Every finding on record at Medicalodges Nevada

Based on observation, interview, and record review, the facility failed to ensure food served was appetizing when staff served pasta salad and mixed vegetables as a cold food that was not within normal temperature limits. The facility census was 39. Review of the facility policy titled Serving Temperature for Hot and Cold Foods, dated 2016, showed the following:-Staff will follow the guidelines below when serving hot and cold beverages and food;-Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking, or cooling of foods;-Fruits, desserts, and salads will be 41 degrees Fahrenheit (F) or below;-The cook will take temperatures of hot and cold food items during approved food thermometers prior to each meal service. Food temperatures will be recorded.;-Salads, desserts, and milk will be kept in the refrigerator until dining service begins;-During dining service, only one tray of salads, desserts, and milk will be out of the refrigerator at once;-If a beverage cart, salad cart, or dessert tray is utilized, cold foods will be iced down or served in a manner that ensures proper temperatures throughout meal service. Review of the facility's recipe for turkey and pasta ranch salad, dated 2026, showed the finished product must maintain a temperature below 41 degrees F during the entire service period. Review of the facility's recipe for chilled steamed vegetables, dated 2026, showed the finished product must maintain a temperature below 41 degrees F during the entire service period. Observation of the dinner meal serve-out on 05/26/26, at approximately 5:00 P.M., showed the following:-Dietary Aide (DA) A removed two containers from the refrigerator and placed them onto the rolling cart. The Dietary Manager (DM) took the rolling cart to the dining room to the steam table. DA A and the DM did not take a the temperature of the food taken from the refrigerator;-DA A came out of the kitchen and removed the keys off the wall outside of the ice machine room and scooped ice into a pan and placed the pan on the steam table;-The DM placed the containers which contained the cold items (turkey and pasta salad and chilled steamed vegetables) into pans of ice on the steam table. The DM did not take temperatures of the turkey and pasta salad or the chilled steamed vegetables.;-During serve-out to residents, each meal was plated and put on a tray. Staff took the tray to the resident, set the food on the table, and returned for the next tray;-At approximately 5:38 P.M., staff served eight to nine residents in the dining room. The surveyor requested the DM to take the temperature of the turkey and pasta salad and chilled steamed vegetables;-The DM took the temperature of the turkey and pasta salad which measured 80 degrees F;-After approximately eight to nine residents in the dining room were served, the DM took the temperature of the chilled steamed vegetables which measured 49.5 degrees F;-The DM instructed staff to remove the turkey and pasta salad and the chilled steamed vegetables;-The DM said the cold food should have a temperature of below 41 degrees F. During an interview on 05/28/26, at 9:10 A.M., DA A said the cook was responsible for taking temperatures of the food served to residents. During an interview on 05/28/26, at 9:37 A.M., DC B said staff should take the temperature of the cold food when they take it out of the refrigerator and place it on an ice bath on the steam table. Cold food temperatures should not be served over 40 degrees F. The pasta salad should not be served at 80 degrees F. During an interview on 05/28/26, at 1:50 P.M., the DM said staff should take temperatures of the cold food when removed from the refrigerator. On 05/26/26, she should not have served the pasta salad and vegetables at a temperature above 41 degrees F. During an interview on 05/29/26, at 1:13 P.M., the Registered Dietician said cold food temperatures of the pasta salad at 80 degrees F and the vegetables of 49 degrees F were not appropriate for serve out. Cold foods should be at a temperature of no more than 41 degrees F. During an interview on 05/28/26, at 2:46 P.M., the Administrator said she expected cold food to be served under 41 degrees F.

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 perform proper hand hygiene during food prep and service and when staff failed to ensure nonfood contact surfaces were clean. The facility census was 39. 1. Review of the facility's policy titled, Hazard Analysis Critical Control Point (HACCP) and Foodborne Illness, dated 2016, showed the following: -Community staff will be well trained in state and federal food sanitation and preparation procedures. Dining services manager will implement a safety system, such as HACCP, to prevent contamination of food and the spread of foodborne illness; -Community staff will know and understand the definition of a foodborne illness, potential hazards, common factors, high-risk populations, and potentially hazardous food; -Preventing foodborne illness requires setting up appropriate food safety programs and training employees to handle food safely; -According to the Centers for Disease Control and Prevention (CDC), the following have been identified as common factors that are responsible for foodborne illness: poor personal hygiene; -A foodborne illness can result if employees fail to wash their hands properly, cough or sneeze on food, touch or scratch sores, cuts, or boils and then touch food, or come to work while they are sick; -High risk populations: Studies have shown the following groups of people have a higher risk of contracting a foodborne illness: elderly people with weakened immune systems due to old age, people taking certain medications such as antibiotics or immunosuppressants, and people who are seriously ill. Review of the facility's policy titled, Hand Hygiene, dated May 2017, showed the following -Purpose to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -Hand hygiene to be completed by staff before and after direct resident contact, before and after food handling, after cleaning of the environment, after handing of bodily fluids, after using toilet, after handling soiled linens, upon beginning work, before and after breaks, and end of shift, and between glove changes during care or procedures; -When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting; -Soap and water are recommended for cleaning visibly dirty hand; -Hand hygiene with soap and water is recommended: before eating and after using the toilet. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following: -Food employees shall keep their hands and exposed portions of their arms clean; -Even though bare hands should never contact exposed, ready-to-eat food, thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food; -Hands must be washed before donning gloves; -Gloves must be discarded when soil or other contaminants enter the inside of the glove. Observation on 05/26/26, at 12:07 P.M., showed the following: -Dietary [NAME] (DC) B wiped the prep counter in the kitchen with a cloth, opened the refrigerator with the same gloves, removed a pan, and placed it on a rolling cart; -DC B removed his/her gloves, did not wash his/her hands, and placed salad dressing containers back in the refrigerator; -DC B moved a rolling cart to the other refrigerator and removed a container of salad and placed it on the rolling cart; -DC B exited the kitchen to the dining room and placed the pans on the steam table; -DC B picked up the ice bucket, removed keys from the wall, and opened the door to the room with the ice machine; -DC B did not wash his/her hands or don gloves and scooped ice into a pan. Observation on 05/26/26, at 4:30 P.M., showed the following: -DC A with gloved hands, placed turkey in the processor, removed the processor blade, removed the glove on his/her left hand and donned another glove; -DC A did not wash his/her hands before donning the glove on his/her left hand and removed slices of bread out of a bag and placed them on parchment paper; -DC A with the same gloves opened the refrigerator and removed a jar of mayonnaise, touched the lid and opened it, moved the food processor back on the counter while touching under the processor, got a spatula from the dishwasher area and with the same gloves scooped out mayonnaise and spread it on each slice of bread touching the bread with his/her left gloved hand; -DC A with the same gloves took out more bread and placed the bread slices on the parchment paper, scooped out mayonnaise from the jar, spread the dressing on each slice of the remaining bread; -DC A covered the sandwiches in the pan with saran wrap; -DC A removed his/her gloves, touched the outer rim of the trash can and liner, did not wash his/her hands, donned another pair of gloves, and covered the food pan with saran wrap; -DC A continued wearing the same gloves, pulled off label stickers, covered puree mixture with saran wrap, pulled marker out of pants pocket, wrote on labels, went to the refrigerator, got out a container of salad and placed it on the utility cart; -DC A with the same gloves took the food processor to the three-vat sink and washed the food processor; -DC A removed his/her gloves, did not wash his/her hands and donned another pair of gloves, opened the refrigerator and removed a pan of food and exited the kitchen; -DC A took the keys off the wall outside the room, which had the ice machine and with his/her left hand scooped out ice and put it into a pan. Observation on 05/26/26, at 5:19 P.M., showed the following: -DC A stood behind the serving counter, did not wash his/her hands, donned another pair of gloves, and served salad, mixed vegetables and ice cream; -At 5:20 P.M., the DM placed his/her gloved hands in a pan of ice to move the ice around, did not remove his/her gloves or wash hands, and touched approximately 30 rolls and placed them in a pan onto the steam table. Observation on 05/27/26, at 11:44 A.M., showed the following: -DC B washed the blender bowl at the three-vat sink, brought the bowl over to the prep area, did not wash hands, wiped wet hands and arms with paper towels, and donned a pair of gloves; -DC B placed a strainer in the prep sink, took pan of cooked ravioli off the stove to the prep sink to drain in the strainer and put drained ravioli in a serving pan on prep counter; -DC B took cooked marinara sauce off the stovetop and poured the sauce into the ravioli pan, walked to coffee station, poured hot water into measuring cup, touched several recipes with gloved hands, and did not change gloves or wash hands as he/she prepared the puree; -DC B took the blender bowl to the three-vat sink, took off gloves, did not wash hands, removed pans of food from the oven and placed them onto the utility cart. DC B took out serving utensils and plastic mat with his/her hands and placed them onto the utility cart; -DC B opened the kitchen door, pushed the utility cart out to the serving area, placed pans of food in the warming slots, removed saran wrap from the food pans, put a plastic mat onto the serving counter and went back into the kitchen; -DC B returned to the serving area, did not wash hands or use hand sanitizer, donned gloves, and used serving spoons to dish food onto the plates. Observation on 05/27/26, at 12:06 P.M., of Dietary Aide (DA) C showed the following: -DA C at the counter beside the dish storage area, did not wash hands, donned gloves, and used gloved hands to scoop out jello into small dishes on the tray; -DA C removed gloves, placed empty jello pan in dishwashing sink, rinsed with water, and washed hands at handwashing sink; -DA C left the kitchen and came back, placed saran wrap over the jello dishes with ungloved hands, grabbed a date sticker gun, and placed stickers on covered jello dishes. Tore off sticker tape, lifted lid of trash with hands and placed in trash, opened refrigerator door and put in jello tray; -DA C opened kitchen door, pushed beverage cart out to dining area, did not wash hands or use hand sanitizer, and started pouring drinks to residents; -DA C rubbed his/her nose and eyes with hands, and continued to pour and serve drinks to residents; -DA C did not wash hands or use hand sanitizer, pushed the beverage cart to a resident's table, pulled out a cup, filled it with ice, poured the drink, set it in front of the resident, pulled out and unwrapped a straw, and touched the top of the resident's straw and inside the resident's drink. During an interview on 05/28/26, at 9:10 A.M., DA C said the following: -Staff should wash hands every third person during meal service or serving drinks; -Staff should wash hands in between tasks, touching any surfaces, or when changing gloves; -Staff should wash hands and change gloves before touching ready to eat food; -Staff should wash hands and don gloves before scooping ice out of the ice machine; -Staff should not touch the top of the straws; -Staff should wash hands and change gloves after touching face, hairnet or clothes. During an interview on 05/28/26, at 9:37 A.M., DC B said the following: -Staff should wash hands and change gloves in between tasks, touching any surfaces, entering and exiting the kitchen; -Staff should wash hands and change gloves after touching face, hair net or clothes; -Staff should wash hands after washing an item in the three-vat sink; -Staff should wash hands and change gloves before touching ready to eat food; -Staff should not touch the top of straws or top of the glasses served to residents; -Staff should wash hands and change gloves before scooping ice out of the ice machine. During an interview on 05/28/26, at 2:14 P.M., DC A said the following: -DC A would wash hands before handling food, between clean and dirty surfaces and handling meat; -DC A should wash hands before donning gloves; -Staff should change gloves after touching dirty surfaces and before touching food; -DC A did not think it was necessary to wash hands between glove changes; -Staff should not touch a trash can or trash liner, refrigerator and other surfaces without changing gloves or washing hands. During an interview on 05/28/26, at 1:50 P.M., the Dietary Manager (DM) said the following: -Staff should wash hands and change gloves in between tasks and when touching any surfaces; -Staff should wash hands when entering and exiting the kitchen; -Staff should wash hands before scooping ice and serving drinks; -Staff should not use gloves to scoop Jello into bowls, staff should use a scoop to serve Jello; -Staff should wash hands and change gloves after touching face, clothes or hair net. During an interview on 05/29/26, at 1:13 P.M., the Registered Dietician (RD) said she expected staff to wash hands and change gloves after touching their face, hair, handles on refrigerators, before scooping ice, preparing food, or scooping out jello. During an interview on 05/28/26, at 2:46 P.M., the Administrator said she expected kitchen staff to wash hands every time staff entered the kitchen, in between tasks, before food preparation, before and after glove use and after touching contaminated surfaces. 2. Review of the facility's policy titled, Dietary Services-Sanitation and Safety Policies, dated 06/03/14, showed the following: -Effective procedures for the cleaning and maintenance of all equipment and work areas have been developed and must be posted where they are available to the one using the equipment; -Cleaning schedules are established and posted and must be checked weekly by the DM to see that the work is being done; -The DM must instruct employees in the use and maintenance of equipment; -Maintenance is responsible for washing filters, hoods, fans, walls and windows in the kitchen; -Floors in the dining room must be mopped after each meal by maintenance or housekeeping. Review of the Daily Tasks – Dietary Aide Tasks checklist, undated, showed the following: -Sweep and mop dish and storage room floor every day; -Wipe down and clear carts every shift; -Clean food carts every shift; -Sweep and mop behind serving line every shift. Review of the Daily Tasks – [NAME] Tasks, checklist, undated, showed the following: -Clean stove top and back every shift; -Clean grill every meal; -Sweep and mop kitchen floor and storage room every day; -Clean food carts every shift. Review of the FDA 2022 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Observation of the kitchen on 05/27/26, at 11:15 A.M., showed the following: -Under the dishwasher area, the floor and pipes under counter were dirty; -Behind and below the oven, the floor was dirty; -Under the prep counter area, the floor was dirty; -Under the three-vat sink, the floor was dirty; -The stovetop burners, metal surface, and backsplash of the stove were dirty; Observations on 05/26/26, at 11:15 A.M., and on 05/27/26, at 11:23 A.M,. of the kitchen showed the following: -Upon entering the kitchen, the kitchen floor was dirty with small debris and black and brown grime present; -Under the three-compartment sink, there was black substance on the floor and along the wall; -Under the dishwasher area, there was a brown and black, wet, grimy substance on the floor and along with wall; -The stove burners had buildup black and white substance with food crumbs present; -The back splash of the oven had brown and black substance present; -The floor under and around the oven had brown substance present and cracked tiles; -The floor under the prep table had brown substance, a roll, and crumbs present; -The back side of the oven had a buildup of a white substance; -The rolling cart beside the prep table had a brown, black substance around the wheels and crumbs on the cart; -The floor under the coffee pot and drink table had a brown substance present; -A grey, steel vent cover above the dishwasher unit had peeling and a bubbly painted area on the left side of the square vent. During an interview on 05/28/26, at 12:10 P.M., the maintenance staff said the following: -Dietary staff were responsible to mop the kitchen floors and under the dishwasher area and report any needed repairs to the maintenance staff; -He/she did not know of the black areas on the floors under the dishwasher areas and floors in the kitchen; -The areas needed mopped; -The maintenance department strips the floors, but it was not scheduled for the kitchen; -He did not know of the area on the vent above the dishwasher that had peeling paint and it could flake off. During an interview on 05/29/26, at 1:13 P.M., the RD said she expected staff to clean the kitchen floors and equipment. During an interview on 05/28/26, at 2:46 P.M., the Administrator said the following:-She expected oven burners to be cleaned along with the oven backsplash; -She expected staff to clean the floors and report any issues; -She expected the vent above the dishwasher to not have a bubbly area or scraped off areas.

