Every finding on record at Northwood Hills Care Center

Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to document monitoring after a fall for three residents (Resident #2, #3, and #4) and failed to inform management of a fall for one resident (Resident #2) who was later found to have a fracture due to the fall. The facility census was 82.Review of the facility's policy, Incident and Reportable Event Management, revised 02/24/26, showed the following:-A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (example, resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred;-Event management includes falls;-To help reduce the risk of an event, all residents receive assistance and supervision as addressed in their care plan. In an effort to minimize the potential for recurrence, if an event occurs, the facility will ascertain what happened or was reported to have happened, provide care and document any injuries, interview to find out who saw the resident last and the time of the event, investigate why it happened, and intervention;-The licensed nurse should evaluate the resident and render first aide if needed;-The nurse evaluation should be complete prior to moving a resident who has fallen, to determine presence of an injury;-The licensed nurse should create an event note and include, the assessment details of the resident (including location details of the resident), presence or absence of injury, and any treatments rendered, if resident is able to report what occurred, this should be included in the notes, notification of family or responsible party and notification of physician and any orders received. 1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 04/01/11;-Diagnosis included diabetic nephropathy and polyneuropathy (progressive kidney damage and widespread nerve damage. Both are primarily caused by chronic high blood sugar and oxidative stress), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), history of falling, osteoarthritis of bilateral knee, Parkinson's disease dyskinesia without mention of fluctuations (a progressive neurological disorder that primarily affects movement), pain in right knee, abnormalities of gait and mobility, unsteadiness on feet, and chronic pain. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/27/26, showed the following:-The resident is cognitively intact;-The resident is independent with transfers;-The resident had one fall with injury since the last admission. Review of the resident's care plan, updated 05/30/24, showed the following:-The resident needed assistance with activities of daily living (ADLs - grooming, bathing, toileting etc.) as required during activities;-The resident as an ADL self-care performance deficit due to activity Intolerance, dementia, impaired balance, limited mobility and pain;-The resident required assistance of one staff with bathing/showering;-The resident was at risk for falls and had history of falls. He/she had gait/balance problems, psychoactive drug use, muscle weakness, and arthropathy (any disease or abnormal condition affecting the joints);-Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs;-Staff to complete a fall assessment;-Encourage to participate in activities that promote exercise, physical activity for strengthening and to improve mobility;-Staff will provide adaptive equipment or devices as needed and provide appropriate non-skid proper fitting footwear when ambulating in room. Remind resident to ask staff for assistance with water spills. Review of the resident's progress notes showed the following:-On 04/03/26, at 6:35 A.M., Licensed Practical Nurse (LPN) E said the shower aide assisted the resident to the floor in the shower room. The resident hit his/her head on the wall with no pain or discomfort noted. The resident's blood pressure was 160/88 millimeters of Merch (mm/Hg) (normal range is less than 120/80 mm/Hg), heart rate 62 beats per minute (bpm) (normal range is 60 to 100 bpm), oxygen saturation of 95% (normal is 95% to 100%), respirations of 18 per minute (normal is 12 to 20 per minute), and temperature of 97 degrees Fahrenheit (F). The resident did not have redness or bruising;-On 04/04/26 to 04/06/26, staff did not document related to the resident's fall and follow-up monitoring;-On 04/07/26, at 3:20 A.M., the resident continued on skilled therapy services. The resident used a walker and knee braces. The resident continued say therapy is too hard on him/her and he/she needed to quit. (Staff did not document related to the resident's fall and follow-up monitoring.);-On 04/08/26 to 04/09/26, staff did not document related to the resident's fall and follow-up monitoring;-On 04/10/26, at 9:32 A.M., the resident refused to go to the dentist and said, I can't go my back hurts. When asked a second time the resident said, I told you I am not going my back hurts. (Staff did not document related to the resident's fall and follow-up monitoring.);-On 04/11/26 to 04/12/26, staff did not document related to the resident's fall and follow-up monitoring;-On 04/13/26, at 8:56 A.M., LPN A said the resident continued to have pain in the lower back and tailbone from falling into a wall. Staff notified the physician and ordered an x-ray;-On 04/13/26, at 3:45 P.M., LPN A said the resident had increased pain to the lower back, coccyx (tailbone) area. An x-ray showed a left pubic rami fracture with mild displacement (a break in one of the bones that make up the front of your pelvic ring). Staff notified the nurse practitioner. During an interview on 06/10/26, at 10:39 A.M., the resident said the following:-He/she fell a few months ago in the shower with a staff member. The staff member tried to help him/her to the floor, but he/she still hit the floor hard;-The facility did an x-ray and he/she had a broken pelvis. During an interview on 06/10/26, at 10:57 A.M., LPN E said the following:-The resident fell in the shower. She was lowered to the floor by a staff member;-He/she came to the shower room, assessed the resident and completed neurological checks on the resident;-The resident did not appear to have any new injuries. The resident complained of back pain, however, that was not a change from baseline. The resident had chronic back pain;-The resident responded well to pain medication;-He/she did not know why there were no further assessments completed or documented in the computer for the resident after the fall;-The resident should have had fall follow up assessments per the facility protocol for falls, completed every shift for 72 hours to assess for any latent injuries. During an interview on 06/10/26, at 1:27 P.M., LPN F said the following:-The resident had an x-ray about a week after his/her fall and had a pelvic fracture;-He/she did not remember completing any fall follow up assessments for the resident around the beginning of April 2026;-The resident did not have any significant increase in pain that would have indicated at injury;-The resident's nurse should have completed fall assessments each shift for 72 hours. During interviews on 06/10/26, at 1:44 P.M. and 2:28 P.M, LPN G said the following:-On 04/07/26, the resident told him/her that he/she had fallen in the bathroom over the weekend;-He/she looked in the medical record and could not find any notes regarding a fall since 04/03/26;-He/she could not find any assessments or fall follow-up documentation. He/she did not understand why staff did not complete neurological checks or at a minimum 72-hour fall follow up assessments;-He/she texted the Director of Nursing (DON) regarding the fall and not finding follow up documentation. The DON indicated he/she did not know about the fall and asked him/her to assess the resident;-He/she did a full assessment and found only a slight bruise to the left scapula (shoulder blade);-He/she forgot to document the assessment in the medical record. He/she should have documented the assessment in a progress note. During an interview on 06/10/26, at 2:04 P.M., LPN A said the following:-He/she did not know why the resident did not have any more assessments after the initial fall assessment;-On 04/13/26, the resident said he/she was having more pain in her lower back, and he/she thought it might be due to the fall he/she had;-He/she called the physician, and they ordered an x-ray. During an interview on 06/11/26, at 10:31 A.M., the DON said the following:-A CNA was with the resident when he/she fell and helped lower him/her to the floor;-The CNA said the resident's head barely bumped the wall and did not indicate that neurological checks needed to be done;-LPN E did not initially tell him/her about the resident's fall. He/she became aware days later, but he/she was not sure exactly what day;-There was a delay in contacting him/her regarding the fall;-A nurse assessed the resident the day he/she became aware, and had no new concerns or bruising;-He/she expected fall assessments be documented in the resident's chart;-He/she did not know why staff did not document fall follow-up assessments the resident's chart. During an interview on 06/11/26, at 1:12 P.M., the Administrator said the following:-The resident should have had fall assessments completed after the fall;-The resident required an x-ray about a week later and they found he/she had a fractured pelvis. 2. Review of Resident #3's face sheet showed the following:-admission date of 02/28/24;-Diagnosis included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side (a neurological condition where a spontaneous bleed in the brain damages the left hemisphere, causing weakness and paralysis on the right (dominant) side of the body), muscle weakness, repeated falls, unsteadiness on feet, other abnormalities of gait and mobility and lack of coordination. Review of the resident's MDS, dated [DATE], showed the following:-The resident had moderate cognitive impairment;-The resident required partial/moderate staff for transfers;-The resident has had two or more falls since the last admission or reentry. Review of the resident's care plan, revised 09/26/25, showed the following:-Resident at risk for falls due to confusion, gait/balance problems, and incontinence;-Staff will assist with ADLs as needed;-Staff will anticipate the resident's needs;-Staff will assess the resident for illness;-Staff will encourage the resident to use the call light in the bathroom for assistance;-Staff will encourage the resident to use non-skin foot wear. Review of the resident's progress notes showed the following:-On 06/08/26, the certified nurse aide (CNA) called the nurse to the resident's room because he/she had to lower the resident to the floor during a transfer due to the resident not pivoting and trying to sit down during the transfer. The nurse assessed the resident for injuries. The resident did not have any injuries. Three staff assisted the resident up to the wheelchair with a gait belt. He/she educated the CNA to use two staff for transfers with the resident. The nurse notified the physician and DON;-On 06/08/26, at 2:00 P.M., the interdisciplinary team members met to discuss the residents fall on 06/08/26. Staff lowered the resident to the floor during a transfer. The nurse assessed the resident for injuries and there were none. Staff assisted the resident to the wheelchair. The staff to implement a new intervention of two staff assist with transfers. The care plan was reviewed and updated. Review of the resident's records showed staff did not document any additional fall follow-up assessments for the fall that occurred on 06/08/26. 3. Review of Resident #4's face sheet showed the following:-admission date of 09/09/25;-Diagnosis included vascular dementia with other behavioral disturbance (occurs when reduced blood flow to the brain causes cognitive decline alongside difficult neuropsychiatric symptoms), repeated falls, unsteadiness on feet, muscle weakness, and unspecified dementia (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). Review of the resident's MDS, dated [DATE], showed the following:-The resident had significant cognitive impairment;-The resident required partial/moderate assistance from staff for transfers;-The resident has had two or more falls since the last admission or reentry. Review of the resident's care plan, updated 03/12/26, showed the following:-Resident at risk for falls;-Staff will anticipate the residents' needs;-Ensure the television is off prior to transfers;-The staff will assist the resident to bed;-The staff will complete increased observation while the resident is in bed. Review of the resident's progress notes showed the following:-On 05/27/26, at 7:08 P.M., while staff was transferring a resident from the toilet to the wheelchair the resident started to fall and staff assisted resident to the floor. Staff yelled for the nurse. The nurse did not find any injuries;-On 05/28/26, at 11:06 A.M., the interdisciplinary team members met to discuss the resident's fall on 05/27/26. Staff were assisting resident to bathroom. The resident lost their balance, and staff lowered them to the floor. The nurse assessed the resident for injuries with none found. The staff assisted the resident up. The physician and DON were notified. A new intervention was put in place. The resident will have two-person assistance with transfers. The care plan reviewed and updated. Review of the resident's records showed staff did not document any additional fall follow-up assessments for the fall that occurred on 05/27/26. 4. During an interview on 06/10/26, at 10:57 A.M., LPN E said the following:-The nurse completes an initial fall assessment and makes a progress note in the resident's medical record;-Fall assessments are continued for 72 hours at least once per shift after then initial assessment. During an interview on 06/10/26, at 1:27 P.M., LPN F said the following:-The nurses respond to every fall. They complete an initial assessment for injury and then continue to assess one time per shift for 72 hours;-Staff lowering a resident to the floor is considered a fall and should be assessed per the facility protocol. The nurse checks the resident's vitals, neurological status and for any physical injuries/ pain;-The nurse completes neurological checks for 72 hours if the resident hits their head;-The nurse sets up an event under the assessment tab on the computer and can document their assessment there. They also document assessments in the progress notes. During interviews on 06/10/26, at 1:44 P.M. and 2:28 P.M, LPN G said the following:-The nurse should always complete an initial assessment and fall follow up assessments once time per shift for 72 hours;-The nurse was to enter an event note and also a progress notes regarding the assessments and any findings.During an interview on 06/10/26 at 2:04 P.M., LPN A said the following:-If a resident had a fall, the protocol was for the nurse to complete an initial assessment. The nurse assessed once per shift for 72 hours following the fall to ensure there are no latent injury;-The nurse documented the assessments in the resident's medical record;-If staff had to lower a resident to the floor it is still considered to be a fall and fall assessments should be completed every shift for 72 hours. During an interview on 06/11/26, at 12:46 A.M., the Nurse Practitioner (NP) said the following:-He/she expected staff to complete a full fall follow up, including assessing the resident every shift for 72 hours and completing neurological checks to make sure there are no latent injuries, after a fall or lowering a resident to the floor;-The nursing staff should document the assessments in the resident's chart and let him/her or the physician know if there are any unusual findings. During an interview on 06/11/26, at 10:31 A.M., the DON said the following:-He/she expected nursing staff to complete fall assessments once per shift for 72 hours following a fall for latent injuries;-Staff lowering a resident to the floor is still considered a fall and he/she expects staff to assess the resident and follow the facility fall protocol;-The nurses document the assessments in the resident's progress notes and pass on the information to the next nurse;-The staff contact the DON or on-call manager if a resident fell. During an interview on 06/11/26 at 1:12 P.M., the Administrator said the following:-He/she expected the staff to complete fall follow-up per the facility protocol;-There should be follow-up assessments completed. He/she did not know for how long but thought they should be completed each shift following a fall. Complaint #2982345

Based on interview and record review, the facility failed to appropriately bill the resident's appropriate Medicare plan during their stay resulting in an overpayment and failed to reimburse the resident 30 days after discharge for the over payment for one resident (Resident #5). The facility census was 82.Review of the facility's policy, Credit Balance and Refund Policy, revised 02/06/26, showed the following:-The purpose of the policy was to provide guidance on managing credit balances efficiently and to ensure accounts with credit balances due to overpayments are refunded in a timely manner and as required by law. These refunds include, but are not limited to, monies due back to federal health care programs, insurance payers, and residents;-Credit Balances may be caused by multiple reasons including, the payer paying more than expected, the resident paying more co-insurance, copay, or deductible than was owed based on the payment received from the payer; duplicate payment of the claim by payers and or resident (e.g., when the primary and secondary insurance companies both pay primary); or an error in the accounts receivable system setup for expected payment andcontractual amount; or an erroneous posting by the facility during payment posting (e.g., payment posted to wrong account);-When an account has a credit balance, it is important to determine the reason, correct any posting errors, and, if applicable, process a refund to the appropriate party in a timely manner;-The facility shall make every reasonable effort to promptly identify and resolve credit balances. If research and analysis confirm the credit balance is in overpayment. Overpayments are returned within 60 days of identification;-For those credit balances confirmed to require refund, the Business Office Manager (BOM) (or designee) should promptly take steps to refund the monies due to the appropriate party. Sometimes the payer will take the refund from future remittances. If not, a refund check must be issued;-Complete the AR Patient Refund form including an explanation of the reason for the refund;-Obtain approval from the Executive Director by them signing the completed form;-The Accounts Payable associate will then enter the invoice into the accounts payable system and scan backup documents;-The treasury department will process the refund and mail to the payee according to the information entered by the facility.-If the credit balance is due to a billing error, an adjustment should be made to the Medicare claim which will cause Medicare to recoup the refund. Open a support ticket with Facility Financial applications if you have any issues with adjusting the claim to return the money;-If the Credit Balance results from overcollection on of a resident's obligation, ensure the refund check is payable to the resident. 1. Review of Resident #5's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 12/23/25;-discharge date of 04/03/26. Review of the resident's discharge Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), date 04/03/26, showed the following:-admission of 12/23/26;-Discharge from facility with return not anticipated on 04/03/26. Review of the resident's eligibility report, dated 01/02/26, showed the following:-The resident's Medicare advantage plan was terminated on 12/31/25;-The resident's Medicare Part A effective date was 11/01/2017;-The resident's plan benefits were Medicare part A first bill, dated 01/01/26. Review of the resident's billing statements showed the facility did not bill Medicare part A for the resident's stay. Review of facility records showed an email to the Business Office Manger (BOM) and Administrator from the Regional Field Controller dated 05/28/26, at 9:43 A.M., that indicated the resident overpaid $9266.97 dollars for his/her stay. During an interview on 06/10/26, at 2:50 P.M., the BOM said the following:-The resident moved from out of state. He/she had Medicare advantage plan through the other state and the facility was out of network;-The resident and his/her family agreed for him/her to be private pay and they were going to cancel their advantage plan and get back on Medicare part A;-He/she qualified for a skilled stay as of 01/01/26, however, the facility failed to complete skilled notes/documentation required to qualify for a skilled stay and have it paid for by Medicare;-He/she did not know why staff did not complete the documentation needed;-Medicare A was not billed for the stay that he/she qualified for;-The resident's family came to the facility after the resident was discharged around the middle of May. They were upset and felt they had been overbilled;-The Administrator investigated the concern. They realized that the resident had qualified for Medicare A but the facility did not bill correctly;-The Regional Field Controller sent an email with the amount that Medicare part A would have covered if they had billed them correctly;-He/she thought Administrator was taking care of the resident reimbursement;-The resident has not been refunded timely;-The resident has not been reimbursed yet. During an interview on 06/10/26, at 2:55 P.M. the Regional Field Controller said the following:-He/she sent the amount that needed to be reimbursed to the Administrator and BOM;-They were supposed to get the check ready and send it back to the corporate office to be signed;-The resident had not been reimbursed yet. During an interview on 06/11/26, at 12:45 P.M., the Director of Nursing (DON) said the following:-The resident's family came to the facility sometime in May and were upset about a billing issue;-Corporate said they were owed a refund;-The resident was private pay when he/she admitted and the medical record did not populate skilled notes;-He/she did not know the resident had Medicare so skilled documentation was not completed;-He/she did not know if the resident has been reimbursed. During an interview on 06/11/26, at 1:12 P.M., the Administrator said the following:-The resident was admitted to the facility on [DATE] with insurance that was of network;-He/she was not sure how they missed that the resident qualified for a skilled stay under Medicare part A as of 01/01/26;-The resident started out as private pay. They discontinued the insurance that was out of network but he/she did not think the Medicare would go into effect until February;-If that had occurred the resident would not have qualified for a skilled stay;-The resident's family came to the facility in mid-May. They were upset about the co-pays;-The Administrator investigated and discovered the resident had qualified for a skilled stay and would have qualified for some of it to be covered by Medicare;-The BOM manager should have realized the resident qualified for a skilled stay at of 01/01/26;-He/she worked with the Regional Field Controller to determine how much money Medicare would have covered if the facility had billed them;-He/she was not sure how long the facility had to reimburse the resident;-The resident had not been reimbursed yet. Complaint #3017587

