plan. Some of the care plan sheets already had the interventions on them. They would fill out a communication form for the MDS Coordinator or place the order in her box. LPN F was not sure where staff should place the catheter during a Hoyer lift transfer but they should keep it below bladder level. During an interview on 6/22/12, at 9:00 A.M., the MDS Coordinator for the long term care residents said if staff placed a urinary catheter it would be part of the care plan. Staff needed to be sure they had a [DIAGNOSES REDACTED]. If the physician ordered for a resident to have a catheter the nurses would care plan for the catheter and then the MDS Coordinator would include the catheter on the next MDS assessment. The charge nurses were responsible to update the care plan with any new issues between the MDS assessment periods. The facility was in the process of going from changing the catheters as needed instead of monthly. The MDS Coordinator got information on residents during morning meetings or through discussions with the nurses. She also tried to read the 24 hour shift to shift report daily. Interventions for a urinary catheter would include catheter care and good perineal care every shift, encouraging fluids, and changing schedule. The care plan would not include positioning of the catheter. The MDS Coordinator was aware Resident #14 had a [DIAGNOSES REDACTED]. She would expect a care plan for the catheter. Any of the nursing staff could update the care plan. During an interview on 6/22/12, at 9:15 A.M., the DON said before staff placed a urinary catheter they should contact the physician and give an assessment of the resident which included how long it had been since they urinated, how they felt, and how their fluid intake was. A lot of times the physician ordered to do an in and out catheterization and if they had over a certain amount of urinary output leave the catheter in. Staff should get an order for [REDACTED]. When staff placed a catheter they should immediately care plan for it. The nurse that took the order for the catheter should put an immediate care plan in the medical record. The MDS Coordinators looked at the 24 hour shift to shift report sheets and they also talked about changes during the at risk meetings where they talked about resident care. When the next MDS assessment was due they include the catheter and interventions. During transfers staff should keep the catheter below the level of the bladder so it did not tag or pull, or have urine flow back into the bladder. Observation showed on 6/22/12, at 10:15 A.M., LPN F prepared to do catheter care. The resident's catheter bag lay on the floor beside the bed. LPN F raised the resident's bed, provided catheter care, then lowered the bed. The catheter bag lay on the floor. LPN F stepped on the catheter bag while positioning the resident in bed. LPN F did not raise the catheter bag off the floor or place it in a dignity bag. During an interview on 6/22/12, at 10:30 A.M., the DON said staff should hang catheter bags on the side of the bed off the floor. She would like the catheter bags to be placed in dignity bags.