Based on interview and record review, the facility failed to implement a completed abuse/neglect policy and procedure that ensured complete screenings and back ground checks were completed for all new staff members when the facility failed to complete a Nurse Aide (NA) Registry Check (a listing of individuals who have had abuse/neglect findings making them ineligible to work in long term care) for three staff members (Minimum Data Set (MDS) Coordinator, Director of Nursing (DON), and Licensed Practical Nurse (LPN) H). The facility census was 39.Review of the facility policy titled Abuse, Neglect and Exploitation, dated 10/2022, showed the following information:-All new employees will be investigated prior to employment for previous history of abuse, neglect or exploitation;-The appropriate certification and/or licensing agencies will be contacted for the status of the employee's license or certification for employment. The person making the call will document registry verification, and the written response will be maintained in the employee's personnel file. 1. Review on 05/28/26 of the MDS Coordinator's personnel fild showed the following: -Hire date of 12/27/24;-Staff did not have documentation of a NA Registry Check completed. 2. Review on 05/28/26 of the DON's personnel file showed the following: -Hire date of 11/21/25;-Staff did not have documentation of a NA Registry Check completed. 3. Review on 05/28/26 of LPN H's personnel file showed the following:-Hire date of 12/11/24;-Staff did not have documentation of a NA Registry Check completed. 4. During an interview on 05/28/26, at 2:58 P.M., the Administrator said the following:-The Business Office Manager and herself were responsible for performing pre-employment screenings on all staff;-All staff, excluding nurses, were expected to have an NA registry completed;-NA registries were not completed on nurses.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of below 5% when a nurse failed to prime insulin pens prior to administration to three residents (Resident #10, #14, and #17) resulting in an error rate of 11% (three errors out of 27 opportunities). The facility census was 39.Review of the facility's pharmacy form titled, Insulin Drug Chart, updated February 2025, showed:-NovoLog FlexPen(insulin aspart). Pen priming requirements of two units;-Humalog KwikPen (lispro insulin). Pen priming requirements of two units. Review of the Humalog KwikPen manufacturer's Instructions for Use, section for instructions for priming the pen showed:-Prime before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working properly;-If a person does not prime before each injection, he/she may get too much or too little insulin;-To prime the pen, turn the dose knob to select two units;-Hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top;-Push the dose knob in until it stops and 0 is seen in the dose window;-Hold the dose knob in and count to five slowly;-Should see insulin at the tip of the needle. Review of the Novolog FlexPen manufacturer's Patient Fact Sheet: How to Use FlexPen, section for instructions for priming the pen showed:-Prior to each injection, turn the dose selector to two units;-Hold the FlexPen with the needle pointing upwards;-Tap the cartridge gently to make air bubble collect at the top of the cartridge;-Press the push button all with way in, the dose selector should return to 0;-A drop of insulin should appear at the needle tip. 1. Review of Resident #10's face sheet showed:-admission date of 06/21/24;-Diagnoses included type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by long-term high blood sugar levels). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 05/08/26, showed moderately cognitively impaired. Review of the resident's Care Plan Report, revised on 05/20/26, showed the following :-Resident at risk for hyperglycemia (high blood sugar)/hypoglycemia (low blood sugar) related to diabetes and use of insulin to manage his/her blood sugars;-Resident needed insulin administered per physician orders;-Please monitor the resident for signs of hypoglycemia including sluggishness, drowsiness, change in level of consciousness, poor coordination, unusual behavior, fast heart rate, and tremors. Resident may become clammy or sweaty. Please notify the nurse. Review of the resident's current Order Summary Report (POS) showed the following:-A physician's order, dated 03/11/26, for insulin lispro cartridge (a short-acting insulin) inject before meals per sliding scale (parameters for insulin dosing, the higher the blood sugar the higher the dose of insulin);-If blood sugar 301 to 350 milligrams per deciliter (mg/dL), administer eight units of insulin. Review of the resident's May 2026 Licensed Medication Administration Record (MAR) showed the following:-A physician's order, dated 03/11/26, for insulin lispro cartridge inject subcutaneously before meals per sliding scale;-If blood sugar 301 to 350 mg/dL, administer eight units of insulin;-On 05/27/26, at 12:00 P.M., staff recorded a blood sugar of 309 mg/dL and administration of eight units of insulin. Observation and interview on 05/27/26, at 12:00 P.M., showed the following:-Licensed Practical Nurse (LPN) D prepared the resident's insulin for administration;-LPN D reported he/she checked the resident's blood sugar, and the result was 309 mg/dL;-The nurse said based on the resident's physician's order, for a blood sugar result between 301 to350 mg/dL, the nurse needed to administer eight units of insulin to the resident;-The nurse removed the resident's Humalog KwikPen (insulin lispro) from the medication cart, removed the cap, cleansed the rubber stopper with an alcohol wipe and inserted a disposable needle. The nurse turned the dial to eight units, entered the resident's room, and administered 8 units of Humalog insulin to the unit via subcutaneous (SQ, into the fatty tissue) injection;-The nurse did not prime the insulin pen prior to administration. 2. Review of Resident #14's face sheet showed:-admission date of 12/27/11;-Diagnoses included of type 2 diabetes mellitus. Review of the resident's admission MDS, dated [DATE], showed the resident was severely cognitively impaired. Review of the resident's Care Plan Report, revised on 05/20/26, showed the following:-Resident at risk for hyperglycemia/hypoglycemia related to diabetes and use of insulin to manage his/her blood sugars;-Resident may need insulin related to high blood sugars, monitor the effectiveness. Review of the resident's current POS showed the following:-A physician's order, dated 03/10/25, for NovoLog FlexPen injector (a short-acting insulin) inject subcutaneously (SQ - into the fatty layer of tissue under the skin) four times per day as per sliding scale;-If blood sugar is 141 to 180 mg/dL, administer four units of insulin. Review of the resident's May 2026 Licensed MAR showed the following:-A physician's order, dated 03/10/25, for NovoLog FlexPen injector inject subcutaneously per sliding scale;-If blood sugar 141 to 180 mg/dL, administer 4 units of insulin;-On 05/27/26, at 12:00 P.M., staff recorded a blood sugar of 141 mg/dL and administration of four units of insulin. Observation and interview on 05/27/26, at 11:50 A.M., showed the following:-LPN D prepared the resident's insulin for administration;-LPN D reported he/she checked the resident's blood sugar, and the result was 141 mg/dL;-The nurse said based on the resident's physician's order, for a blood sugar result between 141 to180 mg/dL, the nurse needed to administer four units of NovoLog insulin to the resident;-The nurse removed the resident's NovoLog FlexPen from the medication cart, removed the cap, cleansed the rubber stopper with an alcohol wipe, inserted a disposable needle turned the dial to 4 units, and entered the resident's room and administered four units of NovoLog insulin via SQ injection;-The nurse did not prime the insulin pen prior to administration. 3.Review of Resident #17's face sheet showed:-admission date of 01/12/26;-Diagnoses included of type 2 diabetes mellitus. Review of the resident's significant change MDS, dated 0310/26, showed resident was moderately cognitively impaired. Review of the resident's Care Plan Report, revised on 05/20/26, showed the following:-Resident at risk for hyperglycemia/hypoglycemia related to diabetes and use of insulin to manage his/her blood sugars;-Resident needed insulin administered per physician orders;-Please monitor the resident for signs of hypoglycemia including sluggishness, drowsiness, change in level of consciousness, poor coordination, unusual behavior, fast heart rate, and tremors. Resident may become clammy or sweaty. Please notify the nurse. Review of the resident's current POS showed a physician's order, dated 02/27/26, for Novolog Flex Pen injector, nurse to inject 15 units SQ three times a day. Review of the resident's May 2026 MAR showed the following:-A physician's order, dated 02/27/26, for Novolog FlexPen injector inject 15 units SC three times a day.-On 05/27/26, at 12:00 P.M., staff recorded a blood sugar of 154 mg/dL and an injection of 15 units of insulin. Observation and interview on 05/27/26 at 12:10 P.M., showed:-LPN D prepared the resident's insulin for administration;-The nurse said based on the resident's physician's order, he/she needed to administer 15 units of insulin to the resident;-The nurse removed the resident's Novolog FlexPen from the medication cart, removed the cap, cleansed the rubber stopper with an alcohol wipe, inserted a disposable needle, turned the dial to 15 units, entered the resident's room, and administered 15 units of NovoLog insulin to the resident via SQ injection;-The nurse did not prime the insulin pen prior to administration. 4. During an interview on 05/28/26, at 12:30 P.M., LPN D said the following:-He/she was unsure how to prime insulin pens;-He/she typically turned the insulin pen dial one unit past the ordered dose and then turned the dial back to the ordered dose but did not compress the button to eject any air. During an interview on 05/28/26, at 12:58 P.M., the Director of Nursing (DON) said the following:-A nurse should prime a resident insulin pen with two units of insulin prior to administration of each dose of insulin;-LPN D told the DON a few minutes ago, he/she was unsure how to prime resident insulin pens. During an interview on 05/28/26, at 3:00 P.M., the MDS Coordinator/Registered Nurse said the following:-When preparing to administer insulin to a resident using an insulin pen, a nurse should first attach the disposable needle to the pen and prime the needle by dialing two units of insulin and wasting the insulin prior to each injection;-By priming an insulin pen, the nurse ensured no air remained in the needle and this helped to ensure administration of the ordered dose of insulin. During an interview on 05/28/26, at 12:35 P.M., the Administrator said nurses should prime the insulin pens prior to administration of the insulin unless the pharmacy policy directed otherwise.

Based on observation, interview, and record review, the facility failed to prevent significant medication errors, when a nurse did not prime insulin pens prior to administration to three residents (Resident #10, #14, and #17). The facility census was 39.Review of the facility's pharmacy form titled, Insulin Drug Chart, updated February 2025, showed:-NovoLog FlexPen(insulin aspart). Pen priming requirements of two units;-Humalog KwikPen (lispro insulin). Pen priming requirements of two units. Review of the Humalog KwikPen manufacturer's Instructions for Use, section for instructions for priming the pen showed:-Prime before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working properly;-If a person does not prime before each injection, he/she may get too much or too little insulin;-To prime the pen, turn the dose knob to select two units;-Hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top;-Push the dose knob in until it stops and 0 is seen in the dose window;-Hold the dose knob in and count to five slowly;-Should see insulin at the tip of the needle. Review of the Novolog FlexPen manufacturer's Patient Fact Sheet: How to Use FlexPen, section for instructions for priming the pen showed:-Prior to each injection, turn the dose selector to two units;-Hold the FlexPen with the needle pointing upwards;-Tap the cartridge gently to make air bubble collect at the top of the cartridge;-Press the push button all with way in, the dose selector should return to 0;-A drop of insulin should appear at the needle tip. 1. Review of Resident #10's face sheet showed:-admission date of 06/21/24;-Diagnoses included type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by long-term high blood sugar levels). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 05/08/26, showed moderately cognitively impaired. Review of the resident's Care Plan Report, revised on 05/20/26, showed the following :-Resident at risk for hyperglycemia (high blood sugar)/hypoglycemia (low blood sugar) related to diabetes and use of insulin to manage his/her blood sugars;-Resident needed insulin administered per physician orders;-Please monitor the resident for signs of hypoglycemia including sluggishness, drowsiness, change in level of consciousness, poor coordination, unusual behavior, fast heart rate, and tremors. Resident may become clammy or sweaty. Please notify the nurse. Review of the resident's current Order Summary Report (POS) showed the following:-A physician's order, dated 03/11/26, for insulin lispro cartridge (a short-acting insulin) inject before meals per sliding scale (parameters for insulin dosing, the higher the blood sugar the higher the dose of insulin);-If blood sugar 301 to 350 milligrams per deciliter (mg/dL), administer eight units of insulin. Review of the resident's May 2026 Licensed Medication Administration Record (MAR) showed the following:-A physician's order, dated 03/11/26, for insulin lispro cartridge inject subcutaneously before meals per sliding scale;-If blood sugar 301 to 350 mg/dL, administer eight units of insulin;-On 05/27/26, at 12:00 P.M., staff recorded a blood sugar of 309 mg/dL and administration of eight units of insulin. Observation and interview on 05/27/26, at 12:00 P.M., showed the following:-Licensed Practical Nurse (LPN) D prepared the resident's insulin for administration;-LPN D reported he/she checked the resident's blood sugar, and the result was 309 mg/dL;-The nurse said based on the resident's physician's order, for a blood sugar result between 301 to350 mg/dL, the nurse needed to administer eight units of insulin to the resident;-The nurse removed the resident's Humalog KwikPen (insulin lispro) from the medication cart, removed the cap, cleansed the rubber stopper with an alcohol wipe and inserted a disposable needle. The nurse turned the dial to eight units, entered the resident's room, and administered 8 units of Humalog insulin to the unit via subcutaneous (SQ, into the fatty tissue) injection;-The nurse did not prime the insulin pen prior to administration. 2. Review of Resident #14's face sheet showed:-admission date of 12/27/11;-Diagnoses included of type 2 diabetes mellitus. Review of the resident's admission MDS, dated [DATE], showed the resident was severely cognitively impaired. Review of the resident's Care Plan Report, revised on 05/20/26, showed the following:-Resident at risk for hyperglycemia/hypoglycemia related to diabetes and use of insulin to manage his/her blood sugars;-Resident may need insulin related to high blood sugars, monitor the effectiveness. Review of the resident's current POS showed the following:-A physician's order, dated 03/10/25, for NovoLog FlexPen injector (a short-acting insulin) inject subcutaneously (SQ - into the fatty layer of tissue under the skin) four times per day as per sliding scale;-If blood sugar is 141 to 180 mg/dL, administer four units of insulin. Review of the resident's May 2026 Licensed MAR showed the following:-A physician's order, dated 03/10/25, for NovoLog FlexPen injector inject subcutaneously per sliding scale;-If blood sugar 141 to 180 mg/dL, administer 4 units of insulin;-On 05/27/26, at 12:00 P.M., staff recorded a blood sugar of 141 mg/dL and administration of four units of insulin. Observation and interview on 05/27/26, at 11:50 A.M., showed the following:-LPN D prepared the resident's insulin for administration;-LPN D reported he/she checked the resident's blood sugar, and the result was 141 mg/dL;-The nurse said based on the resident's physician's order, for a blood sugar result between 141 to180 mg/dL, the nurse needed to administer four units of NovoLog insulin to the resident;-The nurse removed the resident's NovoLog FlexPen from the medication cart, removed the cap, cleansed the rubber stopper with an alcohol wipe, inserted a disposable needle turned the dial to 4 units, and entered the resident's room and administered four units of NovoLog insulin via SQ injection;-The nurse did not prime the insulin pen prior to administration. 3.Review of Resident #17's face sheet showed:-admission date of 01/12/26;-Diagnoses included of type 2 diabetes mellitus. Review of the resident's significant change MDS, dated 0310/26, showed resident was moderately cognitively impaired. Review of the resident's Care Plan Report, revised on 05/20/26, showed the following:-Resident at risk for hyperglycemia/hypoglycemia related to diabetes and use of insulin to manage his/her blood sugars;-Resident needed insulin administered per physician orders;-Please monitor the resident for signs of hypoglycemia including sluggishness, drowsiness, change in level of consciousness, poor coordination, unusual behavior, fast heart rate, and tremors. Resident may become clammy or sweaty. Please notify the nurse. Review of the resident's current POS showed a physician's order, dated 02/27/26, for Novolog Flex Pen injector, nurse to inject 15 units SQ three times a day. Review of the resident's May 2026 MAR showed the following:-A physician's order, dated 02/27/26, for Novolog FlexPen injector inject 15 units SC three times a day.-On 05/27/26, at 12:00 P.M., staff recorded a blood sugar of 154 mg/dL and an injection of 15 units of insulin. Observation and interview on 05/27/26 at 12:10 P.M., showed:-LPN D prepared the resident's insulin for administration;-The nurse said based on the resident's physician's order, he/she needed to administer 15 units of insulin to the resident;-The nurse removed the resident's Novolog FlexPen from the medication cart, removed the cap, cleansed the rubber stopper with an alcohol wipe, inserted a disposable needle, turned the dial to 15 units, entered the resident's room, and administered 15 units of NovoLog insulin to the resident via SQ injection;-The nurse did not prime the insulin pen prior to administration. 4. During an interview on 05/28/26, at 12:30 P.M., LPN D said the following:-He/she was unsure how to prime insulin pens;-He/she typically turned the insulin pen dial one unit past the ordered dose and then turned the dial back to the ordered dose but did not compress the button to eject any air. During an interview on 05/28/26, at 12:58 P.M., the Director of Nursing (DON) said the following:-A nurse should prime a resident insulin pen with two units of insulin prior to administration of each dose of insulin;-LPN D told the DON a few minutes ago, he/she was unsure how to prime resident insulin pens. During an interview on 05/28/26, at 3:00 P.M., the MDS Coordinator/Registered Nurse said the following:-When preparing to administer insulin to a resident using an insulin pen, a nurse should first attach the disposable needle to the pen and prime the needle by dialing two units of insulin and wasting the insulin prior to each injection;-By priming an insulin pen, the nurse ensured no air remained in the needle and this helped to ensure administration of the ordered dose of insulin. During an interview on 05/28/26, at 12:35 P.M., the Administrator said nurses should prime the insulin pens prior to administration of the insulin unless the pharmacy policy directed otherwise.