Based on observation, record review, and interview, the facility failed to maintain effective and complete an infection prevention and control program when staff failed to follow appropriate Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO - bacteria or fungi that have developed resistance to multiple classes of drugs, like antibiotics) that employs targeted gown and glove use during high contact resident care activities) for one resident (Resident #1) with an indwelling catheter (tubing placed to drain the bladder to outside the body), a nephrostomy tube (tubing placed to drain the kidney to the outside the body) and with two wounds present. The facility census was 82.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 of the facility's policy titled Enhanced Barrier Precautions, dated 08/19/25, showed the following:-The facility should use EBP as an additional MDRO mitigation strategy for residents that meet the following criteria, during high-contact resident care activities;-EBP are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO;-Wounds generally include chronic wounds not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing;-Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers;-Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.-EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. 1. Review of Resident #1 face sheet (brief information sheet about the resident) showed the following:-admitted [DATE];-Diagnoses included osteomyelitis (a localized inflammation of the bone due to an infection) of sacral (the large, triangular bone at the bottom of the lower back) and sacrococcygeal region (anatomical region at the base of the spine) vertebra (spine), stage 4 pressure ulcer (full-thickness skin and tissue loss) of sacral region, non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, neuromuscular dysfunction of bladder (loss of bladder control, inability to empty bladder), and hydronephrosis (swelling of one or both kidneys caused by a buildup of urine). Review of the resident's care plan, updated 04/27/26, showed the following:-Resident had potential and actual impairment to skin integrity;-Resident has an indwelling suprapubic catheter (sterile tube inserted into the bladder to drain urine);-Resident had a stage 4 pressure ulcer of sacral region;-Staff should utilize enhanced barrier precautions. Review of the quarterly Minimum Data Set (MDS - an assessment completed by facility staff), dated 04/28/26, showed the following:-Cognitively intact;-Stage 4 pressure ulcer;-Diabetic foot ulcer;-Indwelling catheter.Review of the resident's physician orders, current as of 06/10/26, showed the following:-An order, dated 04/28/26, to check nephrostomy tube (thin, flexible catheter inserted through the directly into the kidney to drain urine) site every shift, verify if tube is draining and no kinks are present in the tube, no signs or symptoms of site infection;-An order, dated 04/28/26, for coccyx (tailbone). Staff to cleanse wound, pat dry, loosely pack with Vashe (brand name wound care solution) moistened gauze, and cover with dry dressing every day shift for wound care;-An order, dated 04/28/26, for the right heel. Staff to cleanse wound, pat dry, cover with Mepilex (brand of soft silicone foam dressing) heel border every day shift every 3 days for wound care;-An order, dated 05/01/26, for EBP for diagnoses of wound, catheter, and nephrostomy tube every shift;-An order, dated 05/19/26, for indwelling catheter to straight drainage. Review of the resident's June 2026 Medication Administration Record (MAR) showed the following:-An order dated 06/01/26, enhanced barrier precautions for diagnosis of wound, foley (catheter) and nephrostomy tube every shift;-Staff signed as completed for day, evening, and night shift on 06/01/26, 06/02/26, 06/03/26, 06/04/26, 06/05/26, 06/06/26, 06/07/26, 06/08/26, 06/09/26, and day shift on 06/10/26. Observation on 06/10/26, at 1:15 P.M., showed the following:-Licensed Practical Nurse (LPN) A prepared wound care supplies at cart in hall;-He/she requested assistance from Certified Nurse Assistant (CNA) B for positioning the resident;-An EBP sign on the resident's door with personal protective equipment (PPE) hanging in a container on the door;-The LPN entered the resident's room and placed wound care supplies on a clean barrier on the resident's bedside table;-CNA B entered the resident's room and applied gloves;-The LPN washed his/her hands at the resident's sink and applied gloves;-LPN A and CNA B did not apply gowns;-LPN A and CNA B assisted the resident to roll to their left side;-The resident had a colostomy bag (waterproof, medical-grade pouch worn over a stoma - a surgically created opening in the abdominal wall-to collect waste) on the right side of their abdomen, a catheter bag hanging on the rail of the bed frame, and a nephrostomy bag on the bed next to the resident;-The LPN removed the wound dressing on the resident's sacral area;-The LPN removed gloves, used hand sanitizer, and applied clean gloves;-The LPN completed wound care and removed his/her gloves, used hand sanitizer and applied clean gloves;-The LPN placed a clean bed pad on the bed and assisted the resident to roll to their right side as the CNA pulled the clean bed pad through and straightened the sheets;-The CNA moved the nephrostomy bag to ensure it was flat with no kinks in the tube;-The LPN moved the catheter bag to the right side of the bed for resident to be repositioned to right side;-LPN A and CNA B ensured the resident's comfort and returned the call light to the resident's reach;-LPN A and CNA B removed the trash and soiled linens, removed their gloves, and completed hand hygiene;-LPN A and CNA A exited the room;-LPN A and CNA B did not wear gowns during the wound care process. During an interview on 06/10/26, at 1:50 P.M., LPN A said the following:-EBP should be used for residents with catheters, tracheostomy, and wounds;-Depending on the situation, staff will wear gown, gloves, and sometimes masks when performing cares;-Staff should wear gowns when completing wound care for the resident. During an interview on 06/10/26, at 2:00 P.M., CNA B said the following:-If a resident had an EBP sign on the room door and staff should wear a gown and gloves with any personal cares;-Staff should wear gowns when providing wound care on the resident. During an interview on 06/10/26, at 2:25 P.M., CNA C said staff should wear a gown and gloves when working with residents that have an EBP sign on the door. Personal protective equipment (PPE) supplies are located on the resident's door. During an interview on 06/10/26, at 2:40 P.M., Registered Nurse (RN) D said the following:-Staff should follow EBP guidelines when a resident had wounds, catheters, or any inserted device;-Staff should wear a gown and gloves with any hands-on care with a resident that required EBP precautions;-The PPE supplies and an EBP precautions sign were located on the resident's door. During an interview on 06/10/26, at 3:00 P.M., the Infection Preventionist (IP) said the following:-All staff are trained on EBP protocol;-Staff are required to wear a gown and gloves during resident cares for any residents with a tracheostomy, PICC line , wounds, G-tubes (medical device surgically inserted through the abdomen directly into the stomach), and catheters;-EBP precautions prevent staff from exposing the resident to any possible infection and to help prevent MDRO infections. During an interview on 06/10/26, at 3:10 P.M., Director of Nursing (DON) said staff must follow EBP policy. Staff should wear a gown and gloves when doing cares with residents who have catheters, wounds, and any tubes. During an interview on 06/11/26 at 1:12 P.M., the Administrator said the following:-The facility follows EBP for infection control. The nurses are familiar with the residents that require EBP be followed and should follow the infection control policy;-He/she expected staff to follow EBP when they are performing wound care, especially on an open wound. This would include wearing gloves, gowns and a mask when necessary. Complaint #3017587

Based on interview and record review, the facility failed to report all allegations of potential abuse immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours when staff did not report an allegation of employee to resident verbal abuse towards one resident (Resident #1) in a timely fashion as required. The facility census was 94. Review of the facility policy, titled Area of Focus: Abuse and Neglect, review date of 11/24, showed the following: -Each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone, including staff; -Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse, to the administrator and other officials including the State Survey Agency. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following information: -admitted [DATE]; -Diagnoses included cerebral palsy (a group of disorders that effect movement and muscle tone or posture), high blood pressure, and depression (mood disorder that is characterized by a low mood and negative emotions). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/26/24, showed the resident had some cognitive impairment and had delusions (misconceptions or beliefs that are firmly held, contrary to reality). Review of the facility's investigation showed the following: -Certified Nurse Aide (CNA) A alleged an incident of staff to resident verbal abuse that happened on 01/15/25, between 7:00 P.M. and 8:00 P.M. CNA A reported to the Director of Nursing (DON) that CNA H called the resident a fat ass and said he/she looked like he/she was sucking a big dick. -The CNA A reported the allegation of staff to resident verbal abuse to the DON on 01/16/25, at 2:30 P.M. (the day after the alleged allegation of abuse occurred). -The DON documented DHSS was notified on 01/16/25, at 3:33 P.M. (the day after the alleged abuse occurred). Review of DHSS records showed the facility self-reported the allegation of staff to resident verbal abuse on 01/16/25. During an interview on 01/28/25, at approximately 1:10 P.M., CNA A said the following: -Staff were to report to a charge nurse immediately if staff suspect any abuse; -He/she was a little afraid to report the incident to the charge nurse, as he/she did not know if the charge nurse would take it seriously, so he/she decided to wait; -The DON educated him/her that staff are always able to go to the DON or other staff directly, if there are allegations of possible abuse; -He/she said the facility must report any abuse within two hours. During an interview on 01/28/5, at approximately 12:10 P.M., CNA B said the following: -He/she would report any kind of abuse to the DON or management immediately upon hearing it or someone letting him/her know; -Any verbal, misappropriation, physical or sexual abuse should be reported; -The facility has 24 to 48 hours to report any abuse to state. During an interview on 01/28/25, at approximately 12:30 P.M., Certified Medication Tech (CMT) E said any kind of abuse must be immediately reported to management and the facility must report allegations of abuse to state within two hours. During an interview on 01/28/25, at approximately 12:20 P.M., Certified Occupational Therapy Assistant (COTA) C said the following: -Anything regarding physical, financial, or verbal abuse needs to be reported immediately to the DON, Assistant Director of Nursing (ADON), or Administrator; -They have to follow-up within 24 hours with the state and interview the residents and investigate. During an interview on 01/28/25, at approximately 12:50 P.M., Licensed Practical Nurse (LPN) F said the following: -He/she would report any abuse allegation; -If anyone told him/her this was happening or witnessed, he/she would call the DON or Administrator immediately; -They would have to call state within 24 hours. During an interview on 01/28/2025, at approximately 12:55 P.M., LPN G said the following: -Staff are to immediately let the Administrator know of any allegations of abuse; -Management only has two hours to report abuse to state. During an interview on 01/28/25, at approximately 12:25 P.M., Registered Nurse (RN) D said the following: -Any kind of sexual, physical or disrespecting of a resident that may be disconcerting, should be reported; -He/she would separate or intervene to stop the abusive situation; -He/she would report immediately any concerns of abuse; -The facility must report within two hours, to state, allegation of abuse. During an interview on 01/28/25, at approximately 11:35 A.M., the Medical Records Staff said the following: -Any reported abuse to the facility must also be reported to state; -Abuse must be reported within two hours of getting the information; -They are to report any kind of verbal, emotional, physical, or degrading incident. During an interview on 01/28/25, at approximately 11:50 A.M., the Business Office Manager (BOM) said the following: -If any kind of abuse happens, it needs to be reported within the two hours to state; -Staff should get the information to management immediately; -Any kind of abuse needs to be reported including hitting, yelling, talking bad or berating a resident, has to be reported. During an interview on 01/28/25, at approximately 11:50 A.M., the Staffing Coordinator said the following: -CNA A did not report the incident because they were intimidated to do so at the time; -The DON told CNA A that this is not an excuse and explained CNA A could have stepped into a bathroom or outside for a moment to call, or could have text; -All reports of abuse must be reported within two hours. During an interview on 01/28/25, at approximately 12:45 P.M., the Infection Preventionist said the following: -He/she ensured to stress the timeframes of reporting to all staff; -There are postings at the nurses desk providing who to contact when there is an allegation of abuse. During an interview on 01/28/25, at approximately 1:20 P.M., the DON said the following: -As soon as he/she was informed of the allegations, an investigation was started; -All staff have been trained that it is only a two hour window frame and all of them should know this. MO00248125

Based on observation, interview, and record review, the facility failed to ensure three nurse aides (NA) (NA I, NA P, and NA Q) completed a certified nurse aide (CNA) training program and obtained certification within four months of employment at the facility as a nurse aide. The facility census was 90. Review of the facility policy titled Nurse Aide Requirements, undated, showed the following: -The facility needed to ensure the nurse aides meet the training requirements to work within a facility including a state approved training and competency program; -The facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis unless that individual is competent to provide nursing and nursing related services and has completed a training and competency evaluation program; -Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met the competency evaluation requirements unless the individual is a full-time employee in a training and competency evaluation program approved by the state; or the individual can prove that he/she has recently completed a training and competency evaluation program and has not yet been added to the registry. Facilities must follow up to ensure that such an individual actively becomes registered. 1. Review of NA P's employee personnel file showed the following: -Initial date of hire was [DATE] with job title of NA; -Rehire date of [DATE] with job title of Non-Certified Aide in Training; -Nurse aide training class start date of [DATE] with no completion date listed. Review of the state agency CNA registry website, on [DATE], showed NA P was certified as a CNA on [DATE] and the certification expired on [DATE]. 2. Review of NA Q's employee personnel file showed the following: -Date of hire as a nurse aide in training was [DATE]; -Nurse aide training class start date of [DATE] with a completion date of [DATE]. Review of the state agency CNA registry website, on [DATE], showed no documentation that NA Q was certified as a CNA. 3. Review of NA I's employee personnel file showed the following: -Date of hire was [DATE] with job title of Nurse Aide in Training; -NA training class showed a start date of [DATE] with a completion date of [DATE]. Review of the state agency CNA registry website, on [DATE], showed no documentation that NA I was certified as a CNA. Observation on [DATE], at 2:07 P.M., showed NA I providing direct care to residents in the facility. During an interview on [DATE], at 2:07 P.M., NA I said the following: -He/she completed NA training about two weeks ago; -He/she took the written and skills test one week ago, but failed the skills portion; -He/she has not rescheduled the skills portion of the test due to distance of testing site and cost. 4. During interviews on [DATE], at 11:07 A.M., and on [DATE], at 2:49 P.M., Licensed Practical Nurse (LPN) R said the following: -NA P is now working in an activities position; -NA I took the test and failed the skills portion of the test and will be rescheduling it; -NA Q took the certification test and failed the knowledge portion, but has rescheduled the test; -NA Q should have completed his/her certification a long time ago and was removed from the floor as soon as he/she realized it. During an interview on [DATE], at 2:56 P.M., the Director of Nursing (DON) said nurse assistants should complete all training and certified in four months. If not certified within that time, the nurse assistant should be taken off the floor and placed in another non nursing position. During an interview on [DATE], at 4:51 P.M., the Administrator said nurse aides should be certified in four months. Aides should not work on the floor if certification is not obtained in four months.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to keep the ice machine vents, air vents, and a standing fan free of lint, debris, and grime; when staff failed to label and date refrigerated food and failed to dispose of outdated refrigerated food; and when staff failed to ensure the dishwasher rinsed the dishes at the recommended temperature and failed to ensure the chemical solution was tested properly. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 90 residents. 1. Review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust, or other contamination. Review showed the facility did not provide a policy related to maintaining cleanliness in the kitchen. Observation on 11/12/24, at 10:08 A.M., showed the following: -The ice machine outside vent had visible lint/dust/grime; -A large standing floor fan near three-part sink full of lint and grime buildup; -Vents over the coffee station and doorway had visible lint and grime; -The Wall behind the oven, fryer, and standing oven was covered in grease and grime. Observation on 11/13/24, a 10:50 A.M., showed the following: -The ice machine outside vent had visible lint/dust/grime; -Two visible dead bugs (crickets or grasshoppers) covered inside one fluorescent light on the ceiling and near the steam table. Observation on 11/14/24, at 11:02 A.M., showed the following: -Two visible dead bugs (crickets or grasshoppers) covered inside one fluorescent light on the ceiling and near the steam table. Observation on 11/15/24, at 8:11 A.M., showed the following: -The ice machine outside vent had visible lint/dust/grime; -Vents over coffee station and doorway had visible lint and grime; -The wall behind the oven, fryer and standing oven was covered in grease and grime; -Two visible dead bugs (crickets or grasshoppers) covered inside one fluorescent light on the ceiling and near the steam table. During an interview on 11/18/24, at 10:48 A.M., Dietary Aide (DA) AA said the following: -There was a cleaning scheduled posted on the outside of the Dietary Manager's office door; -He/she was responsible for cleaning the grill, two sinks, microwave, industrial toaster, and plate warmers; -Cleaning the vents is the responsibility of the maintenance department; -The Dietary Manager (DM) cleans the big floor fan next to the three-part sink. During an interview on 11/18/24, at 12:25 P.M., DA BB said the following: -The cleaning schedule is on the DM's door; -He/she is responsible for cleaning the front area of the kitchen and the dish pit; -Maintenance is responsible for cleaning the air vents and lights; -Nobody cleans the big floor fan near the three-part sink, and he/she assumed it shouldn't have lint or dirt on it; -He/she did not know who is responsible for cleaning the wall behind the oven/stove/fryer area; -Kitchen staff should clean the ice machine, but he/she does not know if the ice machine vent should have lint/dirt or grime on it. During an interview on 11/18/24, at 2:56 P.M., Dietary [NAME] (DC) X said the following: -The cleaning schedule was posted on the DM's door; -His/her main responsibility is to clean the cooking equipment/utensils, sweep and mopping daily at least spot cleaning, behind the stove/fryer/oven area; -He/she has noticed it is greasy behind the stove/fryer/oven area. There are very small amounts of times when the machines are not running, and electrical cords are not long enough to pull out; -Maintenance is responsible for cleaning the ice machine vent, also air vents and light fixtures; -The grill person, cook or DM should clean the big floor fan by the three-part sink; -None of the surfaces should have any lint/dirt/grime as it could get into the food; -There should not be bugs in the lights; -They notify the maintenance director about maintenance responsibilities; During an interview on 11/18/24, at 3:29 P.M., the Dietary Manager said the following: -Maintenance was responsible for cleaning air vents, ice machine vent (monthly) and the lights; -Air vents should not have lint/dirt/grime on them because it could get into food or clean dishes; -He/she had told maintenance about the dead bugs in the light fixture multiple times, but they have not gotten to it yet; -She was assuming she was responsible for cleaning the fan, which had not been cleaned before she came. She does not have the tools to get it clean. The fan was still being used and blows toward the three-part sink where dishes are being cleaned; -She was responsible for cleaning the wall behind the stove/fryer/oven area and said it is gross. She has not had time to clean it thoroughly. During an interview on 11/21/24, at 12:20 P.M., the Registered Dietician (RD) said the following: -She conducted a monthly walk through of the kitchen and checks for cleanliness, food storage, dishwasher temperature and sanitizer test logs; -There should be a cleaning schedule; -Maintenance should clean the air vents and light fixtures and either maintenance or a company services the ice machine; -There should be no lint, grime and dirt in vents, no crickets/grasshoppers in the light fixtures, and the big floor fan should be free of dirt, grime, and lint; -Walls should be clean, free from dirt, grime, and grease; 2. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, updated 03/04/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods, and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Labeling, dating, and monitoring refrigerated food, including, but not limited leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. Review showed the facility did not provide a policy related to food labeling, handling, and storage. Observation on 11/12/24, at 10:08 A.M., showed of the walk-in cooler showed the following: -A large plastic tub with a yellow lid, containing a substance resembling salsa with no name or dated; -A large plastic tub with a yellow lid, three quarters full and labeled tuna casserole with a date of 11/5 and use by date of 11/8; -A plastic tub with a red lid, three quarters full and labeled shredded chicken and dated 11/3 with no use by date. During an interview on 11/18/24, at 10:48 A.M., DA AA said the following: -All food should be stored with labels identifying the food and the open and use by dates; -He/she did not know the expiration date for prepared refrigerated foods such as tuna casserole, but it should not be kept in the fridge longer than a week; -All staff are responsible for checking food dates. During an interview on 11/18/24, at 12:25 P.M., DA BB said the following: -All foods, opened and prepared should be labeled with the product name, date opened and use by date; -Prepared foods should only be kept for three days. During an interview on 11/18/24, at 2:56 P.M., DC X said the following: -All packaged and prepared food items should be labeled with a date made and a use by date of three days; -Prepared foods like the tuna casserole made on 11/5 with a use by date of 11/8, should be discarded on 11/8 at closing shift; -Closing cook should be checking food labels dates, and so should all kitchen staff. During an interview on 11/18/24, at 3:29 P.M., the DM said the following: -Prepared food should be labeled with the date prepared, date expires, and name of the food; -Prepared food should be discarded after three days; -The tuna casserole, shredded chicken ,and unnamed food should have been discarded. During an interview on 11/21/24, at 12:20 P.M., the RD said the following: -She conducts a monthly walk through of the kitchen and checks for cleanliness, food storage, dishwasher temperature and sanitizer test logs; -Prepared food should be kept a maximum of three days, and should be labeled with the name and the dates prepared and use by; -The tuna casserole, shredded chicken, and unlabeled salsa-like food should have been discarded. 3. Review of the facility policy titled, Sanitation and Maintenance, revised 04/26/23, showed the following for the low temperature dish machine: -Dish machine will be used in accordance with the manufacturer specification; -The temperature and parts per million (ppm) of the sanitizer (50-100 ppm for chlorine) will be recorded on the low temperature dish machine log a minimum of three times per day; -The machine will be broken down and cleaned each day; -Dish machine should be drained and flushed after each meal; -Staff will be trained on how to operate and clean the machine and how to rinse, wash, dry and store items appropriately; -If the dish machine is not washing and sanitizing properly, disposable dinnerware will be used for meals and snacks until the issue has been resolved. Review of the manufacturer's recommendations from Ecolab, dated 05/04/07, showed the requirements for use in chemical sanitizing dish machines is a minimum temperature of 120 degrees Fahrenheit (F) and a minimum concentration of 50 parts ppm. Observation and interview with kitchen staff on 11/14/24, at 1:59 A.M., showed the following: -DA BB said he/she did not know where the sanitizer strips were or how to use them or why they are used; -DA BB placed a thermometer not made for a dishwasher in the machine to test the temperature, then realized it was not appropriate thermometer and went to get the correct one; -DC X came to assist DA BB, and DC X said he/she did not know how/what/why to use the sanitizer test strips; -DA BB said he/she did not know what the minimum temperatures for the dishwasher wash and rinse cycles should be; -The DM and RD came into the dish pit to assist and neither knew how to use sanitizer strip tests; -The DM said she has never been shown how to use the sanitizer strips and when she filled out the dishwasher log, she wrote 50 without testing; -DC X tested the temperatures of the wash and rinse cycles and both were 111 degrees F. -DC X was able to test the chemical solution with a test strip with a result between 200-300 ppm. Review of the low temperature dish machine log, dated November 2024, showed the following: -On 11/06/24 and 11/08/24, the DM initialed the sanitizer concentration test strips showed 50 PPM; -On 11/14/24, staff documented the wash cycle temperature at breakfast was 114 degrees F. During an interview on 11/15/24, at 9:07 A.M., with the territory representative for Ecolab showed the following; -He completed monthly maintenance on the dishwasher, which includes temperature checks, testing chemical solution for dishwasher and three-part sink and replaces parts as needed; -The temperatures of the wash and rinse cycle should be a minimum of 120 degrees F, and sanitizer strip test a minimum of 50 ppm; -There is no internal heater in the dishwasher. The heat was based on the hot water heater. It should not take three times of running to get to 120 degrees F, but it depends on location of hot water heater and how high they can turn based on resident needs; -Staff should empty the wash bath from the previous use if it sat for a while before using; -He tells all customers to test first thing in the morning because he can head to the facility if any issues, but recommendation is testing temperatures and chemical solution before every meal service. During an interview on 11/18/24, at 2:56 P.M., DC X said the following: -Dishwasher temperatures should be taken twice a day, but he/she does not deal with it; -The dishwasher temps should be a minimum of 120 degrees F for wash and rinse cycles; -Chemical sanitizer should be tested when temperatures are tested , and sanitation strips should test at a minimum of 50 parts ppm. During an interview on 11/18/24, at 3:29 P.M., the DM said the following: -Dishwasher temperatures should be taken should be taken at each meal service; -He/she did not know what the minimum temperatures for the wash and rinse cycles should be; -Chemical sanitizer should be tested each meal service, and sanitation strips should test at a minimum of 50 ppm; -None of the four staff present during the test run of the dishwasher with the surveyor had been trained on the correct process of checking the wash and rinse temperatures and testing the chemical sanitizer; -She has been relying on the staff who have been here longer to tell the others the minimum temperatures; -She does not know the difference between a high heat and a low heat dishwasher. During an interview on 11/21/24, at 12:20 P.M., the RD said the following: -She conducted a monthly walk through of the kitchen and checks for cleanliness, food storage, dishwasher temperature and sanitizer test logs; -Staff should test dishwasher temperatures and sanitizer strips two-three times daily. The wash and rinse cycles should test at a minimum of 120 degrees F and test strips should test at a minimum of 50 ppm; -If the temperature or chemical sanitizer was not testing appropriately, staff should use paper products to serve, use three-part sink to wash equipment and call Ecolab to service. During the interview on 11/18/24, at 4:51 P.M., the Administrator said the following: -She was not sure when staff should log dishwasher temperatures, but probably at every meal; -Staff should run the dishwasher twice until up to temperature before using; -She expected staff should know the minimum temperatures for the wash and rinse cycles of the dishwasher and if not reaching the minimum temperature, notify the DM, and DM notified Ecolab; -Chemical sanitizer should be tested daily, and she does not know what the minimum ppm should be, but dietary staff should know.

Based on observation, record review, and interviews, the facility to maintain an effective infection control program when the facility failed to screen all staff for tuberculosis (a contagious infection that usually attacks the lungs) as required when the facility failed to ensure the first step of the two-step Tuberculin (TB) skin test was completed prior resident contact for four staff member (Registered Nurse (RN) D, Licensed Practical Nurse (LPN) E, Speech Therapist (ST) F, and RN G) of 10 sampled staff members; and when staff counted resident cigarettes eight times per day by touching the cigarettes with their bare hands for eight residents (Resident #13, #18, #22, #23, #41, #52, #59, #79) out of fifteen sampled residents that were on the smoking list. The facility had a census of 90. 1. Review of the facility policy, Tuberculosis - Testing and Screening (associates and Volunteers), dated dated 09/24/24, showed the following: -The facility will evaluate each associate and volunteer for tuberculosis in accordance with current Centers of Disease Control and Prevention (CDC) guideline, unless more stringent guidance is provided by local or state regulation; -Missouri facility should follow state regulation 19 CSR 20-20.100 that indicated that screening is done on pre-employment procedures and annual testing of associates and volunteers who work 10 hours or more per week; -Provide a tuberculin skin test (Mantoux, 5 tuberculin units (TU) of purified protein derivative (PPD)) to all employees during pre-employment procedures, unless a previous reaction of >10 millimeter (mm) is documented; -If the initial skin test result is 0 to 9 mm, a second test should be given at least one week and no more than three weeks after the first test; -The results of the second test should be used as the baseline in determining treatment and follow up of these employees; -New associates of volunteers who have been made a conditional offer shall be screened for the presence of infection. Review of 19 CSR 20-20.100 showed the following: -All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two (2)-step tuberculin test within one month prior to starting employment in the facility. -If the initial test is zero to nine millimeters, the second test should be given as soon as possible within three weeks after employment begins; -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. 2. Review of RN D's personnel record showed the following: -A date of hire of 04/12/23; -Staff did not document administering a TB to the resident RN. 3. Review of LPN E's personnel record showed the following: -A date of hire of 04/28/23; -Staff documented the first step TB administered 05/02/23 and read on 05/04/23 (six days after the staff members hire date). -Staff documented the second step administered on 05/16/23 and read it on 05/18/23. 4. Review of ST F's personnel record showed the following: -A date of hire of 06/07/24; -Staff documented the first step TB was administered on 07/10/24 and read on 07/13/24 (over on month after the hire date). -Staff documented the second step was administered on 07/24/24 and read on 07/27/24. 5. Review of RN G's personnel record showed the following: -A date of hire of 07/01/24; -Staff documented the first step TB was administered on 08/20/24 and read on 08/23/24 (over one and 1/2 months after the hire date). -Staff documented the second step was administered 09/06/24 and read on 09/09/24. 6. During an interview on 11/15/24, at 10:50 A.M., the Infection Preventionist Nurse (IP) said that newly hired staff should receive the first step TB test on the first date of orientation and then have it read the third day. The orientation is generally three days in length. The test should read before staff begin working with residents. During an interview on 11/15/24, at 11:15 A.M., the Administrator and Director of Nursing (DON) said that staff TB testing should be completed before starting employment on the floor. They did not know why the four staff did not have TB testing completed on time. 7. During interviews on 11/13/24, at 2:00 P.M., Resident #13, #18, and #79, who attended the resident council meeting, said that staff were touching their cigarettes with their bare hands and they did this every time they go out and smoke eight times per day. The residents said it was a different staff that touched the cigarettes each designated time. They did not like that staff did this. Observation and interview on 11/13/24, at 10:40 A.M., showed Certified Nurse Aide (CNA) H was near the front entrance of the facility with a clear box that contained multiple packs of cigarettes. He/she opened the box and opened one box at a time and counted cigarettes with his/her bare finger. His/her finger touched each cigarette filter in eight boxes. He/she then closed the box and opened the front door for the eight residents to go outside. He/she opened a box and gave a resident a cigarette and lit the cigarette with a lighter. The staff then gave the next resident a cigarette from their box and lit the cigarette. He/she did this eight times. He/she did not use hand sanitizer before touching the box of cigarettes. The staff said that they are required to count the cigarettes at each designated smoking time. There were eight designated smoking times each day. During an observation on 11/14/24, at 3:00 P.M., Nurse Aide (NA) I was at the west side nursing desk. He/she obtained the box of cigarettes. He/she took each box and opened each box. He/she did not use hand sanitizer before touching the cigarettes. The residents cigarettes included Resident #13, #41, #79, #22, #52, #23, #59, #18. The NA and the residents went to the courtyard outside of the activity room and the NA gave each resident one cigarette from their designated box. During an interview on 11/18/24, at 10:15 A.M., the Housekeeping Manager said that staff count cigarettes at each designated smoking time by using their fingers and touching the filter end. He/she said that staff should use hand sanitize before touching the box of cigarettes. During an interview on 11/18/24, at 10:20 A.M., RN B said staff should not be touching the residents the cigarettes with their bare hands. Staff should wear gloves to touch and count. They would be touching the part that goes into the resident's mouth. During an interview on 11/18/24, at 10:40 A.M., CNA C said that staff should not touch the cigarettes. He/she had seen staff use an ink pen and there were marks on the cigarettes. Staff have to touch the cigarette to hand it to the resident. He/she was not aware that it bothered any of the residents that staff touch the cigarettes while counting. During an interview on 11/18/24, at 2:55 P.M., DON said that staff should not touch cigarettes with their hands or with a pen. He/she was not aware that was how staff were counting them. During an interview on 11/18/24, at 4:51 P.M., the Administrator said staff are required to count cigarettes because there was an issue in the past with residents smoking too many or complaints of missing cigarettes. She said that staff should not be touching each cigarette, they could just look in the box and easily tell how many were in the box. 31464

Based on observation, interview, and record review, the facility failed to ensure food was served was palatable and at temperatures that were appetizing for resident including four residents (Resident #36, #71, #72, ad #45) who often ate in their rooms. The facility census was 90. Review of the facility policy titled, Food Temperature Control, revised 06/28/24, showed the following: -Food temperatures are maintained during mealtimes to ensure residents received safe food served at acceptable temperatures; -Hot foods are held at a minimum of 135 degrees Fahrenheit (F) per state requirements; -Cold foods are held at or below 41 degrees per federal guidelines, unless the state requirements are more stringent; -Food should not be placed on the steam table more than 30 minutes before meal service begins; -Maximum length of time food is held on the steam table is four hours; -Food reheated in the microwave is heated so that all parts of the food reach 165 degrees F and food is rotated, stirred, covered, and allowed to stand covered for two minutes after reheating; -Foods are reheated only once then discarded. 1. Observation on 11/14/24, at 12:32 P.M., showed the following: -A test tray was requested and received from the uninsulated food cart on 100 hall at the end of the meal service; -The meal included ham, scalloped potatoes, mixed vegetables, and yogurt; -The ham measured 117 degrees F, the scalloped potatoes measured 117.7 degrees F, the mixed vegetables measured 116 degrees, and the yogurt measured at 59 degrees; -The mixed vegetables were mushy, cool and lacked flavor when tasted. Observation on 11/15/23, at 8:42 A.M., showed the following: -A test tray was requested and received from the uninsulated food cart on 100 hall at the end of the meal service; -The meal included scrambled eggs, sausage, and oatmeal; -The scrambled eggs measured 94.7 degrees F, the sausage measured 83.6 degrees F, and the oatmeal measured at 135.7 degrees F; -The eggs were not palatable when tasted and the sausage texture was rubbery when tasted. Neither item was warm. 2. Review of Resident #36's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by staff), dated 09/05/24, showed the resident was cognitively intact and independent with eating. During an interview on 11/12/24, at 11:32 A.M., the resident said the food was awful. During an interview on 11/12/24, at 3:03 P.M., the resident said the food was cold and is not palatable. He/she only ate about a third of the burger because the bun was soggy and the fries were cold. 3. Review of Resident #71's quarterly MDS, dated [DATE], showed the resident was cognitively intact and independent with eating. During an interview on 11/12/24, at 11:32 A.M., the resident said the food was awful. During an interview on 11/12/24, at 3:36 P.M. the resident said he/she received a very soggy bun with a burger today and the fries were limp. The food was consistently cold and not palatable. 4. During an interview on 11/14/24, at 10:28 A.M., Resident #72 said that food arrived cold to luke warm. He/she said this was every meal time. 5. During an interview on 11/14/24, at 9:40 A.M., Resident #45 said the food was cold when it arrives in the room. The facility does not use a covering over the trays when food is being delivered. Staff are currently using a plastic covering over the food cart due to state being in the building. 6. During an interview on 11/18/24, at 9:55 A.M., Certified Nurse Aide (CNA) S said the following: -He/she had received complaints from the residents about food temperatures and food being bland; -The time frame from when meals arrive on 100 hall and the last hall tray is served is about 25 minutes; -Food is not in a warmer and is probably cold if not received before 25 minutes; -Residents needing assistance were likely to be eating food cold by the time staff is done serving and can assist; -He/she has warmed up food in the microwave, but does not have a way to test the temperature; -Staff should not serve cold food. 7. During an interview on 11/18/24, at 10:48 A.M., Dietary Aide AA said the following: -He/she did not know what temperatures foods should be holding at when served; -Residents have complained about cold food. 8. During an interview on 11/18/24, at 12:25 P.M., Dietary Aide BB said the following: -He/she tests the temperatures of the foods on the steam table prior to serve out, but does not know what temperature they should be holding; -He/she just looked at the temperature log for what they should be by what others have logged. 9. During an interview on 11/21/24, at 10:36 A.M., Dietary [NAME] X said the following: -Food temperatures at serve out should ideally be as close to above 135 degrees F as possible; -Foods can be in the danger zone under 135 degrees F for a short period of time 5 to 15 minutes and should be fine; -The test tray temperatures were not acceptable. The hot food was not hot enough and the yogurt was not cold enough. 10. During an interview on 11/18/24, at 2:56 P.M., the Director of Nursing (DON) said she has not received cold food complaints on the halls, she would expect staff to get fresh food if food was cold. 11. During an interview on 11/18/24, at 3:29 P.M., the Dietary Manager said the following: -She has received complaints about food temperatures and food not being palatable. -The hall trays were coming out cold; -Staff began encouraging eating residents to eat in the dining to get fresh trays at the first of May of this year; -Steam table food temperatures should be about 160 degrees F; -Temperatures should be around 100 degrees F when it reaches the halls and then 80 to 85 degrees F when served to the residents; -Cold food temperatures should be at 40 degrees F. 12. During an interview on 11/21/24, at 12:20 P.M., the Registered Dietician said the following: -Foods should be held at a minimum of 135 degrees F on the steam table and cold foods should be 41 degrees F or below per policy; -Hot foods should be served around or above 120 degrees F and cold foods should be at 50 degrees F or below; -Staff should get a new tray for a resident complaining about food temperatures. 41787 49585

Based on observation, interview, and record review, the facility failed to follow approved menus to ensure the nutritional needs of all residents were met when staff failed to provide the approved serving sizes for meals and failed to prepare pureed diets per approved recipes. The facility census was 90. Review showed the facility did not provide a policy related to pureed meals or portions sizes for meal service. 1. Review of the facility's menu spread sheet showed on 11/12/24 residents should have received two-fifths of a cup of mechanically altered and pureed ham and one-half cup of pureed vegetables. Observation on 11/12/24, at 11:55 A.M., showed the following: -Dietary [NAME] (DC) X placed one third cup scoops in the pureed ham, mechanical ham, and pureed vegetables; -DC X used the one third cup scoop to serve pureed ham, mechanical ham, and pureed vegetables for the pureed and mechanical diet trays for 100 hall. Review of the facility's menu spread sheet showed on 11/18/24 resident should receive four ounces of Italian meat sauce and four ounces of parsley spaghetti for regular diets. Observation and interview on 11/18/24, at 12:11 P.M., showed the following: -DC CC used tongs to serve spaghetti and meat sauce mixed together for trays for 100 hall. The DC did not measure the portion sizes; -DC CC said he/she would have to refer to the book to know how much spaghetti to serve from the menu. He/she uses tongs and just looks at the size because it is hard to use the scoop for pasta. During an interview on 11/18/24, at 12:25 P.M., DA BB said the Dietary Manager (DM) showed him/her the book of menus/recipes, but he/she does not refer to it for serving meals. He/she just goes off what he/she knows. During an interview on 11/18/24, at 3:29 P.M., the DM said DC CC did not know how much spaghetti to serve the residents at lunch today. He/she did not use menu/recipe for serving size. He/she just used his/her experience in the field for serving sizes and that is what pretty much all staff is doing. Staff have been trained to look at the blue sheet (menu) for menu serving sizes. 2. Review of the facility's recipe for pureed baked ham showed the following: -Prepare according to the regular baked ham recipe. Place ham in food processor and process until smooth; -Use a three-ounce portion of regular baked ham per serving; -Use a #10 scoop for serving pureed ham, which is equal to two-fifths of a cup. Observation and interview on 11/14/24, at 11:02 A.M., showed the following: -Dietary [NAME] (DC) X began to puree the lunch meal for six puree diets, including one double portion. -DC X said he/she used approximately a four-ounce piece of ham for each puree and uses about 10 ounces of gravy to puree. -DC did not consult a recipe during the puree process. -DC X said he/she has never used a recipe to prepare puree and did not know if recipes existed. He/she used broth for vegetables to puree and gravy for meat and goes by the serving amount for the meal. They do not puree bread for meals. He/she uses a two-ounce ladle for the broth and a four-ounce ladle for the gravy and goes with the serving sizes for the meal to puree and does not use a menu. During an interview on 11/18/24, at 12:25 P.M., Dietary Aide (DA) BB said the following: -He/she cooked and served on the weekends, including preparing pureed meals; -He/she does not use a recipe or menu to prepare puree meals, he/she just eyeballs the amount. During an interview on 11/18/24, at 3:29 P.M., the DM said the following: -The corporation the facility uses for menus said there is not a standard recipe for purees. Prepare according to the regular meal and puree in natural juices should make a natural consistency. If the puree is not smooth as ice cream with a pudding consistency, add one to two tablespoons of the water cooked in until consistency. Meats will add one to two tablespoons of gravy or meat broth until proper consistency; -Dietary staff do not puree bread because the residents do not like it, so they don't serve it. 3. During interviews on 11/21/24, at 12:20 P.M. and 3:10 P.M., the Registered Dietician (RD) said the following: -She observed the staff prepare and serve food once a month; -Staff should follow the menu spreadsheet for scoop and serving sizes; -There are no specific menus for preparing pureed foods, it is basically taken what you have made per the recipe and there is a sauce of choice on the menus to add for the puree process; -Staff should be following the menu for serving puree meals, including if there is bread on the menu. She was unaware dietary staff were not serving pureed bread to even though the menu included for bread.