Based on observation, interview, and record review, the facility failed to protect the self-determination rights of all residents when staff failed to honor the resident's request for food outside of the scheduled mealtimes for one resident (Resident #6). The facility census was 39.Review of the facility policy titled, Your Rights and Protections as a Nursing Home Resident, undated, showed the following: -As a nursing home resident, you have certain rights and protections under federal and state law that help ensure you get the care and services you need. You have the right to be informed, make you own decisions, and have your personal information kept private; -At a minimum, federal law specifies that nursing homes must protect and promote the following rights of each resident; -You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. You have the right to decide when you go to bed, rise in the morning, and eat your meals. 1. Review of the facility's flyer titled, Daily Meals, undated, showed the following: -Location: Dining room; -Morning: 7:30 A.M.-8:30 A.M.; -Afternoon: 12:00 P.M. - 1:00 P.M.; -Evening: 5:00 P.M. - 6:00 P.M.; -Snacks: 10:00 A.M., 2:00 P.M., and 8:00 P.M. Review of the facility's flyer titled, The Always Available Menu, undated, showed the following: -Sandwiches: Deli sandwich, egg salad sandwich, and chef salad; -Breakfast: Scrambled eggs and toast; -Other: Cottage cheese, Jello, and yogurt; -Availability based on supplier ability. 1.Review of Resident #6's face sheet showed: -admission date of 09/02/25; -Diagnoses included depression, muscle weakness, and dysarthria (motor speech disorder caused by damage to the brain or nervous system, which weakens or paralyzes the muscles used for speech), Review of the resident's current Physician Order Summary Report (POS) showed an order, dated 09/02/25, for liberalized geriatric diet (regular texture, regular consistency, cut up into quarter sized pieces). Review of the resident's care plan, dated 09/22/25, showed the following: -Resident required staff assistance with activities of daily living (ADLs) related to physical limitations; -The resident sometimes needed staff to assist the resident propel his/her wheelchair; -Resident did not like to be told that he/she was unable to do something and will yell out when he/she feels like his/her needs were not being met. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/15/26, showed the following: -Cognitively intact; -No swallowing disorder; -No dental issues; -No significant weight loss or gain. Review of the resident's Progress Note dated 03/30/26, at 2:09 P.M., showed the Social Service Designee (SSD) documented the following: -SSD heard a nurse aide ask the resident if he/she wanted to have lunch today. The resident told the nurse aide, no. The resident was marked as a refusal for lunch; -The resident went to the dining room around 2:00 P.M. and requested/demanded a sandwich be made because he/she did not get lunch; -Other residents were in the dining room playing Bingo and the resident was being loud with staff while staff were educating the resident on how the facility passed snacks; -The SSD walked up, and the aide was explaining/educating the resident about how the facility cannot make him/her a sandwich and facility staff were preparing a snack tray to pass around to the residents. The resident agreed to have a snack off the snack cart but refused a drink; -The resident became upset because he/she saw staff give another resident a sandwich; -Staff educated the resident by telling him/her the other resident was out of the building at lunch time, and as soon as the other resident returned to the facility, staff had to offer the other resident a sandwich; -Staff offered lunch to the resident, but he/she declined lunch, and that was the difference explained to the resident; -If the resident declined a meal, then either he/she must utilize his/her own snacks or wait until staff passed snacks, which occurred at 10:00 A.M, 2:00 P.M., and 8:00 P.M. Review of the Resident's progress note dated 05/21/26, at 10:23 A.M., showed the SSD documented the following: -The resident asked the SSD for breakfast and the SSD advised the resident the time was about 10:00 A.M. and breakfast was from 7:30 A.M.-8:30 A.M.; -The resident asked for food and the SSD advised him/her the aides would be passing snacks at 10:00 A.M.; -SSD reminded the resident the aides attempted multiple times to encourage the resident to get out of bed for breakfast; -Staff could not force the resident to get up or move quicker, so the resident had to have more personal motivation to get up to have meals, if he/she wanted to have them; -The aides could only encourage so much and the dietary staff could only serve meals at specific times; -SSD reminded the resident the facility placed a clock in his/her room under his/her television to help him/her better track times; -The SSD asked the resident if a paper showing times of meals and smoke breaks would help; -The resident said it might help. SSD printed out a mealtime sheet and smoke time sheet in very big and bold lettering; -The SSD placed signs next to the resident's clock under the resident's television for easy viewable access from the bed or wheelchair. During an interview on 05/28/26, at 9:10 A.M., Dietary Aide (DA) C said the following: -Staff encouraged the resident to wheel himself/herself to the dining room for meals; -The resident did not come to the dining room for meals about three times a week; -Staff should make the resident a sandwich or snack until the next mealtime if the resident did not eat the meal. During an interview on 05/28/26, at 9:37 A.M., Dietary [NAME] B said the following: -The nurse handled the issue if the resident did not come to the dining room for a meal; -Staff should offer the resident cereal or a sandwich if the resident missed the designated mealtime. During an interview on 05/28/26, at 1:50 P.M. the Dietary Manager said the following: -If the resident missed the mealtime or refused to get up, staff should offer the resident a meal tray; -Staff should offer the resident a sandwich if staff had served all the remaining food for a meal; -No one had instructed him/her to have the resident wait until the next mealtime if he/she missed the meal but wanted to eat between meals. During an interview on 05/28/26, at 9:53 A.M., Certified Nurse Assistant (CNA) I said the following: -Staff tried to encourage the residents to come to the dining room for meals; -At times, the resident did not want to get out of bed for breakfast; -If the resident missed a meal, staff offered the resident a snack or a piece fruit; -If the resident wanted a sandwich after the designated mealtimes, CNA I would ask the dietary staff to fix the resident a sandwich; -The kitchen would prepare a sandwich for the resident upon request, regardless of the time. During an interview on 05/28/26, at 7:30 A.M., Licensed Practical Nurse (LPN) D said the following: -The kitchen had designated mealtimes for the residents; -The mealtimes were 7:30 A.M. - 8:30 A.M, 12:00 P.M.-1:00 P.M., and 5:00 P.M. - 6:00 P.M.; -If a resident refused to eat during the designated mealtimes, and then approached staff later and asked for food, staff should offer the resident a snack or a cold meal, such as a sandwich; -Staff should never refuse to allow a resident to have a meal, if a resident requested a meal. During an interview on 05/28/26, at 9:00 A.M., the SSD said the following: -The resident struggled to have the motivation to come to the dining room for meals; -The SSD posted mealtime sheets by the wall clock in the resident's room; -At times, the resident took too long to come to the dining room and ended up missing meals; -He/she tried to encourage the resident to propel him/herself to the dining room to maintain his/her independence; -If a resident missed a meal, he/she would need to wait for snack time to get something to eat; -To the SSD's understanding, the dietary department did not provide substitute meals to residents outside of the designated mealtimes; -He/she overheard an unknown nurse aide inform the resident he/she would have to wait for the snack time or designated mealtime to eat; -On another occasion, the resident approached the SSD at around 10:00 A.M. and wanted to eat after the resident missed a meal and the SSD informed the resident, he/she would need to wait for a snack; -The SSD said the resident needed more motivation; -He/she placed the meal schedule, snack schedule, and clock in the resident's room so he/she could track time better, if he/she wanted meals. During an interview on 05/28/26, at 8:17 A.M. and 10:50 A.M., the Director of Nursing (DON) said the following: -If a resident decided he/she was hungry after refusing a meal; -Dietary would make the resident a plate of food; -If dietary had already disposed of the food, dietary would make the resident an alternative meal, such as soup and a sandwich; -Nursing could go to the kitchen and ask for an alternative meal for a resident any time during the day/evening; -He/she was not aware of the kitchen ever refusing to prepare an alternative meal, outside of designated mealtimes; -The staff encouraged residents to come to the dining room for meals, but if the resident refused, staff should allow the resident to have an alternate meal or something from the Always Available Menu; -The resident required staff supervision for meals because he/she had a swallowing issue; -After reading the resident's SSD notes regarding resident meal issues, the DON said the SSD should have given the resident a sandwich or asked the nurse on duty what to do for the resident. During an interview on 05/28/26, at 9:25 A.M., the Administrator said the following: -Staff encouraged the resident to come to the dining room for meals, but the resident refused to eat at times; -If the resident did not make it to the dining room during the designated mealtimes, then he/she had the option of having something from the Always Available Menu, such as a sandwich, a salad, or cottage cheese; -In regard to the SSD notes regarding meal issues, the SSD should have offered the resident a sandwich or asked dietary or a nurse what to do for the resident; -The SSD did not know all the resident's medical diagnoses and should not make decisions about whether resident could have a meal or not.

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to update the care plan with all identified skin areas, failed to obtain physician orders time for all identified skin areas, and failed to document completion of, or reason for not completing, wound treatments for one resident (Resident #9) out of a sample of four residents. The facility census was 39. Review of the facility's policy titled Wound Prevention and Management, revised December 2018, showed the following: -Purpose to provide a systemic approach for identifying residents at risk for skin breakdown and develop interventions to decrease the incidence of residents who develop pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) while providing guidelines for optimal care to promote healing for residents with all identified skin alterations; -The Director of Nursing (DON) or designee will be responsible for implementing and monitoring the skin integrity program. 1. Review of Resident #9's face sheet (admission data) showed the following:-admission date of 03/24/26;-Diagnoses included end stage renal disease (kidneys can no longer filter waste and fluids) and type two diabetes mellitus without complications (body can't use insulin properly resulting in high blood sugars). Review of the resident's admission note dated 03/24/26, at 2:37 P.M., showed a nurse documented the following: -Left, fourth toe amputation, sutures intact; -Multiple scabbed abrasions and lesions to resident's bilateral (both sides) upper and lower extremities (arms/legs); -The resident had a deep red/purple area to the bony prominent distal (away from the midline of the body) to his/her left great toe. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 03/25/26, for staff to cleanse the resident's left 4th toe amputation, apply Trifold gauze to site, and tape into place one time a day related to acquired absence of left toe. Review of the resident's March 2026 Treatment Administration Record (TAR) showed: -An order, with a start date of 03/26/26, for staff to cleanse the resident's left 4th toe amputation, apply Trifold gauze, and tape into place one time a day related to acquired absence of left toe; -On 03/27/26, staff did not document completion of the treatment to the resident's left toe; -On 03/30/26, staff did not document completion of the treatment to the resident's left toe; -On 03/31/26, staff did not document completion of the treatment to the resident's left toe. Review of the resident's progress notes, dated 03/27/26 to 03/31/26, showed staff did not document regarding the reason the treatment was not complete. Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment tool completed by facility staff), dated 03/30/26, showed the following:-Cognitive skills intact; -Surgical wound; -Application of dressings to feet. Review of the resident's care plan, revised 03/31/26, showed the following:-Staff to contact the physician as needed if there are changes to the resident's skin condition; -Staff to cleanse the resident's left 4th toe amputation. Treatment of cleanse wound with hypochlorous acid (wound wash) and apply skin prep (skin protectant) surrounding tissue or periwound (the tissue or skin immediately surrounding an open wound). Review of the resident's current POS showed an order, dated 04/02/26, for the following: -Staff to cleanse the resident's left 4th toe amputation with hypochlorous acid (wound wash), apply skin prep to surrounding tissue or peri wound, apply collagen (wound dressing) pad to wound bed with trifold gauze, and secure with tape; -Change dressing on Monday, Wednesday, Friday, and as needed (PRN) every day shift related to acquired absence of other left toe. Review of the resident's skilled service assessment note dated 04/02/26, at 5:11 P.M., showed a nurse documented the resident had an open area to the bony prominence on the left side of the resident's foot at the base of his/her left great toe. The nurse placed a dry protective dressing. Review of the resident's care plan showed, date 03/31/26, showed staff did not care plan related to the new area at the base of the resident's left great toe. Review of the resident's POS showed staff did not document a treatment order for the resident's left great toe. Review of the resident's skilled service assessment note dated 04/12/26, at 2:16 A.M. showed a nurse documented the resident had an open area to bony prominence on his/her left side of foot at the base of the left great toe. Staff applied dry protective dressing. Review of the resident's care plan showed, date 03/31/26, showed staff did not care plan related to the new area at the base of the resident's left great toe. Review of the resident's POS showed staff did not document a treatment order for the resident's left great toe. Review of the resident's skin condition note dated 04/13/26, at 4:49 P.M., showed the following: -The DON documented the resident's left foot: left side of 5th toe was unstageable, 100% eschar (a thick layer of dead, necrotic tissue) with no drainage or odor; -The resident's left foot: right side of his/her great toe was unstageable 100% eschar, no drainage, no odor. (Staff did not document physician notification of the areas.) Review of the resident's care plan showed, date 03/31/26, showed staff did not care plan related to the area at the base of the resident's left great toe for the resident's left fifth toe. Review of the resident's POS showed staff did not document a treatment order for the resident's left great toe or left 5th toe. Review of the resident's current POS showed an order, dated 04/18/26, with a start date of 04/20/26, for the following: -Left great metatarsal (five long bones in the midfoot that connect ankle bones to toes) head diabetic foot ulcer treatment. Staff to cleanse the wound with hypochlorous acid, apply skin prep to surrounding tissue or peri wound, apply calcium alginate (a wound dressing) to wound bed only, wrap in Trifold gauze and secure with tape; -Change Monday, Wednesday, Friday, and as needed (PRN) every day shift for diabetic foot ulcer. Review of the resident's April 2026 TAR showed the following: -On 04/20/26, staff did not document completion of the treatment to the resident's left great metatarsal head diabetic food ulcer; -On 04/20/26, staff did not document completion of the treatment to the resident's left 4th toe amputation. Review of the resident's progress notes, dated 04/20/26, showed staff did not document regarding the reason the treatment was not complete. Review of the resident's May 2026 TAR showed the following: -On 05/01/26, 05/04/26, 05/08/26, 05/11/26, 05/15/26, and 05/22/26 staff did not document completion of the treatment to the resident's left great metatarsal head diabetic foot ulcer; -On 05/04/26, 05/08/26, 05/11/26, 05/15/26, and 05/22/26, showed staff did not document completion of the treatment to the resident's left 4th toe amputation. Review of the resident's progress notes, dated 05/01/26 to 05/22/26, showed staff did not document regarding the reason the treatment was not complete. Observation and interview on 05/28/26, at 2:30 P.M., showed the following: -The Wound Nurse/LPN E entered the resident's room to observe the resident's wounds; -The resident sat in his/her wheelchair and removed his/her own socks; -A 4-inch square piece of gauze with a scant amount of tan colored drainage fell off the resident's left foot bunion area (inner foot at the base of the great toe); -The resident's left bunion area had a circular wound with peeling layers of skin and an open, yellow, slough (moist, dead tissue) center, appearing as a shallow crater; -The nurse estimated the entire left foot bunion wound as the approximate size of a dime and estimated the open slough (moist dead tissue), center as the approximate size of a small pea; -The resident's left second toe had a missing nail and small linear scabbed area, approximately 0.5 centimeters (cm) in size, to the lateral side of the nail bed with no drainage or surrounding redness; -The resident had a paper towel folded and wrapped around his/her left third toe; -The resident said his/her third toe started bleeding earlier that morning, on 05/28/26. The resident said he/she looked but could not find anyone to dress the area, so he/she put a paper towel around his/her toe to stop the bleeding; -The resident removed the paper towel exposing a wound with moist, red tissue present, approximately 1.0 cm in size, to the top of the third toe located between the toenail and the base of the toe; -The nurse estimated the left third toe open area to be the approximate size of a dime; -The resident's left fourth toe was absent (post-amputation) with a brown scab present to the amputation site; -The nurse estimated the amputation site scab as the approximate size of a pea. During interviews on 05/28/26, at 12:10 P.M. and 12:57 P.M., Licensed Practical Nurse (LPN) D said the following: -The resident wore pleather shoes and did not want to wear anything else; -The resident's spouse did not give the resident a choice and brought in sandals with straps to wear which he/she has worn for about a month now; -The resident's bunion on his/her great toe, had an ulcer open but it had decreased in size with a scant amount of drainage, not purulent (containing discharge or causing the production of pus), had a little slough with no odor, or green drainage.; -Staff monitor residents' skin for redness, drainage, signs of infection, swelling and any fever; -Signs of infection include drainage, foul odor or increased pain; -Staff should notify the physician of an infection and get an order for a wound culture and send to laboratory if ordered; -Nurses enter the wound orders; -Nurses provide wound treatments; -Wound treatments pop up on the TAR on the computer when they are due and nurses should document wound treatments on the TAR; -Nurses complete and document a skin assessment weekly; -Nurses should document the reason a wound treatment was not completed in the progress notes and communicate to the next shift; -He/she was not able to get wound treatments completed at times. During an interview on 05/28/26, at 1:03 P.M. and 3:05 P.M., the MDS/Care Plan Coordinator said the following: -The resident had diabetic wounds on his/her left foot; -The resident's wound orders were for staff to cleanse his/her left 4th amputation, lower leg abrasion and left great metatarsal head on top of the toe; -The resident's wound treatment was important to be completed for the intervention; -Staff should complete the resident's wound treatments on Monday, Wednesday, and Friday; -Staff did not document several days of the resident's wound treatments in April 2026 and May 2026; -The resident was at an appointment on those days. The resident was gone all day; -Staff should have reported to the DON and LPN E if staff did not complete the wound treatments; -The nurses worked 12-hour shifts and if the resident was at scheduled appointment from 9:00 A.M. to 4:00 P.M., the night shift nurse should have completed the resident's wound treatments to his/her left foot; -She was not aware of the resident's wound treatments were not documented. -He/she worked the floor as a nurse at times; -She reviewed the wound log and orders to enter information on the MDS for residents; -Wounds, amputations or surgical wounds should be on a care plan; -The Administrator, Social Services, DON, medical record staff, and she have an interdisciplinary meeting (IDT) every morning and discuss wounds; -Nurses should view the wound treatment which pops up on the TAR when it is due; -Nurses should complete and document wound treatments on the TAR; -Staff should report to the DON or LPN E if staff did not complete a wound treatment; -MDS Coordinator, DON, wound care nurse, and the Administrator discuss all resident condition changes including wound care at the twice weekly Risk Meeting on Mondays and Thursdays; -He/she would immediately revise the care plan when there was a new care issue and intervention. During an interview on 05/28/26, at 2:25 P.M., the Certified Nurse Assistant (CNA) F said the following: -CNA F would report to the charge nurse any new skin issue or change in skin condition of a resident. The CNA would chart skin issue in the resident's electronic health record (EHR) under skin condition notes; -Skin issues CNA F would report to nurse included swelling, blisters, rashes, weeping, skin tears, cradle cap, scratches, open areas or dental sores; -When the resident came to the facility, he/she wore regular shoes that caused toe problems. The resident's shoes were changed to a sandal-type shoe due to his/her wound; -The resident needed reminders to stop scratching and picking at skin. During an interview on 05/28/26, at 1:21 P.M. LPN E/Wound Nurse said the following: -Staff did not document wound treatments on the April 2026 and May 2026 TAR; -Staff should provide wound treatments as ordered for the wound to heal properly and not get infected; -He/she had not seen the resident's left foot this week; -Last week the resident's left toe looked good; -The resident wore dress shoes and there was a rip in the resident's shoe; -The resident's spouse brought in Velcro type shoes for the resident to wear; -The resident's wounds were better and the resident picked at his/her scabs also; -Nurses inform him/her if a resident has wounds; -Aides should report to the nurse if a resident has skin concerns; -Nurses contact him/her if a wound is a concern and discuss the possible treatment; -Nurses enter admission wound orders or follow the wound doctor orders; -The wound company comes to the facility one time per week, and he/she rounds with the wound company provider; -The wound order is on the TAR to alert nurses when the wound treatment is due; -He/She and the DON or MDS Coordinator try to review the completed wound treatments on the TAR as often as they can every other week or month; -He/She educates the nurses, and the wound company provides in-services if he/she did not see documented treatments on the TAR. During an interview on 05/28/26 at 1:31 P.M., the DON said the following: -Staff did not document wound treatments on the resident's left foot for the dates listed for March, April and May 2026; -The resident was at scheduled appointment on the days staff did not complete and document wound treatments; -She expected the nurse to report the wound treatments not completed and have the night shift nurse complete the wound treatments; -She expected staff to complete, and document wound treatments on the TAR; -She and LPN E reviewed wound treatments when the wound company came to the facility once per week; -Staff should complete wound treatments as ordered to prevent worsening of any wounds; -She expected nurses to report to her if wound treatments were not completed, a resident was out of the building or refused a wound treatment. During an interview on 05/28/26, at 4:43 P.M., the Administrator said she expected staff to complete and document wound treatments.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection and prevention and control program when the facility failed to care plan the use of and follow enhanced barrier precautions (EBP- infection control intervention designed to reduce transmission of multidrug- resistant organisms (MDROs) in nursing homes. EBP to include gown and gloves during high-contact resident care activities) during wound care for two residents (Resident #2 and Resident #27). The facility census was 39. Review of the facility policy titled Infection Control Surveillance, dated November 2025, showed the following information: -Staff is to be educated on hand hygiene and other infection control prevention practices upon hire and thereafter routinely; -Staff are to be educated on infection control prevention practices as it relates to their job position upon hire and routinely thereafter; -The Infection Preventionist (IP) is to be routinely auditing the infection control practices in the facility through observation and clinical record review; -Staff are to be educated on standard precautions and isolation procedure as it relates to their job position upon hire and routinely thereafter. Review of Centers for Disease Control and Prevention' (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central line (a long, flexible tube inserted into a large vein in the chest, neck, or arm, with the tip ending close to the heart), urinary catheter (a thin, flexible, indwelling urinary tube inserted through the urethra into the bladder to drain urine continuously), feeding tube (a medical device used to deliver liquid food, fluids, and medications directly to the stomach or small intestine), tracheostomy (a surgical procedure that creates an opening, called a stoma, through the neck directly into the windpipe (trachea) /ventilator (a medical machine that helps a patient breathe or fully breathes for them)and wound care of any skin opening requiring a dressing. Review showed the facility did not provide a policy regarding EBP. 1. Review of Resident #2's face sheet (brief look at resident information) showed the following information: -admission date of 03/09/26; -Diagnoses include pressure ulcer of right buttock, stage IV ( full thickness tissue loss with exposed bone, tendon, or muscle). Review of the resident's Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/09/26, showed the resident had a stage IV pressure ulcer. Review of the residents' care plan, dated 05/26/26, showed the following information: -Treatment to right buttocks to cleanse with wound wash, skin prep to surrounding skin, apply calcium alginate (highly absorbent dressing) to wound bed only, cover with foam dressing, secure with tape daily and as needed. (Staff did not care plan regarding EBP.) Observation on 05/28/26, at 9:08 A.M., showed the following: -The resident's room door had an EBP precautions sign present; -Licensed Practical Nurse (LPN) D knocked on the resident's door, performed hand hygiene, placed wound care supplies on a clean barrier, donned gloves, and performed wound care; -The LPN did not don a gown. During an interview on 05/28/26, at 12:30 P.M., LPN D said he/she forgot to wear a gown during the resident's wound care treatment. During an interview on 05/28/26, at 12:58 P.M., the Director of Nursing (DON) said nurses should wear gowns and gloves when performing wound care for the resident. 2. Review of Resident #27's face sheet showed the following information: -admission date of 10/19/25; -Diagnoses included history of cellulitis (tissue infection) of the right lower leg. Review of the resident's care plan, revised 10/20/25, showed the following information: -Resident at risk for skin breakdown; -Assess the resident's skin and report any changes; -Assist the resident in keeping his/her skin clean and dry; -Wound care daily and as needed. (Staff did not care plan related to EBP.) Review of the resident's quarterly MDS, dated [DATE], showed no skin conditions present. Review of the resident's current Order Summary Report showed the following: -A physician's order, dated 04/24/26, for staff to cleanse the resident's right lower leg with wound wash and pat dry; -Apply Hydrogel (an absorbent gel) to the entire right lower leg; -Place Xeroform (a non-adherent dressing petroleum gauze) to the back of the right calf and heel (where it is open and weeping (draining)); -Cover with an absorbent gauze pad and wrap with rolled gauze and secure with tape; -Change daily and as needed due to cellulitis. Observation on 05/27/26, at 11:25 A.M., showed the following: -The resident's room door had an EBP precaution sign present; -Registered Nurse (RN) J knocked on the resident's door, performed hand hygiene, placed wound care supplies on a clean barrier, donned gloves, and performed wound care; -The RN did not don a gown prior to performing wound care. During an interview on 05/28/26, at 12:30 P.M., LPN D said nurses should follow EBP during wound care to the resident's leg ulcers. During an interview on 05/28/26, at 12:58 P.M., the DON said nurses should wear gowns and gloves when performing wound care for the resident if his/her leg wounds were draining. 3. During an interview on 05/28/26, at 4:02 P.M., LPN E/Wound Nurse said nurses should wear gowns and gloves during wound care. During an interview on 05/28/26, at 12:20 P.M. and 3:11 P.M., the DON said the following: -The facility does not have a specific EBP policy; -The staff are to follow CDC guidance; -Staff are expected to wear appropriate PPE for EBP. This includes gown and gloves for the resident; -The staff are aware that a resident is on EBP, by observing for the EBP sign on the resident's door. During an interview on 05/28/26, at 4:45 P.M., the Administrator said the facility did not have a specific EBP policy and the staff were to follow CDC guidance. Staff should place EBP signage on resident room doors if EBP is needed.