Based on interview and record review, the facility failed ensure each resident received a bed-hold notice upon transfer when staff did not provide a bed-hold notice to four residents (Residents #81, #67, #45, and #12) when they transferred/discharged to the hospital. The facility census was 90. Review of the facility's policy titled, Bed Hold Policy, revised 11/17/22, showed the following: -The bed hold policy should be given upon admission, upon transfer to the hospital, or if the resident goes on therapeutic leave of absence; -Before the facility transfers a resident to hospital, the nursing facility must provide written information to the resident or representative the specifies duration of state bed hold policy during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy in the state plan; the nursing facility's policies regarding bed hold periods, which must be consistent with the transfers and discharge policy, permitting a resident to return; the information specified in the transfers and discharges policy; -The facility is obligated to provide two notices related to bed holds. The first notice is given on admission well in advance of any transfer. The second must be provided to the resident or representative at the time of transfer. It is expected that facilities will document multiple attempts to reach the resident representative in cases where the facility was unable to notify the representative. -The notice must provide information to the resident that explains the duration of the bed hold, and the reserve bed payment policy. It should also address permitting the return of residents to next available bed. 1. Review of Resident #81's face sheet (a document that gives a resident's information at a quick glance) showed an admitted [DATE]. Review of the resident's discharge Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/20/24, showed the resident discharged with return anticipated. Review of the resident's nursing progress note, dated 08/20/24, showed the resident discharged to the hospital on 08/20/24. Review showed staff did not document regarding, or have copy of, written bed-hold information provided to the resident or representative at discharge. 2. Review of Resident #67's face sheet showed an admitted [DATE] and the resident had a responsible party. Review of the resident's discharge assessment MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's nursing progress note, dated 09/18/24, showed the resident transferred to the hospital on 09/18/24. Review showed staff did not document regarding, or have copy of, written bed-hold information provided to the resident or representative at discharge. 3. Review of Resident #45's face sheet showed admitted [DATE] and resident was his/her own responsible party. Review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's nursing progress notes showed the resident discharged to the hospital on 05/27/24. Review showed staff did not document regarding, or have copy of, written bed-hold information provided to the resident or representative at discharge. During an interview on 11/18/24, at 2:55 P.M., the Director of Nursing (DON) said there was no transfer notification or bed hold for the resident on 05/27/24. He/she should have sent a written notification of hospital transfer and bed holds. 4. Review of Resident #12's face sheet showed an admitted [DATE]. Review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's nursing progress notes showed on 06/19/24, at 9:55 P.M., staff documented the resident was sent to the emergency room by ambulance. The nurse placed a call to the hospital for update and the resident was being admitted for sepsis. Review showed staff did not document regarding, or have copy of, written bed-hold information provided to the resident or representative at discharge. 5. During an interview on 11/18/24, at 10:20 A.M., Registered Nurse (RN) B said when the nursing staff transfers a resident to the hospital they notify the family or guardian by phone of reason for transfer. The nurse did not notify of the bed hold policy and did not mail any information to family or guardian. During an interview on 11/18/24, at 4:51 P.M., the Administrator said the bed hold policy should be faxed to the guardian or sent with the resident. 41787

Based on record review and interview, the facility failed to ensure each resident or resident's representative was notified in writing of each transfer when staff failed to provide a written notice of transfer to a hospital, including the reasons for the transfer, for four residents (Residents #81, #67, #45, and #12). The facility census was 90. Review of the facility's policy titled, Transfers and Discharges, dated 09/05/24, showed the facility will provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations. 1. Review of Resident #81's face sheet (a document that gives a resident's information at a quick glance) showed an admitted [DATE]. Review of the resident's discharge Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/20/24, showed the resident discharged with return anticipated. Review of the resident's nursing progress note, dated 08/20/24, showed the resident discharged to the hospital on 08/20/24. Review of the resident's notice of resident transfer or discharge sheet, dated 08/20/24, showed the notice was addressed to resident representative and signed by facility staff. There was no signature or indication notice was provided to representative. 2. Review of Resident #67's face sheet showed an admitted [DATE]. Review of the resident's discharge assessment MDS, dated [DATE], showed the resident discharged on [DATE], with return anticipated. Review of the resident's nursing progress note, dated 09/18/24, showed the resident transferred to the hospital on 09/18/24. Review of the resident's notice of resident transfer or discharge sheet, dated 09/18/24, showed the notice was addressed to resident representative and signed by facility staff. There was no signature or indication notice was provided to representative. 3. Review of Resident #45's face sheet showed an admitted [DATE] and resident was his/her own responsible party. Review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated on 05/27/24. Review of the resident's nursing progress note, dated 05/27/24, showed the resident discharged to the hospital on 05/27/24. Review of the resident's medical record showed staff did not document, or have copy of, a written notice provided to the resident regarding the transfer on 05/27/24. During an interview on 11/18/24, at 2:55 P.M., the Director of Nursing (DON) said there was no transfer notification for the resident on 05/27/24. He/she should have sent a written notification of hospital transfer. 4. Review of Resident #12's face sheet showed an admitted [DATE]. Review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's nursing progress dated 06/19/24, at 9:55 P.M., showed the resident was sent to the emergency room by ambulance. The nurse placed a call to the hospital for update and the resident was being admitted for sepsis. Review of the resident's notice of resident transfer or discharge sheet, dated 06/19/24, showed the notice was addressed to resident representative and signed by facility staff. There was no signature or indication notice was provided to representative. 5. During an interview on 11/18/24, at 10:20 A.M., Registered Nurse (RN) B said when the nursing staff transferred a resident to the hospital they notified the family or guardian by phone of reason for transfer. The nurse did not mail any information to family or guardian. During an interview on 11/18/24, at 4:51 P.M., the Administrator said the transfer notice should be faxed to the guardian or sent with the resident. 41787

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment when staff failed to maintain the shower wall and floor tiles and mop areas in four facility shower rooms; failed to maintain the wall and grab bar integrity in one shower room; failed to maintain the wall and mop board area in the 200/400 hall sitting area; failed to adequately clean resident and make free of odors bathroom toilet area for two resident (Resident #20 and Resident #33); and failed to adequately clean and maintain the resident room sinks faucets and mirrors for four residents (Resident #20, Resident #33, Resident #36 and Resident #71). The facility census was 90. Review of a facility's policy entitled Plant Operations, reviewed 06/12/24, showed the following: -A safe, clean, and structurally sound environment shall be achieved in the facility through the development and implementation of the Plant Operations Program, the development and training of personnel, and the evaluation of goals in the department to assure correlation with the goals of the facility; -The maintenance and operation of all facilities, buildings, utilities, sanitary systems, and grounds are the primary responsibilities essential to the Plant Operations Program; -Where authorized, all maintenance responsibilities will include: repairs, alterations, minor construction, remodeling (exceptions included work that needs to be contracted); -Facility personnel will perform all duties when feasible; outside contractors will be utilized when necessary. Review of a facility policy entitled Housekeeping Services, revised 08/09/22, showed the following information: -The facility will provide a safe, clean, comfortable and homelike environment; -Housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable interior; -Keep housekeeping surfaces visibly clean on a routine basis and clean spills promptly; -The environmental supervisor will maintain a schedule of cleaning and disinfection tasks and the employees responsible for this task. Periodic evaluation should be completed to assure competency of the environmental staff; -Lobby and resident common areas: clean high-touch areas and surfaces at least daily and as needed; -Resident rooms: clean clean high-touch surfaces at least daily to include hand washing sinks and floor; -Resident bathrooms: clean and disinfect high touch/frequently contaminated surfaces (sinks, faucets, handles, toilet seat, door handles) at least daily; -Resident shower rooms: nursing to clean and disinfect high touch surfaces after each resident use. Housekeeping will clean resident shower/bath area twice daily. 1. During an interview on 11/13/24, at 2:00 P.M., with a group of 22 residents, the following was said: -The residents all agreed that the shower rooms were nasty and not clean in appearance. -Resident #45 said the showers had black mold that had been there since he/she was admitted in February 2024. The resident said the grab bar on one of the shower walls is not attached securely or safely and the floor and wall tiles are all broken up. He/she showed the surveyor pictures on his/her phone of the black substance and broken tiles. -Resident #62 said the shower rooms had been that bad since April 2021. He/she said there are towels and blankets up against the walls in the sitting area due to water leakage coming from the shower rooms. 2. Observation on 11/14/24, at 8:40 A.M., of the sitting area for the 200/400 halls, showed chairs along the two walls facing the nurses' station. Blankets lie bunched up lengthwise along the wall mop boards behind the chairs. The baseboard was peeled back from the walls for a length of 8 to 10 inches on the 200 hall side and 3 feet on the 400 side, revealing a corroded, dark substance along the walls. Each of the walls was between the sitting area and a shower room. Observation on 11/15/24, at 7:55 A.M., of the sitting area for the 200/400 halls, showed chairs along the two walls facing the nurses' station. Blankets continued to be bunched up lengthwise along the wall mop boards behind the chairs. The baseboard was peeled back from the walls for a length of 8 to 10 inches on the 200 hall side and 3 feet on the 400 side, revealing a corroded, dark substance along the walls. Observation on 11/18/24, at 10:55 A.M., of the sitting area for the 200/400 halls, showed the blankets remained in place along the walls and the baseboard remained unattached from the walls. A dark substance remained on the lower walls for a height of approximately four inches (4) from the floor, visible where the baseboard was peeled back. 3. Observation on 11/15/24, at 1:30 P.M., of the 200 hall shower showed at the floor level, the tile and baseboard was pulled loose for a length of approximately two and one-half feet (2.5 ft), revealing a dark substance (brown, black and green). The substance lined the full perimeter of the baseboard tile and the shower floor tiles. Observation on 11/18/24, at 2:20 P.M., of the 200 hall shower room, showed the grab bar on the right hand wall of the shower was secured to the vinyl type wallboard. When grasped, the bar moved outward, causing the wallboard to also move outward. At the floor level, the tile and baseboard was pulled loose for a length of approximately two and one-half feet (2.5 ft), revealing a dark substance (brown, black and green) lining the baseboard, tile, and shower floor tiles. 45190 4. Observation on 11/13/24, at 12:36 P.M., in the memory care unit shower room showed the following: -Missing linoleum with sharp edges going into the shower space; -Missing tile cubes in the shower space; -Black substance where the floor mes the wall all along the right side of the shower extending 1 to 2 inches and goes around to the front of the shower; -Matted brown or black substance behind the toilet; -Black toilet plunger with what appeared to be dried toilet paper on it; -The toilet bowl had brown fecal like matter inside; -The sink was dirty with grime around the faucet and the mirror was dirty. Observation and interview on 11/15/24, at 12:35 P.M., in the memory care unit shower room showed the following: -CNA V said he/she cleaned the shower room in between showering residents, including cleaning the shower floor and chair, toilet seat, sink and mirror; -Black toilet plunger with what appeared to be dried toilet paper all over it; -Matted brown or black substance behind the toilet. CNA V said the back of the toilet always looks like that because it was old; -The toilet bowl had brown fecal like matter inside; -The sink was dirty with the same grime around the faucet and the mirror was dirty. -CNA V said he/she has attempted to scrub the black substance off the base of the shower and corner, but it will not come off. 5. Review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 10/17/24, showed the following: -admitted [DATE]; -Severe cognitive impairment; -Independent with toileting and showering. Review of Resident #20's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with toileting and showering. Observation on 11/12/24, at 11:19 A.M., of Resident #33's and Resident #20's shared sink, mirror, and toilet area showed the following: -The sink dirty was with grime buildup around and on the faucet; -The mirror was dirty with grime all over; -The toilet area had a very strong odor of urine. The raised seat was dirty in the front with unknown substance and a bath blanket in floor around toilet was visibly dirty. Interview and observation on 11/15/24, at 12:18 P.M., of Resident #33's and Resident #20's shared sink, mirror, and toilet area and an interview showed the following: -Resident #33 said the staff do not clean the sink, mirror, or toilet area often enough; -The sink was dirty with grime buildup around and on the faucet; -The mirror was dirty with grime all over; -The toilet area had a very strong odor of urine. Observations and interview on 11/18/14, at 9:41 A.M., of Resident #33's and Resident #20's shared sink, mirror, and toilet area and interview showed the folowing: -The sink continued to have grime buildup on and around the faucet and the mirror continued to be dirty with grime all over. -Housekeeper (HK) T said staff should clean all rooms daily, including wiping everything down and sweeping and mopping all floors, clean the sink, mirror, toilet commode inside and out and behind, The facility had enough staff to clean all room daily. The resident's room has not been cleaned today. -HK T said the toilet area smelled like urine because of a leak or because the residents urinate in the floor, which is why there is a bathroom blanket around the toilet that should be changed daily. 6. Review of Resident #36's face sheet (a brief resident profile) showed an admitted [DATE]. Review of Resident #36's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with toileting and showering. Review of Resident #71's face sheet showed an admitted [DATE]. Review of Resident #71's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with toileting and showering. Observation and interview on 01/12/24, at 11:32 A.M., of Resident #36's and Resident #71's shared sink and mirror showed the following: -Resident #36 said he/she used to clean businesses and is a clean freak. The staff do not clean his/her sink well enough; -The sink had grime all under the front of the faucet, and some around the drain; -The mirror was dirty. Observation and interview on 01/12/24, at 3:16 P.M., of Resident #36's and Resident #71's shared sink and mirror showed the following: -The sink was dirty with grime around the faucet and drain; -The mirror was dirty; -Resident #36 said staff do not clean the glass. During an interview on 11/12/24, at 3:35 P.M., Resident #71 said staff do not clean the sink or the mirror properly. 7. During an interview on 11/18/24, at 10:41 A.M., CNA L said he/she was a shower aide. The shower room floors were missing tiles which could cause concerns getting residents in and out of the shower due to this floor condition. The grey border at the base of the walls was peeling away in some shower rooms. The showers were not clean, but the aides try to spray them down with disinfectant after showers. The housekeeping staff try to clean it, but there is a black substance in the shower areas where the residents take a shower During an interview on 11/18/24, at 11:00 A.M., CNA C said the facility's showers appear dirty, with black areas, and they do not smell pretty. The broken tiles appear unsafe and could cause falls or cuts. The residents tell staff that the showers are gross. During an interview on 11/18/24, at 9:55 A.M., Certified Medication Technician (CMT) S said he/she was not sure who cleaned the showers, but staff spray them down with disinfectant in between showering residents. Tiles are missing in all of the bathrooms on the general population halls and they all have some mildew. The 400 hall has the most damage and is leaking under the tiles out into the hall, which is why there is a blanket on the floor outside of the shower room. The tiles coming up in the shower rooms are a safety concern for ambulatory residents and for those in wheelchairs, because it is an uneven surface. During an interview on 11/18/24, at 12:49 P.M., Licensed Practical Nurse (LPN) W said the following: -Housekeeping cleans every room daily and deep cleans rooms once per month: -Daily cleaning included sink, mirror, and toilet; -There are a couple of bathrooms that smell like urine all the time because the residents urinate in the floor. A bath blanket is wrapped around the toilet to catch the urine and should be changed daily. The floor should be mopped daily or more, and housekeeping has some sort of spray to help with the odor. -Aides clean the shower room in between showering residents; -Housekeeping cleans the shower room daily; -There is mildew in the shower floor, and the facility is trying to get a contractor in to fix it; -The toilet, sink, and mirror should be cleaned every day. During an interview on 11/18/24, at 2:00 P.M., the Housekeeping Manager said room cleaning included the sink, faucet, and toilet each day. If the mirror was dirty, it should also be done. If an item is not getting clean, staff should try a different cleaner or scraper. The showers are cleaned first thing every day. There are maintenance slips in housekeeping to fill out and give to the Maintenance Director for requested repairs. During an interview on 11/18/24, at 2:10 P.M., the Maintenance Director said there is a clipboard at the west desk for staff to notify him of repairs needed, or they tell him in person. He said they had tried to make repairs to the showers and baseboards using silicone, but it would only last one to two weeks. During an interview on 11/18/24, at 2:55 P.M., the Director of Nursing (DON) said usually staff notifies the Maintenance Director of needed repairs. However, the showers are not repairable. During interviews on 11/12/24, at 11:26 A.M., and on 11/18/24, at 4:51 P.M., the Administrator said the the following; -Shower rooms should be cleaned daily and after each shower. The facility has repaired everything they can, but a contractor is necessary for the remodel which will start in December. -The shower rooms probably have mildew or mold in spite of daily cleaning. -Torn or cracked linoleum and tiles are dangerous and a trip/fall hazard. -Staff are to place bath towels or blankets on the floor as a precaution. -The toilets in the shower rooms should be cleaned daily. -Resident rooms are cleaned daily, including the sink, faucet, toilet, and mirror daily; -The sink and faucets should not have dirt or grime buildup; -The toilet area should not smell of urine.