Based on interview and record review, facility staff failed to provide each resident with a diet that met each resident's special dietary needs when staff served a regular texture meal to the one resident (Resident #1) who had a physician's order for a mechanically altered diet resulting in the resident choking. The facility had a census of 35.On 06/18/25, the Administer was notified of the non-compliance. The facility implemented measures including designated assignment of staff for overseeing serve-out of meals, nurses to be present in the dining room for all meals, assigning only nursing staff to pass prepared meals to residents, implementation of a meal ticket system with written current dietary needs of each resident printed new for each meal, in-servicing all staff, and increased audit/check processes throughout the meal to ensure meals are prepared according to physician's orders. The deficient practice was corrected on 06/20/25.Review of a facility policy titled, Diet Orders, dated 2011, showed the following:-Each resident shall have a diet order prescribed by the physician and documented in their medical record;-Diet orders are to be checked regularly for accuracy;-Diets available include, regular diet, no added salt diet (NAS), limited concentrated sweets/consistent carbohydrate diets, heart healthy diets, renal diabetic diets, finger food diets, gluten free diets, and texture modified diets (mechanical soft, puree, thickened liquid diet, and dysphagia (difficulty swallowing) diets. Review of a facility policy titled, Dental Soft (Mechanical Soft),) dated 2022, showed the following:-Mechanical soft consistency modified diets are for individuals with limited or difficulty in chewing regular textured foods;-Mechanical soft foods should be moist and fork tender with meat ground or chopped into, bite-size pieces approximately 1/2 inch or smaller. 1. Review of the facility dietary menu showed the following:-On 06/18/25, the facility was utilizing the meal set designated on Week 3, Day 18 of their monthly meal rotation;-The lunch meal was listed as resident's choice. Review of a facility document titled, Day 18 Resident's Choice, showed the following meal items:-Hamburger or hotdog;-Grilled Zucchini;-Potato Salad;-Baked Beans;-Spice Cake. Review of the facility recipe sheets, dated 2025, showed a recipe for ground hotdog on a bun with broth with the following instructions:-Place hot dog or franks on a greased baking sheet;-Bake for 15 to 20 minutes for hotdogs or franks or 30 minutes for bratwursts ensuring internal temperature of at least 165 degrees Fahrenheit (F) for 15 seconds;-Place hot dogs in a washed and sanitized food processer, grind to the size and texture of fine hamburger, place in a steamtable pan with enough prepared broth to keep the product moist;-Portion #10 dipper of ground, moist, hotdog or frank on each bun;-Serve with catsup, mustard and/or pickle relish on bun to keep meat moist. Review of Resident #1's face sheet (basic information sheet) showed the following:-An admission date of 09/03/24;-Diagnoses included Cerebral Palsy (a group of neurological disorders that affect movement and posture), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), autistic disorder (a developmental disability impacting social communication and interaction), depression (a mood disorder impacting one's ability to think, feel, and act), contractures (shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints), restlessness, and agitation.Review of the resident's Minimum Data Set (MDS- a standardized assessment tool used to measure health status), dated 05/15/25, showed the following:-The resident was cognitively intact;-The resident required setup assistance for eating.Review of the resident's Physician's Orders showed an order, dated 04/29/25, for regular diet, mechanical soft texture, no mixed consistencies, and food on a divided plate.Review of the resident's nursing notes dated 06/18/25, at 1:05 P.M., a nurse documented the resident was choking in the dining room while seated in his/her wheelchair. Staff began back blows in attempt to dislodge food due to the resident being in a wheelchair and staff contacted 911. Emergency Medical Services (EMS) arrived at 12:55 P.M. EMS suctioned the resident's mouth until the food was dislodged. The obstruction appeared to be 1/2 of a hotdog. During an interview on 08/05/25, at 1:10 P.M., the resident said the following:-He/She received a mechanical soft texture diet;-He/She was served a regular consistency diet once but could not recall how long ago this occurred or what he/she received;-He/She eats fast, and staff have to ask him/her to slow down often;-He/She denied any concerns with meals. During an interview on 08/05/25, at 2:11 P.M., the MDS Coordinator said the following:-He/She was working when the incident occurred;-The incident occurred in the dining room during the lunch meal;-He/She observed mushy hotdog in the resident's mouth;-He/She used the suction machine to try and dislodge the obstruction;-He/She completed multiple finger sweeps (could not recall how many) but was only able to get small chunks of hotdog out of the resident's mouth;-EMS took over and used their own suction machine to remove a large chunk of hotdog from the resident's airway.-The piece of hotdog was solid and 1 1/2 to 2 inches long;-The hotdog was not mechanical soft consistency;-The resident had physician's orders for a mechanical soft consistency diet at the time of the incident;-He/She did not see the resident eating in the dining room prior to choking and did not see the resident's plate served;-The dining process at the time of the incident consisted of laminated cards with dietary orders;-The card would go down the serve-out line as it was being prepared;-Once the plate was delivered the card would go back to dietary staff;-The facility did not have any consistent double-check process to ensure the food plated matched the dietary orders;-Any staff in the dining room were able to deliver a plate to the residents;-Dietary staff were responsible for ensuring plates were properly prepared and plated according to orders;-Cook F was the kitchen staff preparing plates at the time of the incident. During an interview on 08/05/25, at 3:07 P.M., Certified Nurse Aide (CAN) A said the following:-He/She was working at the time of the incident;-The incident occurred in the dining room around 12:30 P.M.;-He/She was in the dining room area and overheard someone (unknown) make a comment that someone may be choking;-Staff responded immediately;-When EMS took over and he/she (CNA A) held the resident's mouth open for EMS as they suctioned a 1 1/2 inch large piece of hotdog from the resident's mouth;-The resident was supposed to receive mechanical soft consistency food;-The piece of hotdog removed by EMS was not mechanical soft consistency;-He/She did not see the resident's plate before, during, or following the meal;-The serve-out process for meals at the time of the incident was changed following the incident;-Dietary staff utilized cards to plate food according to dietary requirements for each resident for the prior process;-Any staff present in the dining room could take a prepared meal tray to a resident;-Meal trays should have been checked by dietary before being taken to the resident to ensure accuracy.During an interview on 08/05/25, at 3:25 P.M., Licensed Practical Nurse (LPN) B said the following:-He/She was working when the choking incident with the resident occurred;-He/She was charting in the nurses' station at the time of the incident;-The SSD reported to him/her the resident was choking in the dining room;-He/She left the nurses station immediately and entered the dining room and staff responded immediately;-EMS arrived and took over;-EMS used a suction device and removed a 2-inch piece of hot dog from the resident's mouth/airway;-The piece of hotdog was intact and not a mechanical soft consistency;-The resident had dietary instructions to receive a mechanical soft consistency diet;-He/She did not see the resident's plate before, during, or after the meal;-The resident eats quickly but had no prior history of choking on food or having difficulty eating;-At the time of the incident, any staff present in the dining room could pass a meal tray to a resident;-Dietary staff were responsible for ensuring the meal was properly prepared and served according to the meal card;-He/She did not know how the resident received the wrong consistency for his/her meal;-Resident's meals should be confirmed according to the meal card prior to giving to the resident. During an interview on 08/05/25, at 3:58 P.M., LPN C said the following:-He/She was working at the time the choking incident with the resident occurred;-He/She was walking through the dining room and overheard the Social Service Director (SSD) say the resident was choking;-Staff responded to assist the resident and called 911; -EMS arrived within 1 to 3 minutes of being called and entered the facility as the MDS Coordinator was attempting to remove the obstruction while the resident was on the floor;-EMS took over assisting the resident;-EMS used their own suction device and removed a 1 1/2 inch intact piece of hotdog from the resident's mouth/airway;-He/She observed the resident's plate following the incident and observed an intact hot dog on the plate;-The hot dog was regular consistency and not mechanical soft;-The resident had orders to receive a mechanical soft diet;-He/She did not know how the resident received a regular consistency plate;-Dietary staff were responsible for preparing plates according to the meal card;-Staff passing the plate were responsible for visualizing the card matched the plate to ensure the meal was appropriate prior to giving to the resident;-The resident's meals should have been checked for proper consistency prior to serving. During an interview on 08/06/25, at 10:38 A.M., the SSD said the following:-He/She was working during the choking incident with the resident;-The incident occurred during the lunch meal;-He/She was talking to another resident and their family member and observed the resident making a jerk type movement;-He/she approached the resident who was making a gurgling type sound from his/her mouth;-Multiple staff immediately responded and called 911;-EMS arrived and took over assisting the resident;-EMS used a suction machine and dislodged the obstruction as the resident started breathing again;-He/She did not see what was removed;-He/She did not see the resident's plate during the meal service;-He/She did not know how the resident was given an incorrect consistency plate;-The resident was to receive a mechanical soft diet;-Dietary staff were responsible for ensuring meals were properly prepared and plated according to the meal cards. During an interview on 08/06/25, at 10:56 A.M., CNA D said the following:-He/She was working when the choking incident with the resident occurred;-The incident occurred during the lunch meal;-He/She was the assigned dining room monitor when the incident occurred;-He/She had the resident meal cards and was reading the cards to dietary;-He/She read the resident's meal card to [NAME] F;-He/She told [NAME] F the resident's plate was a mechanical soft diet;-He/She handed the meal card to [NAME] F who started preparing the plate and passed down the serving line for other dining staff to finish the plate;-He/She did not see what was put on the resident's plate;-Dietary Aide (DA) E passed the resident's plate;-He/She did not see what was on the plate before it was passed;-Staff should have paid more attention to what was on Resident #1's plate;-The staff that delivers the meal was responsible for ensuring the meal was the proper diet and consistency before giving to the resident.During an interview on 08/06/25, at 1:46 P.M., DA E said the following:-He/She was working when the resident choked;-The incident occurred during the lunch meal;-He/She was in the kitchen when the resident started choking;-He/She did not deliver the plate to the resident and did not see what was served to the resident;-The resident had orders for a mechanical soft consistency diet;-Four staff are to check the plates as it goes through the preparation and serving process;-The plate should have been checked by two kitchen staff preparing the plate, one dietary aide, and the dining room monitor;-He/She did not know how the resident could have been served an incorrect consistency plate.During an interview on 08/06/25, at 12:53 P.M., [NAME] F said the following:-He/She was the Dietary Manager at the time of the incident;-He/She was working the day the incident occurred;-The incident occurred during the lunch meal service;-He/She was the first person for the serve-out station preparing plates;-He/She prepared the first portion of the plate and passed the plates down to two other staff;-He/She could not recall what portion of the plate he/she plated and could not recall who the other staff completing serve-out were;-He/She does not recall preparing the resident's plate;-The resident had orders for a mechanical soft diet;-Staff may have brought the resident the wrong plate or someone else's plate which led to him/her choking on a hotdog;-The meal monitor and staff bringing the plate to the resident were responsible for verifying the plate according to the meal card.During an interview on 08/06/25, at 12:48 P.M., the Registered Dietician said the following:-Staff reported the resident choked in the dining room on a hotdog;-The resident was to be mechanical soft consistency;-Staff should verify the plate before giving to the resident to ensure proper consistency;-A resident has increased risk of aspirating if given the incorrect consistency;-If an incorrect consistency is observed by staff the plate should be removed and replaced immediately. During an interview on 08/06/25, at 1:14 P.M., the Medical Director said the following:-He was contacted immediately regarding the incident;-The resident had no prior issues with her diet;-The resident was to receive mechanical soft food following removal of his/her teeth a few months prior to the incident;-Staff should verify consistency of food per orders each meal prior to residents being served the plate;-If there are any issues staff should address it promptly;-A resident being served a regular consistency when they are mechanical soft would increase risk of aspiration to the resident.During an interview on 08/06/25, at 2:13 P.M., the Director of Nursing (DON) said the following:-Meals are to be prepared according to the recipe and plated according to the meal card;-Plates should be checked as they are being prepared to ensure the diet is being prepared according to orders;-The dining monitor organizes and starts the meal serving process by giving the card to the cook;-The cook is to prepare the plate based on the card;-The serving staff should check the plate with the card to ensure it is correct before giving to the resident;-At the time of the incident there were some ancillary non-nurse or non-dietary staff who could pass plates;-They could not determine in the investigation who passed the resident his/her plate.During an interview on 08/06/25, at 2:21 P.M., the Administrator said the following:-She was working the day the incident occurred;-A 1 1/2 to 2-inch piece of hot dog was removed from the resident's mouth/throat;-The piece was not mechanical soft consistency;-The resident had orders to receive a mechanical soft diet;-She was unsure if any staff observed the plate the resident received or was eating at the time he/she choked;-She did not know who served the resident his/her plate;-Meals should be prepared and plated according to resident's dietary orders;-Each meal should be checked for accuracy and proper consistency prior to giving the meal to a resident;-Dietary staff and staff serving the meal are responsible for ensuring meals are prepared and served accurately;-If an incorrect item or consistency is observed on a resident's plate it should be replaced immediately with an appropriate plate;-The facility had a dining process in place at the time of the incident but there were issues with the follow through of the process to ensure it was properly completed. Complaint #1477259

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program when staff failed to follow the facility's infection control policies and guidance by the Centers for Disease Control (CDC) when staff failed to wear N95 masks (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) appropriately after two staff tested positive, with possible contact with other staff, for Covid-19. The facility census was 37. Review of the CDC's Infection Control Guidance: SARS-CoV-2 (Covid-19), updated 06/24/24, showed the following: -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Masks and respirators also offer varying levels of protection to the wearer; -People, particularly those at high risk for severe illness, should wear the most protective mask or respirator they can that fits well and that they will wear consistently; -Source control is recommended for individuals in healthcare settings who have had close contact or a higher-risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure. Review of the CDC How to Use Your N95 Respirator, dated 03/12/25, showed the following: -N95 respirators must form a seal to the face to work properly; -Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted. Review of the facility's policy titled, Checklist for Controlling Covid-19 in LTC Facility, revised 08/15/24, showed when Covid-19 positive cases are in the facility, staff are to wear an N95 face mask for the duration of their shift and in all areas of the facility. Review of facility policy titled, Covid -19 Personal Protective Equipment (PPE): Donning, not dated, showed the following: -Don N95 Respirator: Hold the respirator in the palm of hand with straps facing the floor; -Place N95 respirator on face covering nose and mouth; -Pull the bottom strap over the top of the head and place at the nape of the neck below the ear; -Pull the upper strap over and place it behind the head towards the crown of the head; -Mold the nose piece using pads of fingers over the cheeks and bridge of your nose to obtain a tight seal; -Perform a seal check by taking a few deep breaths and feeling around the mask for escaping air to ensure there is a good seal against the skin; -Staff must resist the temptation to adjust the N95 respirator [NAME] in the patient care area. Review of facility in-service titled, April Covid Outbreak, dated 04/07/25 and 04/9/25, showed the following: -When putting on a facemask, clean hands and put on facemask so it fully covers mouth and nose; -When wearing a facemask, don't allow a strap to hang down. 1. Observations on 04/09/25, at 11:07 A.M., showed the Restorative Aide (RA) and Nursing Assistant (NA) A in the hallway changing out an oxygen tank for a resident. The RA and NA A were wearing N95 masks with the bottom strap of both staff masks hanging under their necks (preventing a proper seal). Observations on 04/09/25, at 11:19 A.M., showed the Administrator walking down the hall wearing an N95 mask. The bottom strap of the N95 mask was hanging under the Administrator's neck (preventing a proper seal.) Observations on 04/09/25, at 2:05 P.M., showed Hospitality Aide (HA) B was participating in an activity with four residents. HA B was wearing an N95 mask. The bottom strap of the mask was hanging under HA B's neck (preventing a proper seal). During observation and interview on 04/09/25, at 2:57 P.M., NA A said the following: -Two staff members had tested positive for Covid-19; -The staff are testing on Monday and Thursday; -The staff were to wear the N95 mask per policy; -NA A had received training on PPE and how to properly wear an N95 mask; -NA A said both straps of the mask were to be around the back of his/her neck; -During the interview, NA A wore an N95 mask with the bottom strap of the mask hanging below NA A's chin. During observation and interview on 04/09/25, at 3:06 P.M., HA B said the following: -Two staff had tested positive for Covid; -HA B had received training on how to properly wear PPE, including the N95 mask; -HA B said the N95 mask was to be worn over the nose and under the chin; -HA B was not sure if both straps of the N95 mask were to be around his/her head; -During the interview, HA B wore an N95 mask with the bottom strap of the mask hanging below HA B's chin. During observation and interview on 04/09/25, at 3:14 P.M., the RA said the following: -The facility had staff who tested positive for Covid-19; -The RA had been trained on how to wear PPE properly; -Both straps of the N95 were to be around his/her head; -The mask was to be worn properly to protect the residents; -During the interview, the RA wore an N95 mask with the bottom strap of the mask hanging below the RA's chin. During observation and interview on 04/09/25, at 3:27 A.M., Licensed Practical Nurse (LPN) C said the following: -LPN C had been trained on how to properly wear an N95 mask; -Once donning, the N95 mask staff were to make sure it was sealed tightly. -During the interview, LPN C wore an N95 mask with the bottom strap of the mask hanging below LPN C's chin. During an interview on 04/09/25, at 4:13 P.M., the Administrator said the following: -All staff have been trained on how to properly wear an N95 mask; -All staff were to wear N95 masks correctly. MO00250089

Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to immediately report an allegation of employee to resident abuse of involving three residents (Resident #1, #2 and #3). The facility census was 31. The Administrator was notified on the morning of 12/17/24 of the Past Non-Compliance which occurred on 12/15/24 between 3:00 A.M. and 5:00 A.M. The accused certified nurse aide was suspended on 12/17/24. Staff assessed both residents for injuries and none were found. On 12/17/24, in-service of all staff was started. Staff began the full investigation on 12/17/24 and completed interviews on 12/17/24. The facility implemented monitoring, including once a week for four weeks or as needed for psychosocial support. The noncompliance was corrected on 12/17/24. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, revised 10/2022, showed the following: -The resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. It is the policy of Medicalodges, Inc., to treat each resident with respect, kindness, dignity and care, to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are to be reported immediately to the Administrator and/or their designated representative, the appropriate state agency and when applicable, law enforcement, not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury. 1. Review of Resident #1's face sheet (resident information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move, maintain balance, and control posture), muscle weakness, and depression. Review of the resident's annual Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), dated 12/05/24, showed the following: -The resident was cognitively intact; -The resident used a wheelchair to ambulate; -The resident was dependent on others for assistance in completing the Activities of Daily Living (ADL's - dressing, grooming, bathing, eating, and toileting). Review of the resident's care plan, updated 12/18/24, showed the following: -The resident yells out at night because he/she is hungry; -The resident frequently screams. Staff to redirect him/her to use his/her words; -The resident needed to develop a trusting, therapeutic relationship with others; -Allow the resident to express his/her emotions without judgement or criticism; -The resident needed staff to follow up on his/her needs and concerns in a timely manner. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included major depressive disorder (mood disorder that is characterized by a low mood and negative emotions), muscle weakness, and dementia (a general term for a number of neurological conditions that cause a decline in cognitive abilities). Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -The resident was dependent on others for assistance in completing his/her ADL's, -The resident used a wheelchair to ambulate; -The resident was dependent on others to push his/her wheelchair. Review of the resident's care plan, updated 12/18/24, showed the following: -The resident needed staff to wheel him/her around his/her home. The resident was unable to do so on his/her own; -Monitor the residents verbal and nonverbal cues for pain. 3. Review of the facility's Investigation Summary, dated 12/17/24, showed the following: -The Administrator was notified on 12/17/24, at 8:30 A.M., of an allegation of employee to resident verbal and physical abuse, that had occurred on 12/16/24 between 3:00 A.M. and 5:00 A.M.; -The staff reported the allegations of abuse to DHSS on 12/17/24 at 9:21 A.M. Review of a written statement, dated 12/17/24, showed Certified Nurse Aide (CNA) E noted the following: -On 12/15/24, at around 3:30 A.M., the CNA heard Resident #1 screaming and then heard a staff tell the resident to Shut-up! You are fine! -On 12/15/24, at around 4:40 A.M., Resident #2 was yelling for help and CNA F came up behind the resident in a wheelchair, grabbed the wheelchair, and roughly began pushed the resident forward hard enough to cause the resident's legs to bend back under the wheelchair. -CNA F then walked over to Resident #3 and without saying anything, ripped the blankets off of the resident. The resident began screaming. The CNA sid hey, I'm chaingng you! and yanked the resident's brief down being rough with the resident. The resident was continued to scream. 4. Review of DHSS's intake information dated 12/17/24, at 9:33 A.M., showed the facility self-reported a verbal allegation of abuse by a CNA. 5. During an interview on 12/23/24, at 1:29 A.M., CNA A said the following: -If he/she witnessed, or if a resident reported, any abuse or neglect to him/her, he/she would immediately report the allegations to the charge nurse; -The state required allegations of abuse and neglect to be reported to the state within two hours; -Before moving a resident in a wheelchair staff should make sure the resident's feet were on the foot pedals and the resident's arms were in their lap; -Verbal abuse was considered abuse and should be reported to the state. 6. During an interview on 12/23/24, at 1:37 A.M., CNA B said the following: -If a resident reported abuse or neglect to him/her CNA B would report it to the charge nurse; -The state required allegations of abuse and neglect to be reported to the state with in two hours; -Prior to pushing a resident in a wheelchair staff should make sure the resident's feet are on the foot pedals and the resident's arm/hands are on their lap; -If a resident does not have pedals on their wheelchair staff should not push that resident. 7. During an interview on 12/23/24, at 1:40 A.M., CNA C said the following: -All allegations of abuse and neglect should be reported to the charge nurse immediately; -The state required all allegations of abuse and neglect to be reported within two hours; -The residents should not be pushed in a wheelchair that did not have foot pedals; -The resident's feet should be on the foot pedals prior to pushing; -The resident should be sitting all the way to the back of the wheelchair; -Being rough with a resident and telling a resident to shut up was abuse and should be reported to upper management. 8. During an interview on 12/23/24, at 10:36 A.M., CNA E said the following: -If he/she witnessed any abuse towards a resident he/she would report it immediately to the charge nurse; -The state required all allegations of abuse and/or neglect to be reported within two hours; -On 12/15/24, around 3:00 A.M., Resident #1 had yelled for help and CNA F responded by saying Shut up, you're fine. -CNA E did not feel that what CNA F said to the resident was appropriate; -The same night CNA F walked up behind Resident #2's wheelchair and started pushing it. CNA F did not make sure the resident's feet were on the foot pedals. Resident #2 started screaming because his/her leg was being bent as his/her foot was on the ground while CNA F was pushing the wheelchair; -CNA E did not tell the charge nurse working about CNA F telling Resident #1 to shut up or about CNA F pushing Resident #2 in the wheelchair roughly; -CNA E contacted the Administrator two days after the incidents with CNA F to report his/her concerns. 9. During an interview on 12/23/24, at 1:45 A.M., Licensed Practical Nurse (LPN) D said the following: -LPN D would report all allegations of abuse and neglect to the Director of Nursing (DON) and the Administrator; -The Administrator should start an investigation and report the allegations to the responsible state agency within two hours; -Staff are trained in the proper way to assist residents in wheelchairs; -The resident's feet should be on the foot pedals of the wheelchair prior to moving the wheelchair; -No staff reported to him/her that CNA F verbally or physically abused or was rough with a resident; -Staff telling a resident to shut up is an allegation of verbal abuse and should be reported immediately. 10. During an interview on 12/23/24, at 12:25 P.M., the DON said the following: -CNA E called the Administrator regarding the incident with CNA F; -No residents have reported any abuse or issues with CNA F to the DON. During interviews on 12/23/24, at 1:55 A.M. and 12:30 P.M., the Administrator said the following: -She had completed the investigation into the allegations of verbal abuse and staff being rough with a resident; -CNA E called the administrator the morning of 12/17/24, upset with what occurred on the over night shift on 12/15/24 and 12/16/24; -CNA E said that CNA F had forcefully pushed Resident #2 in his/her wheelchair causing the resident to scream in pain as the resident's leg was being bent; -CNA E said that he/she heard Resident #1 yelling out and then heard CNA F tell Resident #1 to shut up; -The Administrator said that telling a resident to shut up is abuse and should have been reported immediately; MO00246719

Based on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control (IPC) as the infection preventionist (IP) for the facility's infection prevention control program. The census was 45. Review showed the facility did not provide a policy related to the position of infection preventionist and required certification. 1. During an interview on 06/10/24, at 10:55 A.M., the Administrator said the interim Director of Nursing (DON), in the position for about two months, was currently enrolled in the State's online IPC program, but had not completed the certification. The Administrator said the facility was offering the other staff nurses the chance to enroll and become certified, but none had completed the course as yet. Review showed the facility did not provide documentation of the required certification for the IP position for the DON. During an interview on 06/14/24, at 10:53 A.M., the interim DON said he/she had begun, but was not finished with the online IPC training and certification. The DON said he/she needed to complete the certification, because the facility did not have anyone else who was certified. During an interview on 06/11/24, at 3:00 P.M., the Administrator said the previous interim DON, who was in the position for approximately one month and now works only monthly as needed, was not certified in the IPC program. Someone in the facility should be certified as the IP and she expected the DON to complete the certification process. The other nurses had also been invited to enroll in the online course, but nobody else had done so to date. MO00237558