Based on interview and record review, the facility failed to provide trauma-informed care in accordance with standards of practice when staff failed to identify, assess, care plan, and provide supportive interventions for two residents (Resident #72 and #6) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 90. Review showed the facility did not provide a policy related to Trauma Informed Care (a model of care that acknowledges the impact of trauma on people's lives and aims to provide effective services). Review of the facility's policy titled Resident Rights, dated 09/10/24, showed the following: -At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing, of their rights; -The resident has the right to receive the services and/or items included in the plan of care. 1. Review of Resident #72's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included PTSD, paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Review of the resident's care plan, revised 07/02/24, showed the following: -Dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, disease process, and physical limitations; -Staff should converse while providing care; -Resident had impaired cognitive ability, impaired thought process related to making decisions; -Staff should allow extra time to respond to questions and instructions. (Staff did not care plan related to the resident's PTSD diagnosis and any triggers or interventions related to PTSD.) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/24/24, showed the following: -Moderate cognitive impairment; -Diagnoses included PTSD; -Used of wheelchair for mobility; -Resident dependent on staff for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene; -Resident independent with eating. Review of the resident's nursing behavior notes showed staff documented the following: -On 06/05/24, at 11:32 A.M., the resident struck an aide while receiving care. When the aide was adjusting the resident in bed the resident punched the aide in the chest. Staff notified the Assistant Director of Nursing (ADON); -On 08/27/24, at 11:02 A.M., the nurse entered the room due to resident and roommate yelling and cursing at one another. The resident was yelling out vulgarities and name calling and was verbally abusive to the nurse. The nurse alerted social services of the issue; -On 09/06/24, at 5:44 P.M., the resident was tickling a nursing aide and was asked to stop. He/she proceeded to pinch the second nursing aide when getting the resident up for lunch. The nursing aide told the resident to stop. He/she then swung at the aide; -On 09/06/24, at 5:46 P.M., a nursing aide approached the nurse and stated the resident was hitting and slapping me, and it stung while the two aides were changing him/her. The nurse approached the resident and instructed the resident do not put your hands on my staff, and the staff have every right to press assault charges on you. The resident replied, Did I put my hands on them? The nurse stated, yes for the second time you have either hit at or struck my staff and they have every right to press charges on you. The resident replied Well, let them. The nurse then exited room. The nurse had contacted the physician prior to the second incidence to restart previous discontinued medication prescribed for behavior. Review of the resident's Trauma Informed Care Assessment, dated 09/06/24, completed by social services, showed the resident had personally experienced trauma as a Vietnam War Veteran. The resident answered that he/she had repeated and disturbing dreams of the stressful experience. He/she had sudden feelings as if the stressful experience were happening again. He/she felt very upset when something reminded him/her of the stressful event. He/she had strong physical reactions when something reminded him/her of the stressful event. (Staff did not document any new interventions related to the resident trauma response.) Review of the resident's care plan, dated 07/02/24, showed staff did not update the care plan to reflect the trauma or interventions to assist with the trauma. Review of the resident's nursing behavior notes showed staff documented the following: -On 10/04/24, at 1:11 P.M., the resident was aggressive, hitting at staff and speaking inappropriately; -On 10/14/24, at 9:49 A.M., the aide reported the resident threw a water pitcher at the roommate. The aide reported that on 10/13/24 the resident threatened to get up out of bed and cut his/her head off; -On 10/14/24, at 12:48 P.M., the aide reported to the nurse that the resident threw a cup of water as well as a fork at the roommate. The water and the fork did not hit the roommate and landed on the floor. During an interview on 11/14/24, at 10:30 A.M., the resident declined to discuss his/her past history. He/she said that he/she wanted to be able to go home again. During an interview on 11/18/24, at 10:20 A.M., Registered Nurse (RN) B said the resident displayed behaviors, but he/she did not know if they were related to his/her PTSD or triggers. During an interview on 11/18/24, at 12:00 P.M., the Director of Nursing (DON) said the resident had a diagnosis of PTSD. She/she did not know what the resident's triggers were. The resident just sets off and will start hitting staff. The resident did see the psychiatric physician. He/she would expect the information to be in the resident's care plan. 45190 2. Review of Resident #6's face sheet showed the following: -admitted [DATE]; -Diagnoses included PTSD, paranoid schizophrenia, generalized anxiety disorder, high blood pressure, mild intellectual disabilities, development disorder of scholastic skills (conditions that cause persistent difficulties in acquiring academic skills), dysphagia oral phase (difficulty moving food or liquid into the throat after chewing and sucking), conduct disorder, and childhood-onset type. Review of the resident's care plan, revised on 07/09/24, showed the following: -Limited involvement with activities related to anxiety; -Resistive to care and refusal of medication related to anxiety; -Potential to be verbally or physically aggressive related to mental and emotional illness and will yell out at others using screaming sounds; -Behavior problem when agitated. Staff should explain all procedures before starting and allow time to adjust to changes; -Resident has impaired cognitive ability/impaired though process related to developmentally delayed, impaired decision making, and staff should allow extra time to respond to questions and instructions using yes/no questions to determine needs; -Resident has psychosocial well-being problem related to anxiety. (Staff did not care plan related to the resident's PTSD diagnosis and any triggers or interventions related to PTSD.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Independent with activities of daily living (ADL's); -Diagnosis included PTSD. Review of the resident's Trauma Informed Care Assessment, dated 08/21/24, completed by social services with the assistance of the resident's guardian, showed the resident did not experience any of the listed traumatic events. During an interview on 11/18/24, at 9:55 A.M., CNA S said he/she did not know the resident's specific diagnoses, but would not be surprised if there was a diagnosis for PTSD. The resident has triggers such as people getting too close to him/her, surprising him/her with their presence, strangers, and not being able to communicate with other people frustrates him/her causing him/her to yell out. During an interview on 11/18/24, at 12:49 P.M., Licensed Practical Nurse (LPN) W said he/she was unaware the resident had a diagnosis of PTSD. Staff worked the resident to get him/her on an agreeable medication schedule. The staff had to kind of roll with the resident because he/she will refuse to do things and can do a lot for themselves. The resident will not go out of the facility at all. He/she has gone to the beauty shop in the facility, but does not like to leave the unit doors. He/she does not like people too close, especially in wheelchairs. 3. During an interview on 11/18/24, at 9:55 A.M., CNA S said staff should care plan a diagnosis of PTSD. During an interview on 11/18/24, at 12:49 P.M., LPN W said if a resident has a diagnosis of PTSD, staff should complete a trauma informed care assessment to know triggers/memories to avoid. During an interview on 11/18/24, at 10:20 A.M., RN B said if a resident had PTSD it should be listed on the diagnosis list. Staff should document any issues under behavior documentation. If a resident had known triggers it might be on their care plan. During an interview on 11/18/24, at 11:30 A.M., the Social Worker said he/she just starting in the position and was still learning. He/she did not know everything that should be in the care plan. During an interview on 11/18/24, at 12:00 P.M., the DON said residents with a diagnosis of PTSD should have information in the care plan related to the diagnosis and whether there were known triggers. During an interview on 11/18/24, at 4:51 P.M., Administrator said that residents with PTSD diagnosis should have information in the care plan including known triggers and care needed related to PTSD.

Based on observation, interview, and record review, the facility failed to provide all residents food that accommodated each residents' allergies, intolerances, and preferences, when staff served one resident (Resident #36) food items containing an ingredient identified as an allergen/dislike on the resident's meal ticket and when staff served one resident (Resident #38) food items the guardian had requested not be served to the resident. The facility census was 90. Review of the facility policy titled, Food Allergies and Intolerances, revised 04/25/23, showed the following: -The Director of Food and Nutrition Services obtains food preferences, including any food allergies and intolerances upon admission; -Each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences; -Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; -Facilities should be aware of each resident's allergies, intolerances, and preferences, and provide an appropriate alternative. A food substitute should be consistent with the usual and/or ordinary food items provided by the facility. For example, the facility may, instead of grapefruit juice, substitute another citrus juice or vitamin C rich juice the resident likes; -Food allergies or intolerances are communicated to nursing services and indicated on the resident tray car and resident diet profile; -The information is also recorded in the electronic medical record, including the nutrition assessment and care plan; -The Direct of Food Nutrition Services identifies menu items that contain the food item(s) related to the allergy/intolerances and ensures those items are not used in foods prepared and served to identified residents; -Food service and nursing associates are educated on residents with food allergies and intolerances. Review of the facility policy titled, Food Preferences, revised 04/25/23, showed the following: -Individual, cultural/religious food preferences are honored, when possible, to enhance the resident's satisfaction with food and dining. These preferences are obtained upon admission and updated quarterly and as needed; -The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Menus must reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; -Food and beverage preferences are obtained from each resident at the time of the initial visit. Food preferences may also be obtained from family members, nursing staff and the medical record; -Updated as needed, but no less than quarterly; -Maintained by the Director of Food and Nutrition Services/designee; -Placed in the resident diet profile for production purposes; -Dislikes, food intolerances/allergies, special requests and specific beverage preferences are noted on the tray card; -Allergies, dislikes, and special request (as deemed appropriate) are addressed on the serving line to ensure an appropriate alternate (s) is served prior to the meal being received by the resident. 1. Review of Resident #36's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Allergies included penicillin, sulfa antibiotics. Review of the resident's record showed the resident had been deemed an incapacitated person, and his/her spouse was granted guardianship on 07/14/16. Review of Resident #36's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 09/05/24, showed the resident was cognitively intact and independent with eating. During an interview on 11/12/24, at 11:32 A.M., the resident said he/he was allergic to carrots and the staff continued to serve them until he/she wrote a little note. During an interview and observation on 11/12/24, at 3:03 P.M., the resident said the following: -Staff continue to serve him/her cooked carrots even though the resident has told them he/she is allergic to them; -Staff served mixed vegetables today containing carrots, but he/she was told staff picked the carrots out of the mixed vegetables. Review of the resident's meal ticket, dated 11/18/24, showed the following foods listed under the category allergies/dislikes: -Carrots cooked; -Liver; -Sweet potatoes. Review of the resident's current physician order sheet showed no food allergy. Review of the resident's care plan, last revised on 06/19/24, showed staff did not care plan any food allergy. During an interview on 11/18/24, at 9:55 A.M., Certified Nurse Assistant (CNA) S said the following: -Residents' food preferences and allergies are printed on the meal ticket as well as specific diets such as puree; -The resident might dislike food items depending on the day. He/she is very opinionated, and his/her opinions rotate; -Staff should honor preferences and allergies. During an interview on 11/18/24, at 12:49 P.M., Licensed Practical Nurse (LPN) W said the following: -Diets, allergies and food preferences are on meal tickets; -Staff should honor residents' food allergies and preferences; -He/she was unaware if the resident has any food allergies. The LPN said he/she was really picky. During an interview on 11/18/24, at 2:56 P.M., Dietary [NAME] X said the following: -Meal tickets have food allergies/preferences printed on them; -He/she is not familiar with the resident's allergies/preferences. During an interview on 11/18/24, at 3:29 P.M., the Dietary Manager (DM) said the following: -She meets with residents within 72 hours upon admittance to ask about likes and dislikes and food allergies; -She was not aware the resident has any dislikes or allergies; -She looked in computer and found the residents dislikes/allergies were listed as cooked carrots, sweet potatoes, and liver; -Staff should not be serving the resident carrots; -Staff should provide an alternative vegetable and not tell resident to pick carrots out of the mixed vegetables. During an interview on 11/21/24, at 12:20 P.M., the Registered Dietician (RD) said the following: -She would obtain residents' food allergies and preferences during an initial assessment, which should already be in the record for current residents; -The DM should be assessing the new residents; -Staff should communicate preferences/allergies to dietary upon discovery; -She was not aware the resident has an allergy to cooked carrots; -Staff should not serve mixed veggies and take out the carrots; an alternative should be served. During an interview on 11/18/24, at 4:51 P.M. the Administrator said the following: -Dietary staff should assess new residents about food preferences/allergies and put information on a meal ticket and pass down to staff; -Staff should not serve mixed vegetables to the resident and ask the resident to pick the carrots out. An alternative should be served; -Staff should care plan resident food preferences and allergies. 2. Record review of the Resident #38's face sheet showed the following: -admitted [DATE]; -Diagnoses included type II diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), dysphasia oropharyngeal phase (difficulty swallowing that moves food from the mouth to the upper esophageal sphincter), vascular dementia (brain damage caused by multiple strokes), and other Alzheimer's disease (a progressive disease that destroys memory and other important mental functions. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Independent with eating. Review of the resident's care plan, last revised on 07/30/24, showed the following: -Resident can feed self after tray placed in front of him/her; -Resident has a regular diet/easy to chew; -No food preferences listed. During an interview on 11/13/24, at 9:51 A.M., the resident's family member said the family requested at two care plan meetings for the staff to stop giving the resident kool-aid because of the red dye and to give him/her ice water at every meal. The staff still gives the resident kool-aid from time to time and sometimes does not give him/her ice water. Observation and interview on 11/14/24, at 8:23 A.M., showed Nurse Aide (NA) Y put a cup of red liquid resembling kool-aid in front of the resident at the breakfast meal. NA Y said the cup contained fruit punch kool-aid. Observation on 11/14/24, at 8:29 A.M., showed the resident's meal card had no information listed under allergies/dislikes and listed under beverages was whole milk 8 ounce (oz), water flavored 8 oz, and water 8 oz. Observation on 11/14/24, at 9:07 A.M., showed staff assisted the resident with a drink of the fruit punch kool-aid. The resident did not have water available. Observation and interview on 11/15/24, at 12:35 P.M., showed the following: -CNA V knew the resident was not supposed to have kool-aid with red dye, and his/her family provided flavored water: -He/she knew the resident was not supposed to have red dye because there was a sign on the closet where they keep the resident's snacks and drinks that they purchased for themselves; -The sign taped to the inside of the closet door where snacks are stored read, the resident cannot have any red dye products. During an interview on 11/18/24, at 9:55 A.M., CNA S said the following: -Resident diets, food preferences and allergies are printed on the meal ticket; -He/she is not aware of any food items staff is not supposed to give the resident and was unaware of the sign on the door of the snack closet. During an interview on 11/18/24, at 12:49 P.M., LPN W said the following: -Resident diets, food allergies and preferences are listed on meal tickets; -The resident's family does not want him/her to have red dye; -The regular staff on the unit were aware of this, but not new ones to the unit; -Staff should honor food allergies and preferences; -Staff should not serve the resident red dye. During an interview on 11/18/24, at 1:43 P.M., NA Y said the following: -Resident food preferences and allergies were listed on meal tickets; -He/she was unaware of any food allergies or preferences for the resident; -He/she did not know the resident was not to be served red dye/kool-aid until the resident's family told him/her today; -He/she did not know there is a sign on the snack room door. During an interview on 11/18/24, at 2:13 P.M., Registered Nurse (RN) Z said the following: -Resident food allergies and preferences should be under the profile in the chart and on the meal tickets and listed in the care plan; -There is a sign on the snack room door stating the resident is not to have red dye; -He/she did not know if this is listed on the meal ticket but should be. During an interview on 11/18/24, at 2:56 P.M., Dietary [NAME] X said the following: -Meal tickets have food allergies/preferences printed on them; -He/she was not familiar with the resident's allergies/preferences. During an interview on 11/18/24, at 3:29 P.M., the DM said the following: -She meets with residents within 72 hours upon admittance ask about likes and dislikes and food allergies; -She is not aware the resident has any food dislikes or allergies, and none are listed in his/her profile; -Staff should honor food preferences and allergies. During an interview on 11/21/24, at 12:20 P.M., the Registered Dietician (RD) said the following: -She would obtain residents' food allergies and preferences during an initial assessment, which should already be in the record for current residents; -The DM should be assessing the new residents; -Staff should communicate preferences/allergies to dietary upon discovery; -She was not aware the resident's family did not want the resident to have red dye; -Staff should list this on the meal ticket and honor it. During an interview on 11/18/24, at 4:51 P.M. the Administrator said the following: -Dietary staff should assess new residents about food preferences/allergies and put information on a meal ticket and pass down to staff; -Staff should put the resident is to have no red dye on the meal ticket and in the care plan and should not serve it to him/her.

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when the facility failed to complete timely assessments/reassessments of side rail use, failed to obtain physician's orders for side rail use prior to side rail use, and failed to obtain full informed consent prior to side rail use for two residents (Resident #77 and #70). The facility also failed to care plan the use of side rails and failed to document risk/benefits and alternatives attempted prior to side rail use for one resident (Resident #77). The facility census was 90. Review of the facility policy titled Bed Rails - Safe and Effective Use of Bed Rails, dated 11/16/21, showed the following: -The facility must attempt to use appropriate alternatives prior to installing a side or bed rail; -The facility must ensure correct installation, use, and maintenance of bed rails; -The facility should assess the resident for risk of entrapment prior to installation; -Risks and benefits should be reviewed with the resident or representative and informed consent obtained prior to installation; -Facility should follow the manufacturers recommendations and specifications for installing and maintaining bed rails; -The resident will be assessed upon admission, readmission, or initiation of bed rails; -A reassessment if bed rail use will be assessed at a minimum quarterly and with a potential change of condition; -The facility will document alternatives to the use of bed rails and how these alternatives did not meet the resident's assessed needs prior to utilization of bed rails; -A care plan will be developed within 48 hours of admission to address bed rails; -The interdisciplinary team will review and revise care plan upon completion of each comprehensive, quarterly, and significant change Minimum Data Sets (MDS - a federally mandated comprehensive assessment tool completed by facility staff) for the continued use of bed rails. 1. Review of Resident #77's admission data showed the following: -admitted [DATE]; -Diagnoses included quadriplegia (paralysis that affects all a person's limbs), chronic obstructive pulmonary disease (COPD - condition causing constriction of the airways making it difficult to breathe), and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent for eating, transfer, bed mobility, toilet use, and dressing. Observations on 11/13/24, at 1:52 P.M., and on 11/15/24, at 10:19 A.M., showed the resident resting in bed with both grab bars (side rails) up next to head of the bed. Observation on 11/18/24 at 10:28 A.M. showed resident resting in bed watching television with both grab bars in the up position. Review of the resident's care plan, revised 10/03/24, showed the following: -Activities of daily living (ADL- dressing, grooming, bathing, eating, and toileting) self-care deficit related to quadriplegia; -Totally dependent on staff for showering, dressing, bed mobility, eating, and toileting; -Required the use of a Hoyer lift (mechanical lift used for non-weight bearing residents) and two staff for transfers;; -Limited physical mobility related to quadriplegia and required passive range of motion to fingers, wrists, elbows, and shoulders. (Staff did not care plan related to the grab bars (side rail) use.) Review of the resident's November 2024 Physician's Order Sheet (POS) showed an order, dated 11/14/24, for a grab bar to upper left and right side of the bed. (There was not an order for use prior to 11/14/24.) Review of resident's Quarterly Evaluation for Use of Bed Rails, dated 11/14/24, showed the following: -Bed rails appropriate for resident; -Bed rails being considered related to a medical diagnosis of severe muscle spasms; -Fear of rolling out of bed and severe muscle spasms that cause the body to jerk hard to the side contribute to need for bed rails; -Bed rails are not used to assist in bed mobility. Review of the resident's Physical Restraint Informed Consent, dated 11/14/24, showed upper left and right grab bar to be used while in bed for bed mobility. Staff did not check the consent or do not consent box is checked on the form. The form was signed by a facility representative on 11/14/24 and noted verbal consent on 11/14/24. (Staff did not document who gave verbal consent.) Observation and interview on 11/15/24, at 11:47 A.M., showed the resident sitting up in wheelchair in room and grab bars in the up position on bed. The resident reported he/she was unable to utilize the grab bars, but facility put them on due to him/her having strong spasms. Review of the resident's medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, or ongoing assessments to ensure the side rails were appropriate for use. During an interview on 11/18/24, at 10:22 A.M., Nurse Assistant (NA) K said he/she did not think the resident had side rails. The resident was not very mobile and was unable to use his/her arms so side rails would not be beneficial for him/her. During an interview on 11/18/24, at 10:41 A.M., Certified Nurse Assistant (CNA) L said the resident was total care and required staff to roll him/her from side to side. The resident did not have grab bars. During an interview on 11/18/24, at 10:41 A.M., CNA M said the resident did not have grab bars and was not appropriate for them as he/she was total care. During an interview on 11/18/24, at 12:07 P.M., Registered Nurse (RN) N said the resident was a quadriplegic and had no movement in the right arm and very little movement with left hand and was not appropriate for grab bars. During an interview on 11/18/24, at 2:20 P.M., Physical Therapy Assistant (PTA) O said therapy has not recommended grab bars for the resident. The resident was is not a good candidate for grab bars due to functional mobility issues. During an interview on 11/18/24, at 2:56 P.M., the DON said the resident's side rail consent was completed on 11/14/24 as he/she never noticed the side rails and was unsure how long they had been installed. 41787 2. Review of Resident #70's face sheet (a brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting left nondominant side, vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), dysphagia (difficulty or discomfort in swallowing) following cerebral infarction, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), aphasia (loss of the ability to produce and/or comprehend language, due to injury to brain areas) following cerebral infarction, and lack of coordination. Review of the resident's Quarterly Evaluation for Use of Bed Rails, dated 05/13/24, showed the following: -Bed rails were appropriate for the resident; -Bed rails were not considered related to medical diagnosis; -Bed rails were to assist the resident with bed mobility; -The resident was reassessed during quarterly review for risk of entrapment prior to installation of side rails; -Recommended type 1/8 partial rail, left upper side. Review of the resident's care plan, updated on 07/19/24, showed the following: -Resident had an ADL performance deficit related to disease process, hemiplegia, impaired balance, limited mobility, pain, and stroke; -Staff should have the bed against the wall; -Grab bar to left side per physician's order for safety during care provision and to assist with bed mobility; -Staff should observe for injury or entrapment related to grab bar use. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Limited range of motion bilateral upper extremity and bilateral lower extremity; -Required use of wheelchair; -Dependent on staff for toileting hygiene, showering, upper and lower body dressing, oral hygiene, personal hygiene, transfer from bed to chair, and propelling in wheelchair. Review of the resident's Physician Orders Sheet, current as of 11/18/24, showed an order, dated 11/12/24, for grab bar to left side of bed. Observations showed the following: -On 11/12/24, at 10:45 A.M., the resident was not in the room. The resident's bed had a grab bar on the left side of the bed; -On 11/13/24, at 9:06 A.M., the resident was in bed with blanket over his/her head with bed in the middle of his/her room space and grab bar on left side of bed; -On 11/18/24, at 9:30 A.M., the resident was in his/her bed with eyes open. The resident was holding the left grab bar with his/her hand. Review of the resident's Physical Restraint Informed Consent, dated 11/13/24, showed use of left side grab bar for bed mobility. The form was signed by the facility representative on 11/13/24 with notes that verbal authorization was provided on 11/13/24. (Staff did not indicate who gave the verbal consent on the form.) During an interview on 11/18/24, on 10:20 A.M., RN B said the resident would hang on to the grab bar with transfers and during the night. The bed rail had been on the bed since the resident's admission. 3. During an interview on 11/18/24, at 10:22 A.M., NA K said residents use side rails or grab bars for mobility. During an interview on 11/18/24, at 10:41 A.M., CNA L said grab bars were used for residents to position and pull themselves up in bed. Grab bars can help a resident to roll side to side and for mobility. During an interview on 11/18/24, at 10:41 A.M., CNA M said grab bars were used by residents to lift themselves up in bed. During an interview on 11/18/24, at 12:07 P.M., RN N said grab bars help with resident mobility and turning and require an order. Grab bars should be included on the care plan. Side rails should be assessed, but he/she is unsure how they do that. During an interview on 11/18/24, on 10:20 A.M., RN B said nursing notify the DON of bed rail requests and a risk assessment was completed. There should be a physician order and information on the care plan. The maintenance staff put on the bed rails. He/she was not responsible for the risk and benefit consent with family or guardian. The risk assessment should be completed quarterly. During an interview on 11/18/24, at 2:20 P.M., Physical Therapy Assistant (PTA) O said the following: -Physical therapy does an assessment for side rails while providing therapy to the resident; -Side rails are used for residents that require more help with bed mobility and increase independence; -Physical therapy or the DON discuss side rail use and risks with resident and family; -Physical therapy will write a side rail request and submit it to the DON and he/she will obtain an order; -The DON does all paperwork associated with side rails. During an interview on 11/18/24, at 2:56 P.M., the DON said side rail consents were done quarterly. There is no formal reevaluation for the use of the resident side rails. During an interview on 11/18/24, at 4:51 P.M., the Administrator said side rails were set up with therapy. A side rail consent should be obtained from the resident or representative. Side rails should be measured before placed on the bed and when moved.