Based on observation, interview, and record review, the facility failed to maintain a complete infection prevention and control program when the facility failed to implement the policy regarding enhanced barrier precautions (EBP-precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO-microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) and failed to train staff on EBP. Staff failed to practice proper hand hygiene to prevent possible infection when completing wound care for two residents (Resident #30 and #40). The facility census was 45. 1. Review of the CDC's Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms, dated 07/12/22, showed the following: Review of the facility's table titled Summary of Personal Protective Equipment (PPE) use and Room Restriction for Residents in Nursing Homes, undated, showed the following: -Staff should use EBP for all residents with any of the following: -Infection or colonization with a multi-drug resistant organism (MDRO - bacteria that resist treatment with more than one antibiotic) when contact precautions do not otherwise apply; -Wound and/or indwelling medical devices (example: urinary catheter (A sterile tube inserted into the bladder to drain urine) central line (intravenous (IV) much longer than a regular IV, goes all the way up to a vein near the heart or just inside the heart), feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth or are unable to swallow safely)) regardless of MDRO colonization status: -Staff should wear gloves and gown prior to high contact care activity; -Staff should change PPE before caring for another resident; -High contact activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care such as urinary catheter, wound care of any skin opening requiring a dressing. During an interview on 06/13/24, at 3:00 P.M., Certified Medication Technician (CMT) K said he/she was not aware of the need to wear a gown when completing catheter cares. During an interview on 06/14/24, at 9:35 A.M., Registered Nurse (D) said he/she was unsure if staff should be gowned for catheter care. He/She was unsure if staff should be gowned for wound care unless there is an infection present. During an interview on 06/14/24, at 10:50 A.M., the Director of Nursing (DON) said there had been some recent training of EBP. EBP was not something that staff had been doing for residents with catheters or chronic wounds unless there was a lab confirmation of a positive organism on culture. During an interview on 06/14/24, at 1:24 P.M., the Administrator said they had heard of EBP, but were struggling with this a little. If a resident had a bacterial infection, staff had to wear gowns and gloves when providing any care or changing the wound dressing. There was company wide training about two months ago to discuss the regulation change. 41787 2. Review of the facility policy titled Hand Hygiene, dated May 2017, showed the following: -The purpose of the policy was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (spread from one person to another through a variety of ways) and infections; -Staff to complete hand hygiene before and after direct resident care; before and after handling food; after handling of bodily fluids; after handling soiled linens; between glove changes during care or procedures; and upon beginning work, before and after breaks, and end of shift; -When hands were not visibly dirty, alcohol-based hand sanitizers were the preferred method for cleaning hands; -Soap and water recommended when hands are visibly dirty; after exposure to Clostridium difficile (C-Diff - bacteria causing diarrhea); and after exposure to patients with infectious diarrhea. Review the facility's did not provide a policy or procedures regarding wound care. 3. Review of Resident #30's face sheet showed the following information: -admitted [DATE]; -Diagnoses included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), severe protein calorie malnutrition (a wasting condition resulting from a diet inadequate in either protein or calories or both), depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities), and chronic pain. Review of the resident's physician order sheet, active as of 06/14/23, showed the following: -An order, dated 04/16/24, to cleanse coccyx (tailbone) with hypochlorous acid (disinfectant that can destroy bacteria and viruses), pat dry, apply Santyl (prescription ointment removes dead tissue from wounds so can start to heal) to wound bed, apply calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven fibers derived from brown seaweed or kelp tow help with wound healing), and cover with foam bordered dressing one time per day for pressure ulcer/ Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 05/02/24, showed the following: -Severe cognitive deficit; -Dependent on staff for oral hygiene, toileting hygiene, shower, dressing, and personal hygiene. Review of the resident's care plan, revised 05/14/24, showed the following: -Resident required staff assistance with activities of daily living (ADL) related to physical limitations; -Resident required staff assistance with hygiene and peri-care. Observation on 06/12/24, at 9:45 A.M., showed the following: -Licensed Practical Nurse (LPN) B prepared to complete wound care for the resident. The LPN entered the resident's room with a clean tray with wound care supplies, including the facility shared wound care cleanser bottle. He/she placed the supplies on the bedside table. He/she washed his/her hands at sink, then applied gloves; -The LPN opened the resident's incontinent brief on left side. He/she said the brief was wet and the wound dressing was not intact; -The LPN opened the dresser drawer and obtained a clean incontinent brief and wet wipes. He/she wiped the left side of the buttock with a wet wipe. The LPN rolled the wet incontinent brief under the resident, rolled the resident to his/her back side, and pushed the brief out from between the resident's legs and tucked under the buttock. The LPN wiped the resident's front private area. He/she then rolled the resident further to his/her left side. The LPN wiped the right buttock and tucked the clean incontinent brief under the resident. He/she rolled the resident to his/her right side, pulled out the wet brief, and pulled the clean incontinent brief through with the same contaminated gloves. The LPN wiped the resident's buttock again with a clean wet wipe. The LPN placed the wet brief and wet wipes into the trash; -The LPN removed his/her gloves and without completing hand hygiene, pulled the blanket up over the resident. The LPN went to the sink and washed his/her hands; -The LPN applied new gloves, picked up the wound cleanser bottle, and sprayed the cleanser onto dry gauze. He/she washed the wound on coccyx with the wet gauze. The LPN patted the wound dry with clean dry gauze. Without changing gloves or completing hand hygiene, the LPN applied Santyl to the cotton tip applicator and applied the cream to the wound. He/she then applied dressing cover to wound. The LPN then closed and taped brief close; -Without changing gloves or completing hand hygiene, the LPN placed a pillow under resident's head, then removed his/her gloves. He/she changed the resident television channel with the remote before completing hand hygiene; -He/she removed the supplies from the bedside table and washed hands at sink. 4 Review of Resident #40's face sheet, showed the following information: -admitted [DATE]; -Diagnoses include urinary tract infection, high blood pressure, diabetes, and pain. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Requires substantial to maximum assistance from staff for lower body dressing, showering, and personal hygiene and requires partial to moderate assistance with mobility; Review of the resident's care plan, revised on 05/17/24, showed the following information: -Required staff assistance with ADL's; -Wound on left second toe 1 centimeter (cm) x 1.2 cm. Treatment to cleanse the wound with wound cleanser, pat dry, apply calcium alginate, cover with band-aid, change daily. Placed on Levaquin (antibiotice) 500 milligram daily for 10 days (5/14/24-5/24/24); -Referral to wound care clinic. Observation on 06/12/24, at 12:29 P.M., showed RN D and Nursing Assistant (NA) A in the shower room with the resident. The resident sat in the shower chair with a blanket covering him/her. LPN B entered the shower room and brought a clean tray with the following supplies: wound cleanser, gauze, gentamycin (an antibiotic) , tape, and a q-tip, and placed the tray on top of the resident's wheelchair. LPN B performed hand hygiene and donned gloves. LPN B obtained wound cleanser and gauze pad and cleansed wound starting at the center of the wound. LPN B threw away dirty items and gloves, washed hands, and did not don new pair of gloves. LPN B obtained a q-tip and gentamycin from the tray. He/she applied gentamycin onto the q-tip and rubbed it onto the wound. The LPN threw away the Q-tip and placed gauze placed over the wound without performing hand hygiene. LPN B applied gloves, without hand hygiene) and taped gauze into place. LPN B signed/dated on the dressing, performed hand hygiene, and exited the room. Surveyor [NAME], [NAME]: 5. During an interview on 06/13/24, at 3:00 P.M., CMT K said staff should complete hand hygiene before and after all types of resident cares and should clean hands between glove changes. 6. During an interview on 06/14/24, at 9:35 A.M., RN D said he/she would expect staff to wash their hands prior to donning gloves, changing gloves, and going from dirty to clean. 7. During an interview on 06/14/24, at 11:26 A.M., the DON said she expects all staff to wash their hands as soon as they go into a resident's room. If gloves become soiled, they should be changed, and hands should be washed before donning a new pair. Hands should also be washed if staff are going from a dirty to a clean surface. She would never want to see a staff member touching a dirty environment then going to a clean one without washing their hands and donning new gloves. 8. During an interview on 06/14/24, at 1:24 P.M., the Administrator said she expects staff to wash their hands before and after providing care, and when going from a dirty to a clean surface. MO00237558

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 45. Review showed the facility did not provide written policy regarding the certification requirements of the dietary manager. 1. Review of the facility's new hire list, generated on [DATE], showed the Dietary Manager (DM) was hired on [DATE]. Review showed the facility did not provide documentation of the DM's training, experience, or qualifications that met the required certification requirements for the DM position. During an interview on [DATE], at 12:05 P.M., the DM said he/she had six years of experience in cooking and ten years experience as a food industry manager. The DM said he/she had started an online dietary certification program in [DATE], but had not yet completed the course. During an interview on [DATE], at 9:20 A.M., the Administrator said they received verbal verification of the DM's work experience. However, the DM's training and certification was in another state and had expired when he/she was hired at this facility. The facility did not have documentation of sufficient training or current certification. The DM had not completed the online dietary certification course he/she started in [DATE], but must complete the course in order to be certified per regulations. MO00237558 MO00237588

Based on observation, interview, and record review, the facility failed to ensure suitable, nourishing snack alternatives were available and provided to residents outside of schedule mean services for diabetic residents. The facility census was 45. 1. Review of facility records showed there were 13 diabetic resident at the facility. Observation on 06/17/24, at 8:20 P.M., showed a tray on a shelf in the nurses' station containing multiple pre-packaged cookies and other sweet or salty snacks and a coffee carafe with assorted creamers/sugars. During the observation, Licensed Practical Nurse (LPN) L said the dietary staff usually put a few sandwiches on the tray when they bring it to the station at 7:00 P.M. nightly, but the sandwiches always went fast and none were left at that time. None of the present snacks were considered protein by the nurse. The evening shift and night shift staff did not have access to the kitchen or other food items after 7:00 P.M. During an interview on 06/17/24, at 9:00 P.M., Resident #20 said he/she was diabetic. The resident said they do not provide enough non-sugary evening snacks for diabetics. Most of the snacks are sugary. There are rarely any sandwiches left in the evening if he/she wants one. During an interview on 06/18/24, at 11:10 A.M., the DM said that dietary staff provided approximately three sandwiches (peanut butter and jelly) in the evening to be used for diabetics at night if their blood sugar went low. They provided about 40 other snacks, such as brownies, fig bars, and oatmeal pie cakes. No staff had access to food after the kitchen closed at 6:30 P.M. There was no refrigerator available to non-kitchen staff to keep meat and cheese sandwiches as an evening snack. There was no food available through the night for any residents otherwise. During an interview on 06/18/24, at 11:38 A.M., Registered Dietician (RD) Z said appropriate snacks should be offered to residents at least three times daily; between breakfast and lunch, between lunch and dinner, and in the evening. Although they have the right to refuse and choose something sugary, diabetic residents should be first offered fruit or a protein snack such as cheese/crackers, a meat or peanut butter sandwich, or yogurt. During an interview on 06/14/24, at 1:24 P.M., the Administrator said that before they leave at 7:00 P.M., the kitchen staff puts coffee at the nursing station with a tray of snacks to pass in the evenings. This included sandwiches (peanut butter/jelly and bologna) and a variety of snacks. MO00237558 MO00237588 MO00237628

Based on interview and record review, the facility failed to ensure three nurse aides (NA) (NA A, NA H, NA J) of six sampled NAs, completed a certified nurse aide (CNA) training program within four months of employment in the facility. The facility census was 45. Review showed the facility did not provide a policy regarding nurse aide certification or training. 1. Review of NA H personnel file showed the following: -Date of hire on 09/07/23; -No documentation NA H had completed the nurse aide training program. During an interview on 06/13/24, at 9:50 A.M., NA H said that he/she was hired in September 2023. He/she was unsure when he/she had started the CNA classes online. He/she said that he/she had almost completed the online classes. 2. Review of NA J personnel file showed the following: -Date of hire on 09/11/23; -No documentation NA J had completed the nurse aide training program. During an interview on 06/12/24, at 2:10 P.M., Licensed Practical Nurse (LPN) I said NA J had taken his/her test last week with results pending. 3. Review of NA A personnel file showed the following: -Date of hire on 10/19/23; -No documentation NA A had completed the nurse aide training program. During an interview on 06/12/24, at 2:10 P.M., LPN I said NA A started class in May 2024, but there was some technical issues and they had to reset his/her online classes. 4. During an interview on 06/12/24, at 2:10 P.M., LPN I said that training is at the staff persons own pace and they are told to be ready to test by day 89. All aides were in online classes. He/she was the clinical training supervisor and all classes were completed online. 5. During an interview on 06/14/24, at 10:50 A.M., the Director of Nursing (DON) said she had been in the DON position about two months. Nurse aide training should be done within 4 months of hire. 6. During an interview on 06/12/24, at 2:25 P.M., the Administrator said the staff were hired as NA and worked as a NA onsite. Staff should be certified within four months of hire. She was aware that the facility was out of the window with these staff. There was not a policy on NA training to CNA, the facility followed state guidelines. MO00237558 MO00237588

Based on observation, interview, and record review, the facility failed to ensure proper assessment and documentation was completed before side rail use when staff used side rails for two residents (Resident #39 and #40) who has been assessed as not appropriate for side rail use and when staff failed to document risk versus benefit review, failed to obtain informed consent for use, failed to care plan side use, failed to obtain physician orders for the use of side rails, and failed to complete measurements to reduce risk of entrapment for two residents (Resident #10 and #29). The facility census was 45. Review showed the facility did not have a policy regarding side rail/grab bar use that were not restraints. 1. Review of Resident #39's face sheet (resident's information at first glance) showed the following information: -admitted [DATE]; -Diagnoses included anemia (red blood cell deficiency), high blood pressure, kidney failure, and malnutrition. Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), dated 04/04/24, showed the following information: -Severe cognitive impairment; -Dependent on staff for toileting, showering, dressing, personal hygiene, and mobility. Observations showed the following: -On 06/10/24, at 11:15 A.M., the resident was in bed with the grab bar on the side of the bed in the upright position; -On 06/10/24, at 2:46 P.M., the resident transferred into his/her bed with two staff assist. The grab bar was in upright position on the side of the bed; -On 06/11/24, at 12:56 P.M., the resident transferred into his/her bed with two staff assist. The grab bar was in upright position the side of the bed; -On 06/11/24, at 3:57 P.M., the resident lay in his/her bed, call light on top of the resident, head of bed elevated, and grab bar in upright position on the side of the bed; -On 06/12/24, at 8:59 A.M., the resident was in his/her bed with the grab bar in upright position on the side of bed. Review of the resident's care plan, last revised 10/05/23, showed the following: -Required total assistance with activities of daily living (ADL's -fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). (Staff did not are plan regarding grab bar use.) Review of the resident's clinical health review, dated 03/31/24, showed based on assessment, side rails, grab, or transfer bars will not be utilized at this time. Review of the Maintenance Director's gap measurement binder showed staff did not document use of the resident's grab bar or measurements for the resident's grab bar. During an interview on 06/13/24, at 11:55 A.M., Licensed Practical Nurse (LPN) C said he/she looked in the resident's chart and was unable to find any grab bar use documentation for the resident. 2. Review of Resident #40's face sheet showed the following information: -admitted [DATE]; -Diagnoses included urinary tract infection, high blood pressure, diabetes, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required partial to moderate assistance for mobility. Observation and interview on 06/11/24, at 11:09 A.M., showed the resident sat in wheelchair beside his/her bed. A grab bar was in an upright position on the side of the bed The resident said the therapy department put it on his/her bed. He/she did not have to sign anything for it. At first, he/she thought the staff were trying to keep him/her in the bed, but later discovered it helps with mobility. Observation on 06/12/24, at 9:02 A.M., showed the resident sat in the wheelchair in his/her room. A grab bar was in the upright position on the side of the bed. Observations on 06/12/24, at 11:32 A.M., showed the resident sat in the wheelchair in his/her room, awaiting a shower. A grab bar was in the upright position on the side of the bed. Review of the resident's care plan, revised on 01/27/24, showed the following information: -Required staff assistance with ADL's; (Staff did not care care plan the use of the grab bar.) Review of the resident's clinical health review, dated 01/27/24, showed based on assessment, side rails, grab or transfer bars will not be utilized at this time. Review of the Maintenance Director's gap measurement binder showed staff did not document use of the resident's grab bar or measurements for the resident's grab bar. During an interview on 06/13/24, at 11:55 A.M., LPN C said he/she looked in the resident's chart and was unable to find any grab bar use documentation for the resident. 41787 3. Review of Resident #10's face sheet showed the following information: -admitted date of 02/22/24; -Diagnoses included hemiplegia and hemiparesis (paralysis of one side of the body) following cerebrovascular disease (stroke) affecting left non-dominant side, Parkinsons (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and post traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Use of electric wheelchair for mobility. During an interview and observation on 06/11/24, at 1:45 P.M., a one-quarter side rail was in the upright position on the the side of the resident's bed. The resident was seated in his/her electric wheelchair in his/her room. He/she said that he/she used the side rail to assist with mobility when in the bed. Review of the resident's care plan, reviewed 06/03/24, showed the following: -Required staff assistance with ADL's related to physical limitations; -Left sided hemiparesis; -Resident at risk for falls and injury related to left sided weakness. (Staff did not care plan related the resident's side rail use.) . Review of the resident's physician order sheet, current as of 06/14/24, showed no order for the use of side rails. Review of the resident's medical record showed no consent of risk and benefits, side rail risk assessment, or bed rail safety measurements documented. 4. Review of Resident #29's face sheet showed the following information: -admitted [DATE]; -Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), and repeated falls. Review of the resident's significant change of status MDS, dated [DATE], showed the following: -Cognitively intact; -Use of wheelchair for mobility; -Dependent on staff for toileting hygiene, showering, dressing, personal hygiene. Observations and interview on 06/10/24, at 10:13 A.M., showed the resident had bilateral side rails present on his/her bed. The resident said he/she used the bilateral side rails for mobility in bed and assist with transfers. Observation on 06/12/24, at 9:30 A.M., showed bilateral side rails in the upright position on the resident's bed. The resident was in his/her wheelchair in the room. Review of the resident's care plan, reviewed 05/25/24, showed the following: -Resident at risk for falls and injury related to history of falls; -Resident required staff assistance with ADL's related to physical limitations; -Resident will have a transfer bar; -Resident will use the transfer bar to transfer; -Resident will use the transfer bar to get up and down; -Staff should encourage resident to use assistive devices. Review of the resident's physician order sheet, current as of 06/14/24, showed no order for side rail use. Review of the resident's medical record showed no consent of risk and benefits, side rail risk assessment, or bed rail safety measurements documented. 5. During an interview on 06/12/24, at 9:00 A.M., the Maintenance Director said the nursing staff make him aware of any grab bars that need to be installed. After he installs them, he completes the safety measurements and keeps that information in a binder. 6. During an interview on 06/12/24, at 10:03 A.M., Nursing Assistant (NA) A said he/she did not know what the steps are that required for a resident to have a grab bar. He/she is not sure if a consent form is required, or any type of assessment. He/she said they are used for mobility. He/she believes maintenance installs them. 7. During interviews on 06/12/24, at 12:31 P.M. and at 4:16 P.M., LPN B said grab bars have to have an assessment completed. After the assessment is completed and showed the grab bar would be used for mobile residents, they are installed by the maintenance department. He/she is unsure if there is any monitoring system in place. He/she has never seen a consent form being completed or needing to be completed for any type of grab bar. The therapy department is who completes measurements on the bars, and they do so every three months. 8. During an interview on 06/13/24, at 11:55 A.M., LPN C said residents get grab bars for mobility. The nurses are to complete an assessment in their computer charting system, titled side rail assessment. There needs to be a physician order obtained. He/she is not sure if consents are supposed to be completed. Maintenance does all the measurements and installs the rails. Grab bar use should be documented in the resident's care plan as well as in an assessment within their computer charting system titled clinical health review. 9. During an interview on 06/14/24, at 11:26 A.M., the Interim Director of Nursing (DON) said she was not aware of the process for a resident to use grab bars. She is unsure if any assessment, consent, or monitoring should be completed. The maintenance department should have to measure the bars. 10. During an interview on 06/14/24, at 1:24 P.M., the Administrator said grab bar use should be discussed with the DON and should be used for mobility. The maintenance department will measure them initially and frequently to make sure they are safe. A pre-assessment should be completed, but she is unsure if consents should be.

Based on interview and record review, the facility failed to provide care per standard of practice when the facility failed to complete ordered labs/x-rays for two residents (Resident #26 and #29) resulting in a possible delay in care and when staff failed to provide restorative therapy for one resident (Resident #33). The facility census was 45. Review showed the facility did not provide a policy or procedure related to following physician orders for laboratory or diagnostic imaging. 1. Review of Resident #26's face sheet showed the following information: -admitted [DATE]; -Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with agitation, fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), Raynaud's syndrome (causes some areas of the body - such as fingers and toes - to feel numb and cold in response to cold temperatures or stress) without gangrene (dead tissue caused by an infection or lack of blood flow), hypertension (high blood pressure), and hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone - can disrupt such things as heart rate, body temperature, and all aspects of metabolism). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility), dated 05/09/24, showed the following: -Severe cognitive impairment; -Dependent on staff for toileting hygiene, showering, dressing, putting on/taking off footwear, personal hygiene, and transfers; -Use of wheelchair for mobility; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, reviewed 05/17/24, showed the following: -Required staff assistance with activities of daily living (ADL) related to physical limitations; -Resident will have ADL needs met as exhibited by neat, clean and odor free appearance daily through next review. Review of the resident's nursing progress notes showed the staff documented the following: -On 06/08/24, at 10:09 P.M., the resident had been lethargic and sleepy all evening. He/she did sit up and ate the evening meal in his/her room and later got up and ate a snack. He/she took medications without difficulty. Verapamil (high blood pressure medication) was held due to low blood pressure. Staff notified the physician and received new order for straight catheter (a flexible tube inserted through a narrow opening into a body cavity) urinalysis, complete blood count (CBC - lab), and complete metabolic panel (CMP - lab); -On 06/12/24, at 3:03 P.M., therapy stated they were not able to ambulate with resident because he/she was short of breath and unable to stand without assistance because of severe pain noted in the resident's left side, which therapy said had been going on for days. The resident admitted to left sided pain rated 4 out of 10. Staff administered Tylenol and resident was transported to emergency room (ER) by facility staff. Staff notified family and physician; -On 06/12/24, at 6:47 P.M., the resident returned via facility vehicle with new order for antibiotics for urinary tract infection (UTI). Review of resident's medical record showed staff did not enter the labs ordered by the physician or completion of the labs ordered on 06/08/24. During an interview on 06/13/24, at 12:20 P.M., Licensed Practical Nurse (LPN) I/Medical Records said he/she did not know why the labs on the resident were not done on 06/08/24. He/she found it during the morning clinical excellence meeting on Tuesday, 06/11/23, at 8:00 A.M. that the labs for Saturday, 06/08/24, were not entered or drawn. He/she did not know why the order was not entered at the time it was found. The resident was sent to the hospital on 06/12/23. During an interview on 06/14/24, at 10:50 A.M., the Director of Nursing (DON) said she was unsure why the order for the resident did not get completed until sent to the hospital multiple days later. During an interview on 06/14/24, at 1:24 P.M., the Administrator said on 06/10/24 the nurse was notified the lab orders for the resident needed completed. The next day, she told the nurse that the labs needed to be done that day, but it did not get done and the resident was sent to the hospital on 06/12/24. 2. Review of Resident #29's face sheet showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), dementia, pain, repeated falls, fibromyalgia, and restless leg syndrome (condition characterized by a nearly irresistible urge to move the legs, typically in the evenings). Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toileting hygiene, showering, dressing, and personal hygiene; -Use of wheelchair for mobility; -Use of pain medication routinely. Review of resident's care plan, last reviewed 05/25/24, showed the following: -Required staff assistance with ADLs related to physical limitations; -If had pain may require more assistance with completing ADLs; -At risk for falls and/or injury related to history of falls; -Staff should complete labs as indicated; -Staff should notify family of falls and injury; -Staff should notify physician of injuries; -Resident had pain; -Staff should give pain medications as ordered and monitor for effectiveness; -Staff should monitor for non-verbal cues of pain. Review of resident's progress note dated 05/24/24, at 3:09 P.M., showed the resident was seen by the physician for monthly rounds. The resident complained of pain in his/her hips. The physician ordered an x-ray of bilateral hips. No other orders of concerns noted. Review of the resident's physician orders sheet, dated 05/01/24 through 06/14/24, showed staff did not enter an order for bilateral hip x-rays. Review of the resident's medical record showed no results for bilateral hip x-rays. During an interview on 06/14/24, at 10:39 A.M., LPN I said he/she was unable to locate any results for the resident related to hip x-rays that were ordered on 05/24/24. He/she did not know why the x-ray order was not completed. During an interview on 06/14/24, at 10:50 A.M., the DON said usually, the mobile order company is able to come out the same day the order is sent to them. This should have been addressed much sooner for the resident. During an interview on 06/14/24, at 1:24 P.M., the Administrator said she was unsure why the hip x-rays for the resident were not completed as ordered on 05/24/24. 3. During interviews on 06/13/24, at 12:20 P.M., and on 06/14/24, at 10:39 A.M., LPN I/Medical Records said that when the nurse receives lab orders, they should enter the labs into the physician orders, complete a lab requisition form, and put the pink part of the form in the medical records box. He/she monitored and ensured that the labs results are received and uploaded to the computer. The lab comes several times per week. On the weekend, or other times when labs are needed sooner, the nurses are able to draw the lab, and someone can take to the laboratory. All staff nurses can and should put in x-ray orders and lab orders when received from the physician. He/she entered the routine monthly lab orders. 4. During an interview on 06/14/24, at 10:50 A.M., the DON said that either the charge nurse or LPN I/Medical Records should put in any and all orders received from the physician or other providers. Typically, the charge nurse puts in the orders that were received by phone or fax. Any lab and x-ray orders should be entered immediately after received from the provider. Labs should be done on the shift it is ordered, especially a urinalysis test should be done as soon as possible. A urinalysis ordered on a Saturday should not wait until Monday or later to be completed. Staff should get someone to take it to the hospital lab as soon as possible. 5. During an interview on 06/14/24, at 1:24 P.M., the Administrator said that all nurses can and should put lab and x-ray orders they receive into the EMR system, then any new order has to be reviewed by medical records. Staff follow up with all changes with clinical excellence meeting every day. The clinical excellence morning meeting team reviews all new orders for the previous 24 hours. The nursing staff should be following what is in the physician orders. The nurses should act on the received orders. The nurse should fill out the requisition form for the lab or x-ray and ensure that it was completed. She follows up with nurses every day and tell them everything that that needs follow up at that time. She said that there was no policy related to physician orders, they follow regulation guidelines. 6. Review showed the facility did not provide a policy pertaining to restorative nursing. Review of Resident #33's face sheet showed the following information: -admitted [DATE]; -Diagnoses included Parkinsonism (neurologic disorder affecting movement, often including tremors), dementia with Lewy bodies (characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions), type 2 diabetes, chronic obstructive pulmonary disease (COPD - breathing disorder), post-traumatic stress disorder (PTSD - difficulty recovering after experiencing or witnessing a terrifying event), convulsions, heart disease, sleep apnea (breathing disorder while sleeping), depression, high blood pressure, gastro-esophageal reflux disease (GERD - stomach acid backs up into the esophagus), muscle weakness, chronic pain, and need for assistance with personal care. Review of the resident's care plan, updated 05/01/24, showed the following: -On 05/05/23, resident needed assistance of two staff and a gait belt for transfers and the use of the sit-to-stand lift as a safety back up; -On 05/05/23, resident needed staff to wheel resident around home; -On 05/09/23, resident had limitations on the right side of the body; -On 01/30/24, resident to be discharged from skilled physical therapy and transitioned to restorative aide program one to three times per week; Review of the resident's therapy form entitled Communication with Restorative Nursing, dated 01/23/24, showed the following information: -Date of Discharge: 01/26/24 (Occupational Therapy; OT); 01/30/24 (Physical Therapy; PT); -Patient's status at time of discharge: Maximum to total dependence for all activities of daily living (ADLs). Sit to stand lift for all transfers (use Hoyer mechanical lift as needed); -Recommendations to restorative nursing three to five times per week with bilateral upper and bilateral lower extremities stretching, two-person assist with sit-to-stands with transfer pole, 1-2 each and three times per week use toilet with sit-to-stand lift. Follow-up screening in two months; -Signed by OT. Review of the resident's care plan, updated 05/01/24, showed on 04/03/24, goal that resident will improve or maintain level of functioning. During an interview on 06/14/24, at 7:50 A.M., the Administrator said there was only one restorative entry note in the resident's chart, a therapy order, dated 08/2023 for continued restorative nursing therapy. During an interview on 06/11/24, at 3:18 P.M., the resident's family member said the facility was not consistent with staffing and care. The restorative nurse aide (RNA) got pulled to work the floor fairly often, so no restorative therapy was being done to help maintain/improve the resident's strength. The resident had declined in his/her ability to bear weight on his/her legs. During an interview on 06/14/24, at 8:55 A.M., with Certified Physical Therapy Assistant/Licensed (CPTA/L) X and Certified Occupational Therapy Assistant/Licensed (COTA/L) Y said they both are part time and were not sure if either of them had worked with the resident. They explained the process of evaluating and providing therapy for residents and the process of discharging a resident with recommendation orders to restorative nursing. They said staff should have followed the restorative recommendations/orders given by therapy to maintain the resident's strength. CPTA X and COTA Y said they did a post-therapy screening two months after therapy discharge and no recommendations or changes were made to the restorative orders. Staff should have continued with the plan. During an interview on 06/14/24, at 8:45 A.M., CNA/RNA N said the resident did have an order from the therapy department, dated 08/23/23, for restorative nursing therapy for core strengthening. However, he/she had not been able to work with the resident on restorative due to being pulled to work the floor as an aide. During an interview on 06/14/24, at 10:53 A.M., the Director of Nursing (DON) said the resident needed therapy or exercises to strengthen his/her weaker side, to allow him better weight-bearing. He/she said CNA/RNA N had not been able to work with the resident on restorative therapy, because the RNA had been needed to work the floor as an aide, in between transporting residents to appointments. The DON said there was only one RNA progress note dated 08/23/23. During an interview on 06/14/24, beginning at 1:24 P.M., the Administrator said the physical therapy (PT) department recommends restorative nursing if they feel it would benefit the resident upon discharge from skilled PT. They communicate the need to the nursing staff/restorative nurse, who assigns the restorative therapy to the RNA or other staff. CNA/RNA N also does transportation and has had to work the floor often for the past six to eight months. He/she has not been able to do restorative therapy with the resident. MO00237558 41787

Based on observation, interview, and record review, the facility failed to ensure an qualified individual was designated as the activities program director. The facility census was 45. Review showed the facility did not provide a policy pertaining to the activity program or requirements of the program director. 1. Review of the facility's current staff listing, provided on 06/10/24, showed no individual listed as an activities program director. Review of the facility's staffing schedules for the months of May 2024 and June 2024 showed no individual scheduled to lead activities. Observation on 06/10/24, at 3:10 P.M., showed six to eight residents in the dining room area playing Bingo. A resident was calling the numbers. No staff was present. Observations on 06/11/24, at 10:15 A.M., showed Certified Nursing Assistant (CNA)/Staffing Coordinator M lead approximately six to eight residents in exercising/dancing to music played in the central lobby/living area. During an interview on 06/11/24, at 11:00 A.M., CNA/Staffing Coordinator M said he/she tried to help by leading activities when he/she was available. The facility did not currently have a full-time activity director. Review of Resident #33's care plan, last updated 05/01/24, showed the following: -Resident would like to engage in activities in his/her home; -Resident would like to attend activities throughout the week; -Resident enjoyed Bingo, especially if grand kids are present. Resident enjoyed music and live entertainment. Staff to invite resident to social gatherings and parties. Staff to provide resident with an activity calendar and encourage resident to attend activities. Staff to visit and provide one on one activities throughout the week. During an interview on 06/10/24, at 3:18 P.M., Resident #33's family member said the facility did not currently have an activity director. He/she said the residents no longer received one-on-one interaction for any activity and many of the residents appeared to be bored. The resident just sat in his/her room most of the time in between meals. During an interview on 06/14/24, at 10:53 A.M., the Director of Nursing (DON) said the facility did not currently have a designated activities program director. The former activities director had changed positions and was now a certified medication technician (CMT). Other staff members directed some activities as they had time to do so, including playing music for listening or exercise sessions. There was currently no one-on-one activity being done. The DON said some residents had recently complained about being bored. The facility was trying to hire a new activities program director. During an interview on 06/14/24, at 1:24 P.M., the Administrator said the facility did not currently have a designated activities program director. The former director had changed positions two to three weeks prior. Department heads and volunteers (usually hospice staff) were trying to lead some activities, based on a calendar/schedule set up previously, while the facility was advertising to hire a new director. Current staffing did not allow for consistency in doing one-on-one activities with residents who did not attend group activities. MO00237558 MO00237588