Based on record review, observation, and interview, the facility failed to ensure each resident was treated with dignity and respect when staff spoke to one resident (Resident #72) in a threatening manner. The facility had a census of 90. Review of the facility policy titled Resident Rights, dated 09/10/24, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -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/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident; -The resident has the right to be treated with dignity and respect. 1. Review of Resident #72's face sheet (a brief information sheet about the resident) showed the following information: -admitted [DATE]; -Diagnoses included chronic post-traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), generalized anxiety disorder, major depressive disorder, paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), dementia without behavioral disturbance, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and cognitive communication deficit. Review of the resident's care plan, updated 07/02/24, showed the following: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, disease process, and physical limitations; -Staff should converse to resident while providing care; -If reasonable, staff should discuss behavior and explain and/or reinforce why behavior is inappropriate or unacceptable; -Staff should intervene as necessary to protect the rights and safety of others; -Staff should approach and speak in a calm manner. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 09/24/24, showed the following: -Moderate cognitive impairment; -Resident dependent on staff for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. During observation and interview on 11/12/24, at 10:30 A.M., the resident at time staff could have an attitude. Review of the resident's nursing notes, dated 09/06/24, showed Registered Nurse (RN) A documented the following: -At 5:44 P.M., the resident was tickling a nursing aide and was asked to stop. The resident proceeded to pinch the second nursing aide when getting the resident up for lunch. The nursing aide told the resident to stop. He/she then swung at the aide; -At 5:46 P.M., a nursing aide approached the nurse and stated the resident was hitting and slapping me and it stung while the two aides were changing him/her. The nurse approached the resident and instructed the resident do not put your hands on my staff, and the staff have every right to press assault charges on you. The resident replied, Did I put my hands on them? The nurse stated, yes for the second time you have either hit at or struck my staff and they have every right to press charges on you. The resident replied Well let them. The nurse then exited room. The nurse had contacted the physician prior to the second incidence to restart previous discontinued medication prescribed for behavior. The physician ordered to restart Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 100 milligram (mg)once per day. During an interview on 11/18/24, at 10:20 A.M., RN B said staff should not threaten any resident with assault charges. Staff have been trained on dementia and behaviors and should redirect the resident. He/she was not aware of any staff threatening a resident with assault charges. During an interview on 11/18/24, at 11:00 A.M., Certified Nurse Aide (CNA) C said that he/she had received behavior and dementia training. If a resident was touching the staff, he/she would notify the charge nurse. He/she would not threaten the resident and did not think it was appropriate to threaten a resident. Staff might ask a resident not to touch them but not threaten to press charges. During an interview on 11/18/24, at 12:00 P.M., the Director of Nursing (DON) said that staff receive training that included how to de-escalate a situation and dementia and behaviors. She said that the resident had a diagnosis of PTSD and staff did not know what would trigger a behavior. The resident would just start beating staff up. The resident sees the psychiatric physician. Staff should possibly care plan triggers if known. Staff should not tell a resident that they will press assault charges. During an interview on 11/18/24, at 12:57 P.M., with the DON and RN A, the following was said: -On 09/06/24, the resident was hitting the staff, and the nurse went and told the resident that he/she could go to jail and that the staff had the right to press charges on him/her; -He/she did not feel that he/she was threatening the resident, was just educational. During an interview on 11/18/24, at 4:51 P.M., the Administrator said that residents should not be threatened with assault charges. The staff should redirect and notify the DON and/or Administrator of problem behaviors. She was not aware of the documentation of resident being told the staff could press assault charges.

Based on interview and record review, the facility failed to maintain an effective system of records and disposition of controlled medication when staff could not locate three cards of controlled medications and documented administration of the medication when it was not available for administration one resident (Resident #1). The facility census was 81. Review of the facility policy titled, Administration of Medication, last revised 02/23/23, showed the following: -The facility will ensure medications are administered safety and appropriately per physician order to address resident's diagnoses and signs and symptoms; -Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration, right drug, right resident, right does, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, and right education and information. Review of the facility policy titled, Inventory Control of Controlled Substances, last revised 01/01/22, showed the following: -Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet; -Facility should ensure that its staff immediately reports suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up in accordance with facility policy and applicable law; -Upon a receipt of such a report, facility should ensure that the appropriate facility personnel confirm the discrepancy and follow facility policy and applicable law regarding documentation of the incident; -Facility should also conduct an investigation to determine whether a dose was in face administered and, if so, the reason the administration was not charged and whether a dose was refused. 1. Review of Resident #1's face sheet (a brief profile) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), cognitive communication deficit (difficulty with thinking and how someone uses language), Type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and dysphagia, repaying phase (swallowing problems occurring in the mouth and/or the throat). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/05/23, showed the following: -Cognitively intact; -Resident used a wheelchair; -Resident required partial/moderate assistance with most self-cares and was mostly independent with mobility. Review of the resident's care plan, last reviewed on 11/07/23, showed the following: -Resident used anti-anxiety medications related to anxiety disorder; -Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date; -Administer anti-anxiety medications as ordered by physician and observe for side affects and effectiveness every shift; -Observe for occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, and violence/aggression towards staff/others). Review of the resident's physician order sheet, dated 12/12/23, showed an order for clonazepam (an anticonvulsant controlled medication) 0.5 milligram (mg) tablet, one by mouth three times daily. Review of the resident's Medication Administration Record (MAR), dated 12/16/23, showed the following: -An order, dated 12/12/23, for clonazepam tablet 0.5 mg, give one tablet by mouth three times a day related to generalized anxiety disorder; -Certified Medication Tech (CMT) A documented doses administered at 8:00 A.M., 2:00 P.M., and 7:00 P.M. Review of the resident's Controlled Drug Record Sheet, dated 12/16/23, showed the following: -A sheet for an order, dated 12/06/23, for clonazepam 0.5 mg tablet orally three times a day for 30 days; -CMT A signed out two doses on 12/16/23, one at 8:00 A.M., and one reads 1:23 P.M.; -Staff noted 61 pills remaining after the second dose was administered. Review of the facility investigation summary, undated, showed the following: -On 12/16/23, at about 3:30 PM., Certified Medication Technician (CMT) A discovered three cards containing 63 pills total of Klonopin (named brand clonazepam) 0.5 mg for the resident was missing from the narcotic box. CMT A and Licensed Practical Nurse (LPN) C attempted to locate the cards in the medication cart and medication room. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were contacted at approximately 4:00 P.M., regarding the missing medication. The DON and ADON came to the facility at approximately 5:00 P.M., and searched for the missing medications. The missing medications were not found at that time. Staff reconciled all other narcotics with no irregularities noted; -The DON interviewed CMT A who said he/she noticed the Klonopin was missing about 3:30 P.M. He/she does not remember seeing the Klonopin in the medication cart; -The DON interviewed LPN D who said he/she completed a narcotic count at 6:00 A.M., which was correct and verified by a second nurse. He/she could not remember seeing the Klonopin during the count. He/she did not pass any medication during his/her shift and the cart was locked during his/her shift; -The DON confirmed through interviews the count at 6:00 A.M., was correct and the Klonopin cards were observed on the previous shift; -On 12/17/23, at approximately 12:23 A.M., staff located the medication cards. Staff located one card in the resident's closet wrapped up on clothes with no missing medication. Staff located two of the cards in the shower room inside a folded towel with two pills missing from one card; -On 12/17/23, at approximately 3:34 A.M., the resident brought keys he/she had found in his/her room. One key was the key to the medication cart and the other to the kitchen. The resident did not know how the keys ended up in his/her room. The keys were locked in the ADON's office, and residents and staff do not have access to this office as it is locked when no one is in it. During interviews on 02/08/24, at 1:16 P.M., 4:12 P.M., and 5:14 P.M., CMT A said the following: -He/she administers medications according to the MAR; -He/she would match the narcotic card and narcotic sheet with the MAR, prior to administering a narcotic to a resident; -Narcotic administration is documented in the MAR and on the narcotic sheets, staff sign the narcotic sheet and put the date and time the medication is administered; -Staff should complete narcotic counts at shift change, two times daily; -The staff leaving the shift counts the narcotic sheet while the oncoming staff counts the narcotic cards to ensure they both match; -On 12/16/23, the morning nurse completed the narcotic count with the overnight nurse at 6:00 A.M., with no issues. He/she took the medication key from the morning nurse at 7:00 A.M., and did not complete a count due to the morning nurse not administering any medications during the hour since the shift change count. He/she should have completed a count when taking the medication key from the morning nurse; -On 12/16/23, he/she noticed three narcotic cards of the resident's clonazepam were missing sometime between 2:30 P.M. and 3:00 P.M., after he/she returned from lunch and was checking the narcotics. He/she kept the medication key with him/her at all times during the shift; -He/she immediately notified the charge nurse, LPN B, of the missing medications; -He/she and other staff searched for the cards and notified the DON; -The cards were located by the overnight staff; -He/she does not remember if she saw the clonazepam cards prior to discovering they were missing, and he/she cannot remember if she administered the doses per the MAR on 12/16/23, at 8:00 A.M. and 2:00 P.M.; -He/she is not sure why he/she documented administering the missing clonazepam to the resident on 12/16/23, at 7:00 P.M., as the medication was still missing at this time. He/she may have pushed the wrong button on the MAR due to being flustered. During interviews on 02/08/24, at 2:08 P.M. and 2:59 P.M., LPN B said the following: -Staff administer medications per the MAR; -Nurses only have keys to the narcotic box; -Staff should complete narcotic counts at every shift change and if the keys change hands even if for only an hour with no medication administered; -The staff leaving the shift counts the narcotic sheet while the oncoming staff counts the narcotic cards for reconciliation; -He/she checks the MAR and narcotic card for the name and dosage before popping the medication. After popping medication, sign out in narcotic book, administer to the resident and document in the MAR; -Staff should report any missing medications to the DON immediately; -The facility has one key for the medication cart and one key for the narcotic box. The master key is with the Administrator. During an interview on 02/08/24, at 2:37 P.M., LPN C said the following: -Staff administer medications per the MAR; -Only nurses have keys to the narcotic box; -Staff should complete narcotic counts at the change of every shift and when taking over a cart even if no medications were administered; -The staff leaving the shift counts the narcotic sheet while the oncoming staff counts the narcotic cards for reconciliation; -Staff should report any missing medications to the DON immediately; -He/she checks the MAR, narcotic card, and narcotic sheet for name, dose of medication, medication time and route before popping and administering and then documents administration in the MAR and signs out in the narcotic sheet; -He/she came on shift at 10:00 A.M., on 12/16/23. He/she did not take the keys to the medication cart at that time; -The morning nurse and overnight nurse completed a narcotic count at 6:00 A.M., with no discrepancies. He/she did not know if the morning nurse and CMT completed a count before the CMT took over the medication key and cart at 7:00 A.M.; -CMT A advised him/her sometime after lunch three narcotic cards were missing for the resident and management was notified; -Management came to the facility and searched for the medication unsuccessfully and law enforcement was notified. During an interview on 02/08/24, at 3:10 P.M., LPN D said the following: -Staff administer medications per the MAR; -To administer a narcotic, he/she would check the MAR and verify information on the narcotic card and sheet, sign out of the narcotic sheet, administer, and then document in the MAR; -Staff conduct narcotic counts at every shift change, the staff leaving the shift counts the narcotic book/sheet, while the oncoming staff counts the narcotic book; -He/she came on shift at 6:00 A.M., on 12/16/23, and completed a narcotic count with the night nurse with no missing medications; -He/she and CMT A did not complete another narcotic count at 7:00 A.M., when CMT A took over the medication cart. He/she had the medication cart for one hour and did not administer medications and was his/her understanding it was not required at the time, but the policy has changed since this incident. During an interview on 02/08/24, at 3:44 P.M., the DON said the following: -Staff use the MAR for medication administration; -When administrating a narcotic, staff should verify the order with the MAR and narcotic sheet, open the narcotic box and take out the narcotic card and verify the information on the card, sign the medication out of the narcotic sheet, administer and then document in the MAR; -Staff should complete narcotic counts at every shift change and at any exchange of the medication cart/key; -The staff leaving the shift should count the narcotic book and the oncoming staff counts the narcotic cards; -Staff should complete a narcotic count even if the staff in possession only had the cart for one hour and did not administer any medications; -CMT A noticed the clonazepam was missing on 12/16/23, at about 3:30 P.M.; -CMT A documented administering the clonazepam on the MAR three times that day. She does not know why CMT A documented the last dose at 7:00 P.M. as the medication was missing at the time and the facility does not have clonazepam in the emergency kit; -She and the ADON searched for the medications in the building and did not locate them and notified law enforcement; -The night nurse located one of the clonazepam cards in the bottom of the resident's closet wrapped in clothes with no pills missing; -The night nurse located the other two cards in the shower room inside a folded towel with two pills missing since the last count at 6:00 A.M. There was a total of 61 pills found; -Shortly after the medication was found, the resident found the master keys in his room. The master keys are locked in the DON's office; -The facility ordered 90 clonazepam pills to replace the missing at the facility costs prior to locating the medication. During an interview on 02/08/24, at 4:35 P.M., the Administrator said the following: -Staff administer medications per the MAR; -Staff should complete narcotic counts at shift change and if the key/cart changes hands; -One staff member counts the narcotic cards and the other compares the narcotic book; -The staff member responsible for the medication cart has the key; -Staff should notify administration immediately upon discovering missing medications; -Staff should never document medication administration on a medication not administered; -The keys located in the resident's room were the master keys and a kitchen key, which are kept locked in the DON's office. MO00228878

Based on record review, observation, and interview, the facility failed to provide a sanitary environment for all residents, staff, and the public, when staff failed to keep the wall behind the dirty dish sink clean and failed to repair the missing caulking between the sink an wall. The facility census was 91. Review of the facility's Cleaning Schedule Policy, revised 04/25/23, shows the following information: -The Director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietician, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times; -The Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned; -Designated cleaning tasks are assigned to each position; -The cleaning schedule is posted in a location where it can be easily read; -The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately. Review of the facility's Kitchen Cleaning Schedule, undated, showed the dirty dish area and wall behind it were not specifically mentioned on the cleaning schedule. 1. Observations on 08/23/23, at 1:31 P.M., of the dishwashing area showed the following: -A black gritty looking substance on the wall close to the baseboard under the dirty dish sink. The spots varied in location and size with the largest amount being approximately two foot long by six inches tall; -A black slimy looking substance approximately two feet wide by a foot tall on the wall above the sink; -The caulking between the sink and wall was black and several inches of the caulking is missing, leaving a small gap between the wall and the sink. Observation on 8/23/23, at 2:10 P.M., showed approximately a half an inch of water standing under the dirty dish sink. During an interview on 08/23/23, at 2:17 P.M., Dietary Cook A said the following: -There is mold in the dirty dish area on the wall above the sink, the caulking is black, and the mold is also on the wall under the sink. The water stands under the sink; -Night aides do wipe down the wall; -He/she did not know if the aides wipe down the wall behind the dirty dish sink every night; -The the dietary aides scrape the water into the drain and wipe the wall down; -They use the Mold Stain and Mildew Stain Remover' on it too; -The moldy wall continues to be a problem. During an interview on 08/25/23, at 3:25 P.M., Dietary Aide B said the following: -He/she has seen mold in the dirty dish area on the wall above and below the sink; -He/she has never been specifically told to clean that wall, but he/she has seen the black substance and he/she has tried to clean it. He/she has tried to clean it regularly -He/she has used bleach and Mold Stain and Mildew Stain Remover; -The dishwasher aide is supposed to clean the dirty dish area every night and it is on their cleaning sheet. The Dietary Aide is not normally assigned to clean that area. During an interview on 08/25/23, at 9:32 A.M., the Maintenance Director said yesterday (08/24/23) he/she was told about black mold on the dirty dish sink walls and caulking. The caulking had parts missing. Yesterday was the first time he/she had been told about it. The Dietary Manager reported the mold to him/her yesterday, but not before then. During interviews on 08/23/23, at 1:31 P.M. and 2:10 P.M., and on 08/25/23, at 12:40 P.M., the Dietary Manager said the following: -There had been an issue with mold in the dirty dish room on the wall around the sink. He/she sprays it with Mold Stain and Mildew Stain Remover weekly; -The dietary aide is supposed to sweep and mop the entire kitchen, including the dirty dish area, but they probably don't get under the sink and clean the wall; -He/she reported the mold to management back in November 2022. Management said to try to keep it clean; -There is no weekly cleaning designated for cleaning the mold off the wall behind the dirty dish sink; -There is half an inch of standing water on the floor under the dirty dish sink; -The water leaks behind the sink counter where the sink caulking has fallen off and caused holes between the sink counter and the wall; -He/she should have told the Maintenance Director about the moldy/missing caulking back in November 2022. During an interview on 08/25/23, at 3:36 P.M., the Administrator said the following: -The facility is kept clean. If staff see black substances they should clean it up; -If black substances are seen in the kitchen, kitchen staff should clean it; -If caulking is dirty, the Maintenance Director should remove the old caulking and recaulk it; -If staff see a black substance, they should report it to the Maintenance Director or a department head, so the management can make sure it is followed up on; -Cleaning of the kitchen is done by dietary aides, who should be cleaning the dirty dish sink daily, and then they should clean the wall behind the dirty dish sink monthly if not weekly. MO00223359

Based on interview, observation, and record review, the facility failed ensure all food was protected from possible contamination during storage, preparation, and distribution when staff stored dented cans with other cans of food to be used in food service; stored dishes in a manner that trapped moisture; had unpasteurized eggs purchased and in the cooler for use; and failed to keep food free of contaminates when foil was stirred into noodle. The facility had a census of 88. 1. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: - Food packages should be in good condition and protect the integrity of the contents so the food is not exposed to potential contamination; - Food held for credit, such as damaged products, should be segregated and held in an area separate from other food storage. - Food packages that are damaged, spoiled or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods and should be kept in separate and segregated areas; - Damaged packaging may allow the entry of bacteria or other contaminants into the contained food. Observations of the kitchen on 2/26/2023, at 9:24 A.M., showed the following: -In dry food storage area, there was one six pound (lb) can of pickled beets with a small dent on the bottom of the front side; -In dry food storage area, one 6 lb can of cream-style corn with a small dent to the middle of the side of the can; -There was no signage for an area to hold dented cans for return. During an interview on 3/2/23, at 11:58 A.M., Dietary Aide (DA) P, said he/she knows they are to put dented cans to the side and not keep them with the other cans. During an interview on 3/2/2023, at 12:05 P.M., Cook Q, said he/she knows dented cans are to be separated and thought those must have been overlooked. During an interview on 3/2/2023, at 12:15 P.M., the Kitchen Manager said kitchen staff keep dented cans away from the res,t but somehow the two spotted were left in with the rest. 2. Record review of the facility's policy titled Safe Food Handling, revised 9/8/2022, showed the following: -Unpasteurized eggs and undercooked meat are not served to any resident; -Only pasteurized liquid and shell eggs will be used. Observations of the kitchen on 2/26/2023, at 9:24 A.M., showed inside the walk-in freezer were two boxes of unpasteurized eggs (60 total). During an interview on 3/2/2023, at 12:15 P.M., the Kitchen Manager said they ran out of eggs and someone in the front office went and grabbed eggs at the local store. He/she did not even notice they were not pasteurized. During an interview on 3/2/2023, at 2:59 P.M., the Director of Nursing (DON) said the following: -He/she is the one who went to buy the eggs. The facility ran out of eggs and they needed only a few until the next truck came; -The DON didn't even realize they were unpasteurized, but would not have purchased them if he/she had realized that. 3. Record review of the facility's policy titled Safe Food Handling, revised 9/8/2022, showed the following: -All cooking utensils, pans, dinnerware will be stored dry. Record review of the facility's policy titled Sanitation and Maintenance, revised 11/4/22, and showed the following: -Food and Nutrition Services associates are trained in the proper use, cleaning and sanitation of all equipment and utensils; -For washing all eating and cooking utensils instructions for manual, two-compartment sinks and mechanical ware washing, shows the items are to be air dried before storing; -All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow Observation of the kitchen on 2/26/2023, at 9:24 A.M., showed the following: -Sixty plates, clean and washed, and placed in the plate warmer. The plates were wet with water droplets on them and between them; -Forty-five plastic bowls, lying flat on trays where no air was able in to get between the rims and the tray. This caused trapping of moisture inside the bowls; -Twenty-nine hard plastic plates, stacked, trapping water between the plates; -Twenty-four brown plastic coffee mugs, turned upside-down, where no air was able in to get between the rims. This caused trapping of moisture inside the mugs; -Twenty-eight clear plastic juice cups, turned upside-down where no air was able in to get between the rims and the tray. This caused trapping of moisture inside the cups; -A stack of three large metal pans, that go inside the steam table, were turned upside-down, trapping moisture inside and between them; -A stack of five large metal pans that go inside the steam table were turned upside-down, trapping moisture inside and between them. During an interview on 3/2/23, at 11:58 A.M., DA P, said he/she did not realize dishes could not be stacked wet or placed upside down. During an interview on 3/2/2023, at 12:05 P.M., Cook Q said he/she did not know the dishes could not be stacked wet. During an interview on 3/2/2023, at 12:15 P.M., the Kitchen Manager said the following: -He/she knows that dishes cannot be stacked wet and has been taught that this can cause bacteria growth. During an interview on 3/2/2023, at 4:30 P.M., the Administrator said the dishes being stacked wet is not acceptable. 4. Record review of the facility's policy titled Safe Food Handling, revised 9/8/2022, showed the following: -Store, prepare, distribute and serve food in accordance with professional standards for food service safety; -All food is handled carefully to avoid contamination with potentially harmful debris, such as glass. Observations on 3/1/2023, at 11:15 A.M., showed the following was observed: -Cook O, was standing at the steam table, serving out trays; -Small flecks of aluminum foil were seen stuck to the macaroni noodles, towards the back, upper left corner of the pan; -The cook began stirring the noodles, mixing all of the noodles together; -The cook had began placing the noodles on plates to serve. During an interview on 3/2/2023, at 12:05 P.M., Cook Q said the following: -If he/she had seen foil in food, she would make sure the foil pieces were removed, or would have made a new batch of noodles. He/she would not serve it out. During an interview on 3/1/2023, at 1:22 P.M., the Administrator and DON said the following: -It would never be acceptable to serve food like this; -The administrator said they expect food to be safe and healthy for residents to eat. 31464

Based on observation and interview, the facility failed to ensure a clean and homelike environment when staff failed to adequately clean resident bathroom floors for ten residents (Resident #5, #8, #19, #21, #29, #37, #45, #47, #48, and #51); failed to adequately clean resident bathroom ceiling for two residents (Resident #5 and #51); failed to adequately clean and maintain the resident room sinks for five residents (Resident #8, #21, #29, #37, and #47); failed to maintain toilets in good working order for three residents (Resident #49, #63, and #69); failed to maintain the shower floor tile in one facility shower room; and failed to maintain the tiles and mop board areas for five residents (Resident #8, #19, #29, #37, and #48). The facility census was 88. Record review of the facility policy titled Housekeeping Services, dated 8/9/22, showed the following information: -The facility will provide a safe, clean, comfortable and homelike environment; -Keep housekeeping surfaces visibly clean on a routine basis and clean spills promptly; -The environmental supervisor will maintain a schedule of cleaning and disinfection tasks and the employees responsible for this task; -Clean high-touch areas and surfaces at least daily and as needed, to include handwashing sinks and floors. 1. Observations on 2/27/23, at 10:33 A.M., of Resident #5's and #51's bathroom showed the following: -A brown substance around the base of the toilet; -Two, approximately basketball size in diameter, black areas on the ceiling. 2. Observation and interview on 2/27/23, at 10:55 A.M., of Resident #19's and 48's room showed the following: -The tiles at the main entry to the room had a large black mark across floor following the path of the door opening and closing; -The bathroom had dark brown discoloring around the base of the toilet on top of the caulk; -The bathroom had an approximate area of one to four inches of brown discolored area on the wall above the mop board; -There was an approximately four inch area of broken tile in the bathroom near the toilet base; -The closet had no door or curtain covering clothing. There was an approximate three inch gap between the room tile and the closet tile with no tile or threshold covering the gray floor area; -Resident #48 said that he/she would prefer to have a clean room that does not contain stains. 3. Observation and interview on 2/27/23, at 10:48 A.M., of Resident #37's room showed the following: -The bathroom had a brown substance around the toilet, on top of the white caulking; -There was a black and brown appearance on the back of wall behind toilet; -There was brown appearance on wall around water inlet to toilet; -The sink in the resident's room had broken laminate toping of approximately 5 inches that showed the wood under the laminate; -The resident said that he/she tried not to let it bother him/her, but did wonder if there was mold in the bathroom. 4. Observations on 2/27/23, at 11:09 A.M., of Resident #21 and #47's room showed the following: -The sink in the room had a baseball size area of brown rust appearing area from the overflow hole down towards the sink drain; -The bathroom had a brown appearing substance around the caulking at the base of the toilet. 5. Observation and interview on 2/27/23, at 1:58 P.M., of Resident #8's and #29's room showed the following: -The bathroom had a dark brown substance around toilet base, on top of the caulking; -The sink in bedroom had rust colored appearance at the overflow hole about one to two inches in diameter; -The mop board in the resident room had pulled away from wall and has black/brown discoloration visible to residents; -Resident #29 said that it bothered him/her that the room does not appear clean. He/she preferred to have a clean and tidy home. 6. Observations on 2/27/23, at 2:47 P.M., of Resident #45's bathroom toilet showed it had brown appearing substance around the base of the toilet covering the caulk. 7. During an observation on 3/2/23, at 10:15 A.M., of shower room in the near the activity room, showed multiple red tiles on the shower floor to be loose from the floor and an area of approximately 12 inches in diameter with no tiles present. 8. Observation and interview on 3/02/23, at 2:52 P.M., of Resident #63's bathroom showed a bath type blanket wrapped around the base of the toilet. The resident said that it had been that way since he/she had been in that room. He/she said that he/she was told there had been a leak, but was unsure if it was fixed or not. 9. Observation and interview on 2/26/2023, at 12:45 P.M., of Residents #49 and #69's room showed the following: -Both said the toilet in their room leaked. They said they had notified the Maintenance Director, but it had not been fixed yet. They kept a towel wrapped around the base of the toilet; -A towel was in place around the base of the toilet. Observation on 3/2/2023, at 2:33 P.M., of the residents' bathroom showed a white towel was wrapped around the base of the toilet. Observation and interview on 3/2/2023, at 4:18 P.M., showed a saturated towel was wrapped around the base of the toilet. 10. During an interview on 3/02/23, at 1:50 P.M., Certified Medication Tech (CMT) D said that if he/she noticed a dirty area in a resident room or bathroom, he/she would normally try to clean the soiled bathroom if able. He/she would then notify housekeeping and/or maintenance. 11. During an interview on 3/2/2023, at 2:30 P.M., Licensed Practical Nurse (LPN) F said that if there are discoloration, stains, or dirty bathrooms, he/she would notify housekeeping. Some items require maintenance to be notified. 12. During an interview on 3/1/2023, at 3:00 P.M. Housekeeping S said he/she cleaned the assigned rooms daily and notified maintenance if anything was broken or damaged and need of repair. 13. During an interview on 3/02/23, at 3:30 P.M., the Maintenance Director said that staff and residents will tell him directly if there is a leaking toilet. There are times that he will try to repair and find there was not a leak and then a few days later staff will tell him there is a leak and he will not find anything. Staff put a towel around the toilet so that he would not have to argue with the resident. He/she said that housekeeping was usually notified for stains on the floors in the bathrooms. They work on getting out discoloration and notify maintenance if unable to get the area clean. 14. During an interview on 3/02/23, at 4:21 P.M., with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the Administrator said they were not currently aware of any toilets that were leaking. The Administrator said if there were black and brown stains in the bathroom floors, walls, and ceilings she would get maintenance involved. Staff should report to maintenance. She was aware that the Maintenance Director was working on some sinks that were needing replaced. There was currently a plan and layout in place to repair broken tiles and update shower rooms, but the plan was pending budget approval by the corporation. When residents were taken to the shower room, a shower sheet was put on the floor before the resident was in the shower to protect the residents' feet from the broken/missing tiles. 31464

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J." A monitoring visit was completed on 11/18/11. Based on record review and interview, completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at this time. The facility in-serviced staff, identified residents at risk for abuse, completed head-to-toe assessments on residents at risk for abuse, implemented interventions for staff to follow regarding residents at risk for abuse, and implemented frequent monitoring of staff interaction with residents at risk for abuse. Record review, completed during the monitoring visit, a nurse's note on 11/08/11, at 7:45 P.M., showed one resident had a purple-colored bruise to area beneath the left side of the resident's scrotum; the scrotum was also swollen. Origin of the bruise unknown. An interview conducted on 11/18/11, at 12:15 P.M., the nurse, who initially observed the bruise, described the bruise on the resident's scrotum as a little smaller than an egg, bright blue in color and swollen. The nurse said the bruise had not been there (on the scrotum) long. After several interviews of facility staff, it remained unclear if and when staff reported the bruise to the administrative staff. On 11/09/11 staff completed a very brief investigation. Staff did not thoroughly investigate the injury of unknown origin and did not follow the facility abuse policy for reporting and investigating. Due to the facility's failure to follow their policy, the severity of the deficiency was not corrected but lowered to a "G." This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.