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when the staff failed to provide a dignity bag for a catheter (a sterile tube inserted into the bladder to drain urine) bag for three residents (Resident #40, #10, and #16), failed to knock before entering the room of one resident (Resident #41), and when staff stood over three residents (Resident #33, #23, and #24) when assisting the residents with a meal. The facility census was 45. Review of the facility's policy titled State and Federal Regulation, dated 10/2019, showed the following information: -A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Review of facility policy titled Your Rights and Protections as a Nursing Home Resident, undated, showed the following: -The resident had the right to be treated with dignity and respect, as well as make his/her own schedule and participate in the activities he/she chooses; -The resident has the right to proper privacy, property, and living arrangements. 1. Review of Resident #40's face sheet (resident's information at first glance) showed the following information: -admitted [DATE]; -Diagnoses included urinary tract infection and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal, or nerve problems). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/02/24, showed the following information: -Cognitively intact; -Dependent on staff for toileting; -Indwelling catheter. -Diagnoses included neurogenic bladder (lack of bladder control due to brain, spinal, or nerve problems). Review of the resident's care plan, last revised on 01/31/24, showed the resident had a Foley catheter related to neurogenic bladder. (Staff did not care plan regarding the use of dignity bags.) Observation on 06/10/24, at 11:00 A.M., showed the resident in his/her room with the door open. The resident sat in the wheelchair facing the window. A catheter bag was attached to the back of the wheelchair with yellow urine visible from the hallway. There was no dignity bag in place over the catheter bag. Observation on 06/11/24, at 9:17 A.M., showed the resident walked up and down 200 hall with therapy staff. A catheter bag hung underneath the resident's wheelchair with yellow urine visible. There was no dignity bag in place over the catheter bag. Observation and interview on 06/11/24, at 11:10 A.M., showed the resident in his/her room with door open, catheter bag hung from the back of wheelchair. Yellow urine visible from the hallway. Resident said the catheter bag should be inside of a dignity bag. The therapy staff often take it out to allow for full extension of his/her lower extremities during therapy. Observation on 06/11/24, at 12:26 P.M., the resident sat at dining room table, catheter bag draining visible yellow urine hung on the back of the wheelchair, dignity bag hung beside the catheter bag. 41787 2. Review of Resident #10's face sheet, showed the following information: -admitted [DATE]; -Diagnoses included malignant neoplasm (cancer) of bladder, neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder), and hemiplegia and hemiparesis (paralysis of one side of the body) following cerebrovascular disease (stroke) affecting left non-dominant side. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Indwelling catheter; -Dependent on staff for toileting hygiene, personal hygiene, showering, and dressing. Review of the resident's care plan, last revised on 06/03/24, showed the showing information: -Required staff assistance with activities of daily living (ADL) related to physical limitations; -Required one staff assistance for dressing and personal care. (Staff did not care plan related to the use of catheter and dignity bags.) Observation on 06/10/24, at 12:35 P.M., showed the resident in an electric wheelchair in the dining room. His/her catheter bag layed on the footrest of electric wheelchair between his/her feet with the cloudy yellow urine visible in the bag. The catheter bag was not covered with a dignity bag. Observation on 06/11/24, at 11:05 A.M., showed the resident in his/her room in an electric wheelchair with television on. The catheter bag laid flat on the foot pedals of the electric wheelchair between the resident's feet, not covered by a dignity bag, with cloudy yellow urine visible from hallway. Observation 06/11/24, at 12:43 P.M., showed the resident in the dining room. The catheter bag completely on the foot pedal of electric wheelchair between resident's feet and was not covered with a dignity bag with cloudy yellow urine visible. During an interview on 06/11/24, at 2:00 P.M., the resident said that he/she had not had a blue cover over the catheter bag for some time. He/she said no one seems to know where to find them. He/she would prefer to have the bag covered when in common areas. Observation on 06/12/24, at 12:20 P.M., showed the resident in an electric wheelchair in the dining room. His/her catheter bag was setting on the footrest of electric wheelchair between his/her fee with cloudy yellow urine visible in the bag. Observation on 06/13/24, at 9:30 A.M., showed the resident was his/her room in the electric wheelchair, resting with eyes closed. The catheter bag was setting on the wheelchair pedals with no dignity cover and cloudy yellow urine visible from hall. 3. Review of Resident #16's face sheet, showed the following information: -admitted on [DATE]; -Diagnosis included multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and neuromuscular dysfunction of bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Indwelling catheter; -Dependent on staff for toileting hygiene, personal hygiene, showering, and dressing. Review of the resident's care plan, last revised on 02/26/24, showed the showing information: -Required staff assistance with ADL's related to physical limitations secondary to primary diagnosis of MS; -Required assistance of one staff for dressing and personal cares; -Resident had suprapubic catheter (a catheter surgically inserted through the abdomen into the bladder) related to neurogenic bladder; (Staff did not care plan related to the use of a dignity bag.) Observation on 06/10/24, at 12:35 P.M., showed the resident in his/her electric wheelchair in the dining room. The catheter bag was hanging on the back side of her wheelchair with no dignity bag in place with clear yellow urine in the bag. Observation 06/11/24, at 12:42 P.M., showed the resident's catheter bag only partially covered by a dignity bag hanging on the left side of the wheelchair off the arm of wheelchair with clear yellow urine visible in the bag. During interview and observation on 06/12/24, at 10:10 A.M., the resident rested in bed, fully dressed, with catheter laying on the bed. The resident said that staff went to get the lift to get him/her out of bed. The resident said he/she preferred to have the catheter bag in a blue cover, he/she did not want everyone else to see the catheter. Observation on 06/13/24, at 9:40 A.M., the resident was resting in bed with eyes closed. The catheter bag was hanging on the lower left side bed rail with no dignity bag and yellow urine visible from hallway. 4. During an interview on 06/12/24, at 10:03 A.M., Nurse Aide (NA) A said catheter bags should always have a dignity bag on them. 5. During an interview on 06/13/24, at 9:50 A.M., NA H said some residents' catheter bags had privacy bag when in common areas, but in the resident rooms the catheter bags just hang on the bed rail. 6. During an interview on 06/12/24, at 12:31 P.M., Licensed Practical Nurse (LPN) B said staff must keep catheter bags inside a dignity bag to protect the resident's privacy. 7. During an interview on 06/14/24, at 11:26 A.M., the Director of Nursing (DON) said catheter bags should be covered with dignity bag, at all times, especially in common areas. 8. During an interview on 06/14/24, at 1:24 P.M., the Administrator said the staff realized on Tuesday that they did not have any dignity bags. Catheter bags should be covered with a dignity bag, at all times. 9. Review of Resident #41's face sheet showed the following information: -admitted [DATE]; -Diagnoses included chronic heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), squamous cell carcinoma (cancer that begins in the outer layer of skin), obstructive and reflux uropathy (urine cannot drain through the urinary tract, may back up into the kidneys), neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder), and residual schizophrenia (subtype of schizophrenia in which the individual has suffered an episode of schizophrenia but there are no longer any delusions, hallucinations, disorganized speech or behavior). Review of resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Used a wheelchair for mobility; -Had an indwelling catheter; -Always continent of bowel. Observation on 06/13/24, at 2:38 P.M., showed the following: -Certified Medication Technician (CMT) K in the resident's room to perform catheter care; -The resident's room door was closed; -The resident and the CMT were in the bathroom with door partially open for catheter care and medication application; -A laundry assistant walked into the room without knocking and proceeded past the bathroom door to hang up clothing and then left the room; -A staff opened outside door and then closed the door without knocking; -The Administrator and maintenance staff opened the bedroom door without knocking to check on the call light; -The resident said well, bring in the whole baseball team and their friends. During an interview on 06/14/24, at 8:45 A.M., NA A said that staff should knock before entering a resident room. During an interview on 06/14/24, at 9:20 A.M., CMT K said that staff should not enter a resident room without knocking or requesting entrance from the resident. During an interview on 06/14/24, at 4:15 P.M., Registered Nurse (RN) D said that staff should always knock before entering a resident room, they should announce self and wait for response. During an interview on 06/14/24, at 10:50 A.M., the DON said that staff should always knock and announce themselves before entering resident room. During an interview on 06/14/24, at 1:24 P.M., the Administrator said that resident have the right to privacy, staff knock before entering. 31464 10. Review showed the facility did not provide a policy pertaining to meal assistance. Observation on 06/14/24, at 7:56 A.M., showed NA W stood over Resident #33 and Resident #23 to assist them with bites of food and offer them drinks. Observation on 06/14/24, at 7:59 A.M., showed CNA R stood over Resident #24 to offer him/her bites of food and then Resident #23 to give him/her a drink. During an interview on 06/14/24, at 3:55 P.M., CNA P said that staff should assist residents with food and offer drinks between bites. Staff should help at the resident's pace and should be seated next to resident, making eye contact, and should be involved with the resident. He/she said if staff stand over the resident, it could be seen as posturing. During an interview on 06/14/24, at 4:15 P.M., RN D said staff should interact with residents when assisting with meals. They should ask the resident what they want first, give them a bite, and offer them a drink. Staff sitting next to the resident is the best option. During an interview on 06/14/24, at 10:53 A.M., the DON said staff should sit down next to a resident to feed them or cue them to feed themselves. During an interview on 06/14/24, beginning at 1:24 P.M., the Administrator said staff should sit down next to a resident while assisting them to eat. They should interact directly with the resident and not rush them to eat.

Based on interview, and record review, the facility failed to ensure all residents were free from abuse when staff acted in an abusive manor by laughing, yelling, and making derogatory comments at one resident (Resident #1) and told the resident he/she would die on his/her birthday. The facility census was 36. Record review of the facility's Abuse and Neglect Policy and Procedure, updated in August 2016, and showed the following information: -Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; -Mental abuse is includes, but is not limited to, verbal or non-verbal conduct which causes or has potential to cause humiliation, intimidation, fear, shame, degradation, harassment or threats of punishment or deprivation; -The facility policy affirms that all residents be free from verbal, sexual, physical and mental abuse. Residents will not be subjected to abuse or neglect by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, or staff of other agencies serving the residents family members or legal guardians, friends or other individuals; -Direct care staff shall be consistently monitored and counseled by supervising staff on the shift as well as by department heads, the DON and the Administrator for inappropriate behaviors such as, derogatory language, talking down to residents and rough handling. 1. Record review of the Resident #1's face sheet showed the following information: -admitted [DATE]; -Diagnoses included alcohol dependence, alcohol induced persisting amnestic disorder (a disturbance in memory caused by the persisting effects of alcohol), major depressive disorder, and Wernicke's encephalopathy (a disorder that primarily affects the memory system in the brain). Record review of the resident's care plan, updated on 11/01/21, showed the following: -Deficit in cognitive functioning, characterized by deficit in memory, judgement, decision making and thought process related to short term and long term memory loss -Risk for feelings of sadness, anxiety, and depression related to psychosis and anxiety. Staff to convey acceptance of the resident and provide repeated honest appraisals; -Directed staff to discuss feelings with the resident; -Risk to weight gain due to memory loss and eating extra meals; -Risk for alteration in mood due to cognition loss, flat effect, and psychotic diagnosis. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/30/22, showed the following information: -Moderately impaired cognition; -No mood problems; -No behavior problems. Record review of the facility investigation, dated 7/18/2022, showed the following: -On 7/18/22, at 7:00 A.M., Administrator M received a complaint from the Social Services Director (SSD) alleging three staff members (Dietary Aide (DA) A, Certified Nurse Aide (CNA) B, and Housekeeper (HK) K) had verbally harassed the resident; -On on 7/16/22, CNA E, CNA F, CNA J and the SSD, observed DA A and CNA B verbally abuse, the resident. During interviews on 7/19/22, at 11:55 A.M., and 7/20/22, at 11:30 A. M., on SSD said the following: -On 7/16/22, from 5:45 A.M. to 2:30 P.M., she worked the halls and performed CNA duties; -At approximately 7:30 A.M., she was in the dining room passing out trays with CNA E and CNA F; -The resident was one of the last residents to eat breakfast in the dining room; -Staff sang a happy birthday song for the resident; -DA A said he would get some balloons, put bug spray inside balloons and pop them and kill the resident; -DA A Said killer clowns will kill the resident and the resident will die when the balloons pop up; -Laughed at the resident; -The resident's demeanor changed; -The resident lowered his/her head down; -The resident appeared to be upset, sad and afraid; -DA A continued taunting and making fun of the resident for approximately 30 minutes saying Killer clowns are out to kill you and they will have much meat to eat; -At approximately 12:30 P.M., during lunchtime DA A and CNA B continued making fun of the resident; -CNA B walked over to the resident and said the killer clowns were waiting outside to kill you; -DA A then said You will die; -Both DA A and CNA B have a reputation of using derogatory remarks when talking to residents. -On several occasions, she observed DA A and CNA B mock residents. They have yelled and shouted you have had enough food already. During an interview on 7/19/22, at 12:30 P.M., CNA E said the following: -On 7/16/22, he/she assisted residents with showers and served resident meals in the dining room; -The resident has memory problems; -The resident is compliant and follows directions easily; -On 7/16/22, it was the resident's birthday; -Staff always sing birthday songs on any resident's birthday; -At approximately 8:30 A.M., DA A verbally abused the resident at breakfast and carried on at lunch time. The DA taunted and made fun of the resident dying on his/her birthday; -At lunchtime, at approximately 12:30 P.M., the resident requested a second cup of coffee; -CNA B was serving lunch at the time, said killer clowns were coming through the window, to wish the resident happy birthday with red balloons; -DA A then said he/she will fill the balloons with bug spray and the resident will die when the balloons pop up; -DA A and CNA B continued taunting, yelling, and laughing at the resident for approximately 15 minutes; -The resident and other residents were within hearing distance; -DA A continued and said it would be one less body to take care of if the resident dies; -DA A Said the resident is overweight, the clowns will have a lot of meat to eat; -He/she was in the dining room area with SSD and CNA F; -Residents heard the comments and were disturbed; -Abuse of residents is against facility policy. During interviews on 7/19/22, at 2:35 P.M., and on 7/20/22, at 11:06 A.M., CNA F said the following: -On 7/16/22, he/she worked from 6:00 A.M. to 6:00 P.M.; -The resident always asks for extra food in the dining room; -DA A and CNA B get frustrated and yell at the resident when the resident asks for extra food; -On 7/16/22, at approximately 7:50 A.M., the resident sat at the breakfast table with another resident; -DA A was laughing at the resident; -DA A said the resident was going to die today; -DA A said he/she will put bug spray in the balloons and poison the resident; -DA A said the killer clowns will have a good time eating the resident's meat; -CNA B said he/she wishes the resident would stop eating too much; -Another resident was at the table drinking coffee next to the resident; -DA A and CNA B's remarks were not acceptable; -The resident was upset and confused; -CNA A and DA A have made fun of the resident on several other occasions when the resident requested extra food; -It is not acceptable to abuse any resident; -The resident was visibly upset; -The resident did not finish his/her food; -The resident usually eats everything on his/her plate. During an interview on 7/20/22, at 11:15 A.M., Certified Medication Technician (CMT) I said the following: -On 7/16/2022, he/she was on duty from 6:00 A. M. to 6:00 P.M.; -At approximately 12:30 P.M., staff called for assistance in the dining room area; -Staff gave the resident a birthday cake; -DA A yelled Killer clowns are coming to kill you; -DA A was abusive towards the resident saying the killer clowns will kill you today and they will have so much meat to eat. During an interview on 7/20/22, at 10:30 A.M., LPN G said the following: -On 7/16/2022, he/she was the charge nurse from 6:00 A.M. to 6:00 P.M.; -At approximately 7:30 A.M., CNA E and CNA F said CNA B and DA A gave the resident a hard time; -Treated the resident like crap; -CNA E and CNA F were upset about CNA B and DA A's behavior; -It is not appropriate to make fun of residents; -Making fun of residents regarding their death is a form of verbal abuse. During an interview on 7/19/22, at 2:45 P.M., DA A said the following: -On 7/16/22, he/she worked from 6:00 A.M. to 2:30 P.M., -He/she washed dishes and passed trays to residents; -On 7/16/22, the resident had a birthday; -Stuff sang happy birthday to the resident at breakfast; -At lunchtime, stuff gave the resident a birthday cake; -He/she said the clowns were coming to celebrate the resident's birthday; -The resident is afraid of clowns; -CNA B said the resident was fat; -Staff should not have made fun of the resident. During an interview on 7/20/22, at 11:55 A.M., CNA B said the following: -On 7/16/2022, he/she worked as a cook at the facility from 5:30 P.M. to 2:00 P.M.; -He/she is a certified CNA; -On 7/16/22, at approximately 12:30 P.M., DA A said something about balloons and the clowns; -DA A has made multiple comments to the resident on previous occasions regarding the resident's eating habits; -DA A gets annoyed when the resident, asks for extra food repeatedly; -He/she has told DA A to communicate with the resident in a respectful manner; -It's not appropriate to tell any resident they will die on their birthday. During an interview on 7/20/22, at 12:20 P.M., HK K said the following: -On 7/16/2022, he/she was on duty at the facility from 5:30 P.M. to 3:00 P.M., -He/she helped in the kitchen during breakfast and lunch meal service; -The resident got his tray, sat down, and ate breakfast; -The resident asked for additional food; -DA A was upset and said the resident will die today, killer clowns are coming to kill you; -The clowns have red balloons with bug spray, you will die on your birthday; -DA A kept repeating the same thing for approximately 20 to 30 minutes; -CNA B joined DA A and mocked the resident verbally and repeatedly in the dining room saying killer clowns will kill the resident; -CNA B made similar comments and said the resident would die on his/her birthday; -DA A has a history of making derogatory comments to residents like the resident eats like a horse. During an interview on 07/19/22, at 9:50 A.M., HK C said the following: -On 7/16/22, he/she worked the halls; -HK C noticed the resident was sad, withdrawn, and stayed in his/her room most of the day; -He/she said staff said he/she would die; -The resident is afraid to die. During an interview on 07/19/22, at 9:50 A.M., HK D said the following: -The resident enjoys food and always asks for extra portions; -The resident is polite and does not talk much; -DA A and CNA B enjoyed making fun of the resident; -DA A makes jokes about the resident's eating habits in front of other residents; -DA A and CNA B have both made fun of the resident more than five times in the last month; -Verbal abuse is not acceptable in any form. During an interview on 7/19/22, at 10:55 A.M., the Activity Director (AD) said the following: -Staff mocked the resident about dying on his/her birthday; -The resident has trouble remembering recent and past events; -DA A and CNA B frustrate the resident; -The resident often forgets he/she just had a meal and occasionally ask for another plate of food five times after the first one; -DA A and CNA B inappropriately speak derogatory terms to the resident knowing the resident will not remember anything. DA A and CNA B are verbally abusive the resident about his/her eating habits. During an interview on 7/19/22, at 11:20 A.M., the Dietary Cook (DK) L said the following: -DA A and CNA B both work in dietary; -DA A has a habit of yelling to residents; -The resident comes to the door more than five times a day asking for coffee; -DA A yells, when the resident asks for coffee. The resident can hear the yelling and always nods his head down and does not make any comments; -The resident has a hard time remembering. During an interview on 7/19/22, at 2:05 P.M., the resident said the following: -His/her birthday was a few days ago; -Staff celebrated his/her birthday in the dining room area; -CNA B and DA A were teasing and making fun of him/her; -DA A and CNA B have made fun of him/her on multiple occasions; -Tries to ignore DA A and CNA B; -It is not nice to laugh at residents. During an interview on 7/19/22, at 2:10 P.M., the Resident Representative said the following: -He/she is aware facility said inappropriate comments to the resident; -Believes the resident was terrified, angry, and upset. During an interview on 7/19/22, at 1:50 P.M., Resident #2 said the following: -On 7/16/21, Resident # 1 had a birthday; -DA A and CNA B yelled at the resident; -DA A said the resident should die on his birthday; -The resident was sad and afraid. During an interview on 7/19/22, at 2:15 P.M., the Resident #3 said the following: -Some staff enjoy yelling and making fun of residents in the dining room area; -It is not acceptable to yell and make fun of anyone; -He/she does not like it. During an interview on 7/19/22, at 3:45 P.M., Administrator M said the following: -On 7/18/22, at 7:30 A, M., SSD reported DA A and CNA B verbally abused the resident. The staff emotionally abused the resident and made fun of his/her eating habits; -SSD, CNA E and CNA F, said the resident was visibly upset and sad about the incident; -The resident is not confrontational; -Staff should never make fun of residents when they ask for extra food; -Staff said DA A and CNA B have picked on the resident many times before saying things like the resident he wouldn't be so fat if he did not eat too much. During an interview on 7/20/22, at 1:09 P.M., the Director of Nursing (DON) said the following: -The resident's short-term memory has been deteriorating; -The resident frequently asks for coffee and extra food in the kitchen; -The DON said the actions of CNA B and DA A were abusive and unacceptable. During an interview on 7/20/22, at 2:07 P.M., the Dietary Manager said the following: -DA has made comments about the residents that are mostly unprofessional; -Residents complain about DA A's meanness such as yelling and shouting at residents. During an interview on 7/20/22, at 2:30 P.M., Administrator N said said the actions of CNA B and DA A were abusive. MO00204152