Based on interview, observation and record review, the facility staff failed to immediately report an allegation of abuse perpetuated by one certified nurse aide (CNA K); failed to immediately notify administrative staff of an allegation of abuse; failed to complete a thorough investigation of an allegation of abuse; failed to implement the steps, as outlined in the facility policy, following an allegation of abuse for at least four vulnerable residents (Resident #11, #12, #13 and #14) who resided on the Special Care Unit and were cognitively impaired. One nurse aide was aware of CNA K's abusive treatment for [REDACTED]. The facility also failed to ensure newly hired employees were screened to rule out the presence of a Federal indicator with the Certified Nurse Aide (CNA) Registry for four out of five newly hired employees reviewed. The facility hired 44 new employees since the last annual survey and licensure inspection, completed on September 24, 2010. These deficient practices had the potential to affect all residents in the facility. Fourteen residents were sampled out of a facility census of 81. Record review of the facility's "Reporting Alleged Abuse" policy, undated, showed the following information: -This facility does not condone resident abuse and/or neglect by anyone. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin; -All personnel, residents, families and visitors are encouraged to promptly report incidents of suspected resident abuse and/or neglect to facility administration; -All alleged or suspected violations involving mistreatment, abuse, neglect and injuries of unknown origin will be promptly reported to the administrator and/or Director of Nursing; -The person(s) observing an incident of resident abuse or suspecting resident abuse will immediately report such incidents to their immediate supervisor and/or the charge nurse. The supervisor and/or charge nurse will illicit the following information when the incident is reported: the name of the resident involved in the incident, the date and time the incident occurred, where the incident took place, the name of the person(s) committing or involved with the incident, the name(s) of any witnesses to the incident, the type of abuse and/or neglect that was committed and any additional information that may be pertinent to the incident; -The charge nurse will immediately assess the resident and offer medical attention, if necessary. Findings of the assessment and any treatment provided will be documented in the resident's medical record; -The charge nurse will complete and sign the incident report and notify the physician and the resident's responsible party of the occurrence. The incidence will be immediately reported to the administrator and the Director of Nursing; -When an incident of resident abuse is suspected, the incident must be reported to the supervisor regardless of the time lapse since the incident occurred. The supervisor notifies the Director of Nursing and the executive director of the alleged incident; -All phases of the investigation will be kept confidential. 1. Record review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by facility staff, dated 09/07/11, showed the following information: -Entry date into the facility on [DATE]; -Short and long term memory problem; -Severely impaired decision-making skills; -The resident continuously had difficulty focusing attention and disorganized thinking; -The resident required staff supervision with bed mobility, transfers, walking in the room and corridor; -The resident required maximum assistance with dressing, personal hygiene and bathing; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the care plan, updated 09/13/11, showed the following information: -The resident lived on the Special Care Unit (SCU); -Displayed socially inappropriate behaviors; -Staff to redirect the resident when he/she is sexually inappropriate; -Staff to report any sexual behavior or contact with other residents; -Short and long term memory loss; -Approach the resident with a warm and friendly attitude; -Allow enough time for the resident to make a decision. Record review of a nurses' note, dated 09/27/11, at 5:10 A.M., showed certified nurses aide (CNA) K reported that while he/she assisted the resident to dress, the resident grabbed his/her breast. The CNA removed the resident's hand and told him/her that was inappropriate. The nurse documented he/she also told the resident that was inappropriate behavior. Interview with the facility administrator and Director of Nursing (DON) on 10/27/11 at 10:10 A.M., revealed a newly employed aide reported on 10/24/11 that CNA K was rude to residents. The facility began an investigation of this report and suspended CNA K while the allegation was being investigated. The DON stated she found a statement written by CNA J under her office door this morning with additional complaints. Record review of CNA J's written statement, dated 10/26/11, (left under the DON's door)showed CNA K slapped the resident twice, on his/her hands, because the resident touched CNA K's breast. This note also included information regarding CNA K's treatment of [REDACTED]. During an interview on 10/27/11, at 11:30 A.M., CNA K said when the resident grabbed his/her breast, he/she removed the resident's hand. He/she did not hit the resident's hand. The CNA said residents who usually do those things are confused. During an interview conducted on 10/27/11, at 3:00 P.M., CNA J said one morning, about a month ago, he/she and CNA K were in the resident's room assisting him/her with morning cares. The resident grabbed CNA K's breast, then removed his/her hand. CNA K slapped the resident's hand, hard, two times. CNA J said he/she was in shock. "It is not right to slap a resident for any reason." CNA J did not report the incident to the charge nurse. CNA K tells the resident he/she can get dressed without assistance then tells him/her to put on his/her shirt. The resident just stands there. CNA K tells CNA J to let the resident dress him/herself, but CNA J does not think the resident understands, so he/she dresses the resident. Record review of the social services progress notes showed the following information: -On 10/27/11 the resident had short and long term memory problems, typically oriented to self and place and was able to walk without assistance. The resident was occasionally difficult to redirect; -10/28/11, untimed, the Social Services Designee (SSD) completed the abuse, neglect and exploitation risk assessment; the resident was at risk due to multiple areas. Record review on 10/28/11,of the nurses' notes showed staff did not document performing a head-toe assessment, on the resident according to the facility's policy. During an interview on 10/25/11, during initial tour of the facility, at approximately 11:30 A.M., the assistant director of nursing (ADON) said Resident #11 was alert and very confused. The resident ambulated self and required minimal assistance with activities of daily living (ADLs). Observation on 10/27/11, at 9:45 A.M., the resident wandered over to another resident. Staff asked Resident #11 what he/she was doing. Resident #11 said he/she was going to "[***] (him/her) up". Observation on 11/2/11, from 9:30 A.M. to 10:20 A.M., the resident sat at the table in the dining room with two other residents. The resident sat quietly and did not say anything. 2. Record review of Resident #14's face sheet showed he/she lived on the SCU. Record review of the resident's secured unit placement form, dated 5/11/11, showed the resident at risk for the following: -Wandering away from familiar setting with the inability to find way home; -Disturbing others related to disruptive behavior; -Less restrictive alternatives have been unsuccessful in preventing harm to self or others. Record review of the resident's face sheet (admission data) included the following Diagnoses: [REDACTED]. -Obsessive-compulsive disorder; -History of physical abuse; -Speech disturbance; -[MEDICAL CONDITION] (either partial or total loss of the ability to communicate verbally or using written words). Record review of the care plan, last updated 08/02/11, showed the following information: -Required assistance of one staff member for grooming and dressing; -Walked independently; -Required assistance with toileting and is incontinent at times; -Had short and long term memory problems. Record review of the resident's quarterly MDS assessment, dated 10/19/11, showed the following information: -Entry date into the facility on [DATE]; -Short and long term memory problem; -Severely impaired decision-making skills; -The resident continuously had disorganized thinking; -The resident had trouble concentrating nearly every day; -The resident was independent with bed mobility, transfers, toilet use and walking in the room and corridor; -The resident required limited assistance with dressing and personal hygiene; -Always continent of bowel; -Frequently incontinent of bladder; -[DIAGNOSES REDACTED]. Record review of the nurses' notes, showed the following information: -On 9/8/11, at 8:30 P.M., the nurse documented the resident had increased tearfulness with conversation. The resident had an increase in pacing and staff was unable to redirect the resident at times; -On 9/15/11, at 8:50 A.M., the resident had increased tearfulness and pacing. The nurse notified the physician; -On 10/10/11, the resident with confusion at times, occasional bladder incontinence. The resident ambulated independently with steady gait. The resident required verbal cues with activities of daily living (ADLs). The resident eats in the dining room without staff assistance. The resident required many verbal and tactile cues to eat meals. Record review of CNA J's written statement, dated 10/26/11, found by the DON on 10/27/11, showed, at times, the resident gets up several times during the night. On those nights, CNA K asks the resident. 'You want me to have (CNA J) give you a shot?' CNA J is unable to administer injections. During an interview on 10/27/11, at 11:30 A.M., CNA K said the resident likes to wander. When he/she wanders, the CNA tries to redirect him/her back to his/her bad. The CNA said he/she would never tell a resident he/she would receive a shot if he/she did not do something. CNA K said one night the resident was incontinent of urine. The CNA removed the wet linens from the bed then began to make up the bed with clean linens. The resident assisted the CNA in making the bed. The CNA said the resident usually helps him/her make the bed. Record review of the October 2011 daily staffing sheet showed CNA L worked with CNA K on Friday 10/14/11, Monday 10/17/11 and Tuesday 10/18/11. During an interview conducted on 10/27/11, at 12:20 P.M., CNA L said the last time he/she worked with CNA K (10/18/11), he/she worked in the unit. The resident was incontinent of urine. CNA K acted like he/she was angry and ripped the soiled sheets off the bed then said, in a hateful, firm tone, to the resident, 'If you are going to pee in the bed; you are going to make the bed'. CNA K positioned him/herself on one side of the bed while the resident stood on the other side. The CNA and the resident made the bed. If the CNA did not think the resident did something right he/she would tell the resident to do it again. For example, CNA K did not think the resident correctly applied the fitted sheet to the mattress and told him/her to redo it. CNA K told the resident to get the incontinent pad and place it on the bed. The CNA had to tell the resident two to three times before the resident understood. The resident placed the incontinent pad on the bed. CNA K told the resident to "fix" the pad. The resident picked up the incontinent pad, placed it again on the bed and straightened it out. CNA L said it was not right for CNA K to make the resident make the bed. After the resident straightened out the incontinent pad, CNA L said he/she left the resident's room. It was like CNA K was yelling at the resident and he/she could not watch anymore. CNA K remained in the room with the resident. About 10 to 15 minutes later, the resident walked out of his/her room and paced up and down the hall. The resident looked agitated, frustrated more confused. During an interview conducted on 10/27/11, at 12:55 P.M., Nurse Aide (NA) M said when he/she worked with CNA K, about a week ago (10/19/11), CNA K yelled at the resident. NA M and CNA K entered the resident's room and noticed the resident's clothes and bedding were wet. CNA K told the resident, in a rude, raised voice, "You wet it, you make it," then left the room. NA M said he/she left the room, returned with clean linens and made the resident's bed. During an interview conducted on 10/27/11, at 3:00 P.M., CNA J said Saturday night (10/22/11) he/she worked with CNA K. CNA K was "acting different towards me". He/she was nice, but was not any different to the residents. When assisting the resident to the bathroom, CNA K told the resident, "You can pull down your own pants." CNA K told the resident if he/she did not go to bed CNA J would give him/her a shot. CNA J is a Certified Medication Technician (CMT). Record review of the nurses' notes dated 10/28/11, at 7:05 P.M., showed staff completed a skin assessment of the resident. The resident's skin was pink, dry, warm, and intact. The resident did not have any bruising. Record review of the social services progress notes, dated 10/28/11 (incidents occurred on 10/19 and 10/21/11), showed the SSD completed the Abuse, Neglect and exploitation risk assessment; the resident was at risk because he/she was non-verbal and cognitively impaired. Observation on 10/31/11, at 11:27 A.M. through 12:36 P.M., showed the resident wandered aimlessly in and out of rooms and wandered down the hallway and to the dining room. A staff member spoke to the resident and asked the resident if he/she liked pasta. The resident said, "Yes" and smiled. During the lunch meal, the resident continued to wander aimlessly in and out of the dining room. The resident removed a piece of toast from another resident's plate and ate it. 3. Record review of Resident #12's face sheet showed he/she lived on the SCU. Record review of the resident's quarterly MDS assessment, dated 08/10/11, showed the following information: -Entry date into the facility on [DATE]; -Severe cognitive impairment; -Severely impaired decision-making skills; -The resident continuously had difficulty focusing attention and disorganized thinking; -The resident exhibited verbal behavioral symptoms one to three days a week; -The resident required staff supervision with bed mobility, transfers, walking in the room or corridor and eating; -The resident required limited assistance with toilet use and maximum assistance with dressing, personal hygiene and bathing; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the care plan, last updated 08/23/11, showed the following information: -Speak to the resident in a soft, kind tone; -Approach the resident with a warm and friendly attitude; -Have patience with the resident when he/she speaks; -The resident speaks very softly; -Assist the resident with personal hygiene when he/she is incontinent; -Assist the resident with grooming, dressing, oral care, toileting and bathing. Record review of the nurses' notes showed the following information: -On 09/16/11, at 9:55 A.M. staff found the resident "sitting on the floor;" -On 09/16/11, at 11:00 A.M., the resident "screamed out in pain," holding his/her groin, when staff assisted him/her to a standing position; -On 09/17/11, at 2:30 A.M., the resident refused to get out of bed. When staff assisted the resident into a sitting position, he/she cried out, then lay back down; -On 09/17/11, at 9:40 A.M., the resident remained in bed this shift and frequently yelled out. Staff administered pain medication with some relief; -On 09/18/11, at 4:10 A.M., the resident refused to get out of bed and complained of pain when he/she moved; -On 10/17/11, at 2:15 A.M., the nurse assessed a bruise, of unknown origin, on the resident's back. The resident's medical record showed no documentation of a fall or injury. The bruise was purple in color and extended from the middle of his/her back down to his/her buttocks. Staff notified the physician of the bruise. Record review of CNA J's written statement, dated 10/26/11, found by the DON on 10/27/11, showed one night, when the resident was sick, CNA J and CNA K entered the resident's room to take him/her to the bathroom. The resident started to cry. CNA K covered the resident's mouth with his/her hand in order to "shut (him/her) up." During an interview on 10/27/11, at 11:30 A.M., CNA K said if a resident is yelling, he/she tries to quiet them by "shushing" them. He/she also attempts to talk to them and tries to figure out why the resident is yelling. If the resident continued to yell, the CNA would get the charge nurse. The CNA would not place his/her hand over a resident's mouth in order to quiet the resident. Record review of the October 2011 daily staffing sheet showed CNA L worked with CNA K on Friday 10/14/11, Monday 10/17/11 and Tuesday 10/18/11. During an interview conducted on 10/27/11, at 12:20 P.M., CNA L said he/she and CNA K entered the resident's room to take him/her to the bathroom. The resident was lying in bed. CNA L said staff was to approach the resident in a calm manner but when CNA K entered the room he/she began to yell, in a mean tone, at the resident, 'Stand up, get up, you can do it, I have seen you do it'. CNA L said the resident is very sensitive and began to cry. The resident got out of bed, walked into the bathroom and sat down on the toilet. When the resident finished, CNA K told the resident, in a mean tone, to "stand up, stand up and pull up your pants". CNA K waited a few minutes for the resident to begin to stand then roughly pulled up the resident's incontinent brief. CNA L said this incident occurred the first night he/she had ever worked with CNA K (10/14/11). During an interview conducted on 10/27/11, at 12:55 P.M., NA M said one night, about two weeks ago, he/she was in the dining room, located next to the resident's room, and could hear CNA K yell at the resident. CNA K told the resident to get up. The resident said he/she did not want to get up because he/she was hurting. CNA K told the resident he/she had to get up. It took the resident a while but he/she did get out of bed. The resident was crying. During an interview conducted on 10/27/11, at 3:00 P.M., CNA J said, about a month ago, the resident was sick. When CNA J and CNA K assisted the resident into a standing position, the resident began to yell. CNA K placed his/her hand over the resident's mouth; the resident continued to yell. Record review of the social services progress notes, dated 10/28/11 (incident occurred 10/14/11), showed the SSD completed the abuse, neglect and exploitation risk assessment; the resident was at risk due to multiple risk factors on the assessment. Record review on 10/28/11 of the nurses' notes showed staff did not document performing a head-toe assessment, on the resident according to the facility's policy. Observation on 11/2/11, at 12:50 P.M., showed Resident #12 sat in the dining room chair. After finishing lunch, the resident stood up and began to exit the dining room with a walker and staff stood by and verbally cued the resident how to get to his/her room. 4. Record review of Resident #13's face sheet showed he/she lived on the SCU. Record review of the nurses' notes showed the following information: -On 09/10/11, at 3:50 A.M., the resident required assistance to the bathroom and was continent of bowel and bladder; -On 09/19/11, at 2:30 P.M., the physician instructed staff to administer a Z-pack (an antibiotic) to the resident as directed; -On 09/19/11, at 7:55 P.M., the resident was alert with confusion and had expiratory wheezes in both of his/her lungs; -On 09/24/11, at 3:45 A.M., the resident was up and down this shift with complaints of pain. Staff administered pain medication with no further complaints of pain. The resident continued to wheeze and continued to receive an antibiotic for an Upper Respiratory Infection (URI); -On 10/07/11, at 1:05 A.M., the resident was alert with confusion. He/she was continent of bowel and bladder and required assistance with all cares. Record review of CNA J's written statement, dated 10/26/11, found by the DON on 10/27/11, showed when the resident was sick, he/she requested assistance to the bathroom. CNA K told the resident he/she could go by him/herself then told CNA J the resident could go by him/herself. When the resident wanted his/her slippers on, CNA K told him/her he/she could put them on his/herself. During an interview on 10/27/11, at 11:30 A.M., CNA K said at night, the resident is usually able to care for him/herself. When he/she needs to go to the bathroom, he/she will turn on the call light, wait until staff enter the room then go to the bathroom unassisted. The CNA said he/she does not do things for the residents that they are capable of doing for themselves and becomes aggravated at staff that does everything for the residents. During an interview conducted on 10/27/11, at 3:00 P.M., CNA J said the resident is blind but was usually able to go to the bathroom unassisted. A little less than a month ago, the resident was sick and required assistance to go to the bathroom. CNA K told the resident to put on his/her own shoes and to take him/herself to the bathroom; the resident had done it before so he/she can do it now. Record review of the annual MDS assessment, dated 10/13/11, showed the following information: -Entry date into the facility on [DATE]; -Severely impaired vision; -Moderate cognitive impairment; -The resident required limited assistance with bed mobility, transfers, walking in the room and corridor, dressing, toilet use and personal hygiene; -Always continent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the care plan, last updated 10/18/11, showed the following information: -Long term memory problems; -The resident can only see shadows. Always tell the resident who you are and what you plan to do before any activity occurs; -During episodes of confusion speak with the resident one on one to calm and reassure him/her; -Required time to process and respond to information; -[MEDICAL CONDITION] in both eyes; -Speak and identify self upon entering the resident's room; -Speak in a soft tone instead of a loud and boisterous tone; -Place frequently used items within easy reach and visual field of the resident; -Required one staff assists to use the toilet; -Required set-up, supervision and hands-on assist for dressing, perineal (cleansing of the genitalia and surrounding area) care, oral care and meals; -Required reminders not to walk or transfer without assistance. Record review of the nurses' notes, on 10/28/11, showed staff did not document performing a head-toe assessment, on the resident. Record review of the social services progress notes, dated 10/28/11, showed the SSD completed the abuse, neglect and exploitation risk assessment; the resident was at risk due to poor judgment skills, inability to make needs known, [MEDICAL CONDITION] and cognitive impairment. Observation on 10/31/11, at 12:25 P.M., showed Resident #13 sat in the special care unit dining room eating lunch. The resident sat quietly and did not interact with other residents or staff. 5. Record review of CNA J's written statement, dated 10/26/11, found by the DON on 10/27/11, showed CNA J had wanted to talk to the Director of Nursing, for a long time, about CNA K. CNA J said he/she thought CNA K was mean to the residents. During an interview conducted on 10/27/11, at 11:30 A.M., CNA K said he/she was hired February 28, 2011 and worked the night shift, usually on the SCU. An interview conducted on 10/27/11, at 12:20 P.M., with CNA L showed the following information: -CNA L said he/she had worked the night shift for about a month. The CNA said if he/she witnessed abuse, he/she would report it the next morning; -CNA L said the first night he/she worked with CNA K, CNA K was mean to Resident #12. After the first incident (10/14/11) CNA L thought CNA K was just having a bad day but when it happened the next night (10/17/11), after his/her shift ended, CNA L reported the incidents to Licensed Practical Nurse( LPN) N. CNA L said LPN N was not the charge nurse, he/she could not find the charge nurse. LPN N told CNA L he/she needed to report the incidents because they were abuse. CNA L said LPN N did not report the incidents to anyone else because LPN N did not witness the incidents; -CNA L said Monday (10/24/11) he/she reported to the Staff Development Coordinator (SDC), by phone, what he/she had witnessed. The SDC then told the Director of Nursing (DON). The DON called CNA L and told him/her to write a statement about what he/she witnessed. An interview conducted on 10/27/11, at 12:55 P.M., with NA M, showed the following information -NA M said CNA K is rude to all of the residents; he/she does not talk in a polite voice; -NA M said he/she had told Registered Nurse (RN) P, on several different occasions that CNA K was rude to the residents and he/she did not want to work with him/her; -On 10/19/11, CNA K was rude to NA M and the residents residing in the unit. NA M asked RN P if he/she could trade halls with CNA S because NA M had enough of hearing CNA K be rude. NA M said RN P told him/her he/she would look into it but NA M did not think RN P did anything; -NA M said Monday (10/25/11) he/she told RN O because NA M thought it had gone on long enough. NA M said he/she did not report the incidences to the DON. NA M reported what he/she witnessed to RN O; RN O told the SDC who then told the DON. The DON called NA M and told him/her to write a statement about what he/she witnessed. An interview conducted, on 10/27/11, at 2:10 P.M., with LPN N showed the following information: -LPN N said on the instances of abuse he/she knew of, he/she left a note for the DON because it was during the night shift and he/she did not witness the claim. The LPN said if he/she witnessed abuse in the facility, he/she would notify the administrator on-call and dismiss the person who committed the abuse; -LPN N said he/she did not remember the day, but it was a night CNA K did not work, that CNA L and NA M told him/her CNA K made Resident #14 make his/her own bed when he/she was incontinent. CNA K thought the resident's incontinence was a behavior and told the resident if you wet it, you make it. The CNAs told LPN N that CNA K made Resident #12 cry. CNA K told the resident to quit crying; you are only crying to get attention. CNA L and CNA K told LPN N that CNA K slapped Resident #11's hands but did not tell him/her why. The LPN told the aides they needed to tell the DON because he/she did not witness it; -LPN N said he/she witnessed CNA K be rude to staff but not to residents. LPN N said CNA K is abrasive, rough and gruff; -LPN N said he/she did not know if the CNAs had reported the incidences before. He/she told the CNAs they needed to tell the DON, but apparently the DON already knew because CNA K was suspended; -LPN N said this morning (10/27/11), CNA J told him/her the facility was letting CNA K come back to work. CNA J said he/she had written a note describing what he/she witnessed and was going to give it to the DON. An interview conducted on 10/27/11, at 3:00 P.M., with CNA J showed the following information: -CNA J said CNA K is verbally abusive to the residents; CNA K is rude, bossy, gruff and yells at them; -CNA J said he/she should have reported the incidents immediately but he/she let this go. The CNA said he/she did not know what to do; -CNA J said he/she noticed "problems" since July 2011, when he/she started working nights. The CNA said he/she did not report anything until 10/5/11; -On 10/5/11, CNA J said he/she reported the "issues" to LPN C when he/she worked with him/her as an aide; -CNA J said CNA K was so rude he/she was afraid of retaliation from CNA K; -CNA J said he/she dreaded coming to work because he/she would have to work with CNA K. CNA J said he/she could not do his/her job; it had to be CNA K's way. CNA J said he/she was going to talk to the SDC about changing schedules. An interview conducted on 10/28/11, at 9:50 A.M., with the SDC showed the following information: -The SDC said on Monday (10/24/11) RN O told him/her CNA L reported to him/her CNA K was verbally abusive to residents on the special care unit, -CNA K caused Resident #12 to cry and made Resident #14 make his/her own bed when he/she was incontinent. The SDC called CNA L and left a message for him/her to call the facility. CNA L called and talked to the SDC. He/she told the SDC about the incidents. CNA L told the SDC he/she did not want to be in trouble or be thought of as a trouble-maker for reporting; -The SDC said CNA L did not report any other incidents; -The SDC said she was surprised that CNA K was accused of the allegations. The SDC said CNA K is gruff and outspoken and sometimes it is difficult to tell if he/she is mad or not. CNA L was new and had not worked with CNA K much so we did not know if it was abuse or CNA L's perception. An interview conducted on 10/28/11, at 10:20 A.M., with RN O showed the following information: -RN O said sometime last week CNA L, his/her daughter, looked upset and asked if a resident with dementia should have to make his/her own bed and be yelled at. RN O told CNA L he/she needed to report that and it was not right. RN O said he/she and CNA L do not usually discuss work matters but CNA L was very upset and in tears; -RN O said last Tuesday (10/18/11) NA M reported CNA K made Resident #12 cry, made Resident #14 make his/her own bed and yelled at residents. RN O told the CNA he/she needed to report it because it was not right for staff to yell at residents. NA M said okay; -RN O assumed NA M reported it to someone because he/she said he/she was going to; -RN O said last week, Wednesday (10/19/11) or Thursday (10/20/11) CNA L came home and said he/she did what RN O had said and reported the incidents to LPN N; -Monday (10/24/11) RN O told the SSD what CNA L had reported to him/her. The RN just wanted to make sure there was not abuse occurring in the facility and nothing being done. An interview conducted on 10/28/11, at 10:28 A.M., with LPN C showed the following information: -LPN C said on 10/05/11 he/she worked the night shift as an aide. CNA J told LPN C CNA K was loud with the residents and slapped Resident #11's hand after he/she touched the CNA on the breast. LPN C told CNA J that was abuse and he/she needed to report it to the DON. Any time you hear an employee talking rough or ignoring a resident it is abuse and staff can not lay a hand on a resident. LPN C said the "nurse came out in me." CNA J said he/she was worried CNA K would find out he/she told the DON. LPN C said he/she told the CNA this would not necessarily happen; -LPN C said he/she thought CNA J told the DON. LPN C did not report the incidents to the DON because he/she was not at work. The next